This document summarizes a presentation on the efficacy and safety of radiosurgery for patients with intracranial dural arteriovenous fistulae. The presentation analyzed 13 studies including over 800 patients, finding a complete obliteration rate of 64% at 3.5 years follow up, but with a morbidity rate of around 4.5% from hemorrhage, radiation necrosis or neurological deficit. The presentation concluded that while radiosurgery can treat these fistulae, it may not be very effective for fistulae with cortical venous drainage and is not suitable as a first-line treatment strategy due to the moderate success and morbidity rates.

1. EBS presentation 1
“ Efficacy and safety of radiosurgery in
patients with intracranial dural
arteriovenous fistulae”
Santhosh George Thomas
Evidence Based Surgery presentation
11/08/2014

2. EBS presentation 2
Background
• 41 year old doctor diagnosed to have a right
transverse sigmoid junction dural AV fistula
• Options of treatment explained
• Question of efficacy of SRS

3. EBS presentation 3
Searchable question (PICO format)
• P – Patients with intracranial dural av fistulae,
• I – Radiosurgery
• C -
• O –Safety and efficacy
Question:
What is the efficacy and safety of
radiosurgery in patients with intracranial dural
arteriovenous fistulae?

4. EBS presentation 4
Search strategy
• Ovid Medline
• Embase
• Scopus
• Cochrane Reviews

5. EBS presentation 5
Medline

6. EBS presentation 6
Embase

7. EBS presentation 7

8. EBS presentation 8
PRISMA flow diagram
Embase 65
Medline 43
After duplicates removed in end note, 165
articles
13 articles for review
- Not relevant after title and/ or abstract
screening
-Excluded case reports/reviews/letter to
the editor (4)
- Excluded 4 articles by the same group
from 2002-2013
Scopus 98
Cochrane 0

9. EBS presentation 9
Summary of papers
• Only 13 studies with reqd data (N=821)
with Cortical venous drainage (N=299,
~37% of the total)
• 4 were prospective and 9 retrospective
• 3 Linac systems and 10 GKS
• Mean and 95% CI calculated using the
modified Wald’s method

10. EBS presentation 10
Clinical
Presentation
Mean (%) 95% CI Lower
limit
95% CI Upper
limit
Tinnitus/Bruit 42.57% 35.96 49.47
Hemorrhage 26.24 % 20.64 32.72
Chemosis/heada
che
21.29 % 16.18 27.47
Neurological
Deficit
4.95% 2.6 8.98
Acute
Hydrocephalus
1.98% 0.59 5.16

11. EBS presentation 11
• Previous Craniotomy in 5.22% (95% CI 3.68-
7.64)
• Previous / Immediate post SRS embolisation
in 28.79% (95% CI 25.29 -32.56)
• Mean follow up 40.72 months
• Mean prescribed dose was 19.7 GY

12. EBS presentation 12
64.62%

13. EBS presentation 13
4.51% (Hemorrhage/ Radiation necrosis/ Neurological deficit)

14. EBS presentation 14
• Mortality was 0.24% (only 2 cases, 95% CI
0.01-0.94)
• ~37% of the group had CVD

15. EBS presentation 15
Conclusions
• Difficult condition to treat effectively
• Though a total of ~33% pts had received
some previous modality of treatment, the
three and half year complete obliteration rate
was only 64%
• This came with a morbidity of ~4.5%
• May not suitable as a first line treatment
strategy
• Not very effective in fistulae with CVD