@article{44c095650c6e40a4abfd89c6a1759e0b,
title = "Intervention for unruptured high-grade intracranial dural arteriovenous fistulas: a multicenter study",
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.",
keywords = "dural arteriovenous fistula, embolization, endovascular, high grade, intracranial, radiosurgery, surgery, unruptured, vascular disorders",
author = "{the Consortium for Dural Arteriovenous Fistula Outcomes Research} and Chen, {Ching Jen} and Buell, {Thomas J.} and Dale Ding and Ridhima Guniganti and Kansagra, {Akash P.} and Giuseppe Lanzino and Enrico Giordan and Kim, {Louis J.} and Levitt, {Michael R.} and Abecassis, {Isaac Josh} and Diederik Bulters and Andrew Durnford and Fox, {W. Christopher} and Polifka, {Adam J.} and Gross, {Bradley A.} and Minako Hayakawa and Derdeyn, {Colin P.} and Samaniego, {Edgar A.} and Sepideh Amin-Hanjani and Ali Alaraj and Amanda Kwasnicki and {van Dijk}, {J. Marc} and Potgieser, {Adriaan R.E.} and Starke, {Robert M.} and Samir Sur and Junichiro Satomi and Yoshiteru Tada and Abla, {Adib A.} and Winkler, {Ethan A.} and Rose Du and Lai, {Pui Man Rosalind} and Zipfel, {Gregory J.} and Sheehan, {Jason P.} and Piccirillo, {Jay F.} and Hari Raman and Kim Lipsey and Waleed Brinjikji and Roanna Vine and Cloft, {Harry J.} and Kallmes, {David F.} and Pollock, {Bruce E.} and Link, {Michael J.} and Patibandla, {Mohana Rao} and Gabriella Paisan and Meyer, {R. Michael} and Cory Kelly and Jonathan Duffill and Adam Ditchfield and John Millar and Jason Macdonald and Dimitri Laurent and Brian Hoh and Jessica Smith and Ashley Lockerman and Lunsford, {L. Dade} and Jankowitz, {Brian T.} and Gutierrez, {Santiago Ortega} and David Hasan and Roa, {Jorge A.} and James Rossen and Waldo Guerrero and Allen McGruder and Charbel, {Fady T.} and Aletich, {Victor A.} and Finnell, {Linda Rose} and Peterson, {Eric C.} and Yavagal, {Dileep R.} and Chen, {Stephanie H.} and Yasuhisa Kanematsu and Nobuaki Yamamoto and Tomoya Kinouchi and Masaaki Korai and Izumi Yamaguchi and Yuki Yamamoto and Phelps, {Ryan R.L.} and Michael Lawton and Martin Rutkowski and Aziz-Sultan, {M. Ali} and Nirav Patel and Frerichs, {Kai U.}",
note = "Funding Information: Dr. Kansagra reports consultant fees from Medtronic and Penumbra and non–study-related clinical or research effort from MicroVention and Medtronic. Dr. Lanzino is a consultant for Superior Medical Editing and Nested Knowledge. Dr. Kim reports funding support from the NINDS, consultant fees from MicroVention, and stock ownership in SPI Surgical. Dr. Levitt reports funding support from the NINDS, AHA, Stryker, and Medtronic, and consultant fees from Medtronic, Minnetronix, and Metis Innovative; and ownership in Synchron, Cerebrotech, and Proprio. Dr. Polifka is a consultant for DePuy Synthes. Dr. Gross reports consultant fees from MicroVention and Medtronic. Dr. Derdeyn reports ownership in Pulse Therapeutics; is a consultant for Penumbra, Rapid Medical, and NoNo; and received clinical or research support for this study from Siemens Healthineers. Dr. Alaraj reports funding support from the NIH, and consultant fees from Cerenovus and Siemens. Dr. Starke reports funding support from NREF, Joe Niekro Foundation, Brain Aneurysm Foundation, Bee Foundation, and the NIH, and consultant fees from Penumbra, Abbott, Medtronic, and Cerenovus. Publisher Copyright: {\textcopyright} AANS 2022",
year = "2022",
month = apr,
doi = "10.3171/2021.1.JNS202799",
language = "English",
volume = "136",
pages = "962--970",
journal = "Journal of Neurosurgery",
issn = "0022-3085",
number = "4",
}