Intervention for unruptured high-grade intracranial dural arteriovenous fistulas: a multicenter study
Ching-Jen Chen, Thomas J. Buell, Dale Ding, Ridhima Guniganti, Akash P. Kansagra, Giuseppe Lanzino, Enrico Giordan, Louis J. Kim, Michael R. Levitt, Isaac Josh Abecassis, Diederik Bulters, Andrew Durnford, W. Christopher Fox, Adam J. Polifka, Bradley A. Gross, Minako Hayakawa, Colin P. Derdeyn, Edgar A. Samaniego, Sepideh Amin-Hanjani, Ali Alaraj, Amanda Kwasnicki, J. Marc C. van Dijk, Adriaan R. E. Potgieser, Robert M. Starke, Samir Sur, Junichiro Satomi, Yoshiteru Tada, Adib A. Abla, Ethan A. Winkler, Rose Du, Pui Man Rosalind Lai, Gregory J. Zipfel, Jason P. Sheehan, _ _, _ _, Gregory J. Zipfel, Akash P. Kansagra, Ridhima Guniganti, Jay F. Piccirillo, Hari Raman, Kim Lipsey, Giuseppe Lanzino, Enrico Giordan, Waleed Brinjikji, Roanna Vine, Harry J. Cloft, David F. Kallmes, Bruce E. Pollock, Michael J. Link, Jason Sheehan, Ching-Jen Chen, Mohana Rao Patibandla, Dale Ding, Thomas Buell, Gabriella Paisan, Louis J. Kim, Michael R. Levitt, Isaac Josh Abecassis, R. Michael Meyer, Cory Kelly, Diederik Bulters, Andrew Durnford, Jonathan Duffill, Adam Ditchfield, John Millar, Jason Macdonald, W. Christopher Fox, Adam J. Polifka, Dimitri Laurent, Brian Hoh, Jessica Smith, Ashley Lockerman, Bradley A. Gross, L. Dade Lunsford, Brian T. Jankowitz, Minako Hayakawa, Colin P. Derdeyn, Edgar A. Samaniego, Santiago Ortega Gutierrez, David Hasan, Jorge A. Roa, James Rossen, Waldo Guerrero, Allen McGruder, Sepideh Amin-Hanjani, Ali Alaraj, Amanda Kwasnicki, Fady T. Charbel, Victor A. Aletich, Linda Rose-Finnell, J. Marc C. van Dijk, Adriaan R. E. Potgieser, Robert M. Starke, Eric C. Peterson, Dileep R. Yavagal, Samir Sur, Stephanie H. Chen, Junichiro Satomi, Yoshiteru Tada, Yasuhisa Kanematsu
Abstract
OBJECTIVE: The risk-to-benefit profile of treating an unruptured high-grade dural arteriovenous fistula (dAVF) is not clearly defined. The aim of this multicenter retrospective cohort study was to compare the outcomes of different interventions with observation for unruptured high-grade dAVFs. METHODS: The authors retrospectively reviewed dAVF patients from 12 institutions participating in the Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR). Patients with unruptured high-grade (Borden type II or III) dAVFs were included and categorized into four groups (observation, embolization, surgery, and stereotactic radiosurgery [SRS]) based on the initial management. The primary outcome was defined as the modified Rankin Scale (mRS) score at final follow-up. Secondary outcomes were good outcome (mRS scores 0-2) at final follow-up, symptomatic improvement, all-cause mortality, and dAVF obliteration. The outcomes of each intervention group were compared against those of the observation group as a reference, with adjustment for differences in baseline characteristics. RESULTS: The study included 415 dAVF patients, accounting for 29, 324, 43, and 19 in the observation, embolization, surgery, and SRS groups, respectively. The mean radiological and clinical follow-up durations were 21 and 25 months, respectively. Functional outcomes were similar for embolization, surgery, and SRS compared with observation. With observation as a reference, obliteration rates were higher after embolization (adjusted OR [aOR] 7.147, p = 0.010) and surgery (aOR 33.803, p < 0.001) and all-cause mortality was lower after embolization (imputed, aOR 0.171, p = 0.040). Hemorrhage rates per 1000 patient-years were 101 for observation versus 9, 22, and 0 for embolization (p = 0.022), surgery (p = 0.245), and SRS (p = 0.077), respectively. Nonhemorrhagic neurological deficit rates were similar between each intervention group versus observation. CONCLUSIONS: Embolization and surgery for unruptured high-grade dAVFs afforded a greater likelihood of obliteration than did observation. Embolization also reduced the risk of death and dAVF-associated hemorrhage compared with conservative management over a modest follow-up period. These findings support embolization as the first-line treatment of choice for appropriately selected unruptured Borden type II and III dAVFs.