Ching-Jen Chen1, Thomas J Buell1, Dale Ding2, Ridhima Guniganti3, Akash P Kansagra3,4,5, Giuseppe Lanzino6, Enrico Giordan6, Louis J Kim7, Michael R Levitt7, Isaac Josh Abecassis7, Diederik Bulters8, Andrew Durnford8, W Christopher Fox9, Adam J Polifka9, Bradley A Gross10, Minako Hayakawa11, Colin P Derdeyn11, Edgar A Samaniego11, Sepideh Amin-Hanjani12, Ali Alaraj12, Amanda Kwasnicki12, J Marc C van Dijk13, Adriaan R E Potgieser13, Robert M Starke14,15, Samir Sur14, Junichiro Satomi16, Yoshiteru Tada16, Adib A Abla17, Ethan A Winkler17, Rose Du18, Pui Man Rosalind Lai18, Gregory J Zipfel3, Jason P Sheehan1. 1. 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia. 2. 18Department of Neurosurgery, University of Louisville, Kentucky. 3. 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri. 4. 15Mallinckrodt Institute of Radiology and. 5. 16Department of Neurology, Washington University School of Medicine, St. Louis, Missouri. 6. 3Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota. 7. 4Department of Neurosurgery, University of Washington, Seattle, Washington. 8. 5Department of Neurosurgery, University of Southampton, United Kingdom. 9. 6Department of Neurosurgery, University of Florida, Gainesville, Florida. 10. 7Department of Neurological Surgery, University of Pittsburgh, Pennsylvania. 11. 8Department of Radiology, University of Iowa, Iowa City, Iowa. 12. 9Department of Neurosurgery, University of Illinois at Chicago, Illinois. 13. 10Department of Neurosurgery, University of Groningen, University Medical Center Groningen, The Netherlands. 14. 11Department of Neurosurgery, University of Miami, Florida. 15. 17Department of Radiology, University of Miami, Florida; and. 16. 12Department of Neurosurgery, Tokushima University, Tokushima, Japan. 17. 13Department of Neurosurgery, University of California, San Francisco, California. 18. 14Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts.
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.
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.
Authors: Mohammed A Azab; Emma R Dioso; Matthew C Findlay; Jayson Nelson; Cameron A Rawanduzy; Philip Johansen; Brandon Lucke-Wold Journal: J Rare Dis Orphan Drugs Date: 2022-06-07