Progress in neurological surgery
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Dural arteriovenous fistulas (DAVFs) are abnormal arteriovenous communications within the dura. The symptoms depend on their location and the pattern of the venous drainage. Patients with cavernous sinus DAVFs often present with ocular manifestations such as exophthalmos, chemosis and diplopia. ⋯ The prescribed mean margin dose was 17.2 Gy. In our series, 98% of patients had a stable or improved clinical condition after radiosurgery. Stereotactic radiosurgery using the Gamma Knife is a safe and effective alternative for the treatment of DAVFs.
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Treatment options for dural arteriovenous fistulas (DAVFs) have expanded with the application of stereotactic radiosurgery (SRS). Our objective was to provide guidelines about the use of SRS in symptomatic patients with imaging-identified DAVFs of the brain. The authors reviewed evidence-based medicine and clinical experience with radiosurgery for DAVFs of the brain and developed guidelines and provided a scientific foundation for patients and physicians. ⋯ The dose range for DAVFs is similar to that of arteriovenous malformations. A clinical algorithm for the potential role of SRS for a symptomatic brain DAVF was defined. These guidelines provide a framework for professional judgment and treatment selection alternatives for the management of DAVFs.
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Gamma Knife stereotactic radiosurgery was first applied for the treatment of an intracranial arteriovenous malformation (AVM) in 1968. Using biplane angiography to target a small-volume, deep-seated lesion, photons were cross-fired on the pathological shunt. The AVM was obliterated within 3 years. ⋯ Established roles have been found for pediatric cases and for larger-volume AVMs unsuitable for surgical removal. The role and technique of embolization prior to radiosurgery continue to be evaluated. Current dose response data based on volume and predictions of adverse radiation effects guide current care.
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Widespread availability of magnetic resonance imaging has helped our understanding of the natural history of cavernous malformations (CMs) of the brain. CMs present with diverse clinical manifestations. Supratentorial CMs are often identified incidentally. ⋯ History of prior hemorrhage was the most important risk factor for subsequent hemorrhage. The annual hemorrhage was 0.6% in patients who never had a symptomatic hemorrhage. Patients who had prior hemorrhage have a higher (4.5%) annual hemorrhage rate.
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Comparative Study
Stereotactic radiosurgery with or without embolization for intracranial dural arteriovenous fistulas.
Treatment options for symptomatic dural arteriovenous fistulas (DAVFs) include surgery, embolization and stereotactic radiosurgery (SRS). We reviewed our DAVF experience at the University of Pittsburgh and assessed the role of SRS. We evaluated 40 consecutive patients who underwent Gamma Knife SRS for 44 DAVFs. ⋯ In our experience cavernous/carotid fistulas were associated with higher rates of obliteration and symptomatic improvement compared to transverse/sigmoid sinus region fistulas. Our experience suggests that successful DAVF obliteration is possible in most patients with upfront SRS in conjunction with embolization. SRS alone is an effective treatment for selected patients with a small-volume, low-risk DAVF.