Intervention for unruptured high-grade intracranial dural arteriovenous fistulas: a multicenter study.
(Journal Article;Multicenter Study)
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.
Chen, C-J; Buell, TJ; Ding, D; Guniganti, R; Kansagra, AP; Lanzino, G; Giordan, E; Kim, LJ; Levitt, MR; Abecassis, IJ; Bulters, D; Durnford, A; Fox, WC; Polifka, AJ; Gross, BA; Hayakawa, M; Derdeyn, CP; Samaniego, EA; Amin-Hanjani, S; Alaraj, A; Kwasnicki, A; van Dijk, JMC; Potgieser, ARE; Starke, RM; Sur, S; Satomi, J; Tada, Y; Abla, AA; Winkler, EA; Du, R; Lai, PMR; Zipfel, GJ; Sheehan, JP; Consortium for Dural Arteriovenous Fistula Outcomes Research, ; CONDOR Collaborators,
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