1. Multispecialty Treatment of Dural Arteriovenous Fistulas: Embolization, Craniotomy and Radiosurgery David Barnett, MD Chief of Neurosurgery Baylor University Medical Center August 13, 2013 7am

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3. © 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Goals What is a Dural Arteriovenous Fistula (DAVF)? How do they present? What constitutes a potentially dangerous DAVF? The roles of the different treatment options. 3

4. © 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Definition of DAVF An arteriovenous shunt in which the nidus is solely contained within the leaflets of the dura mater. Also referred to as Dural Arteriovenous Malformation (DAVM). 4

5. © 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Background 10-15% of all intercranial AVM More common in women Mean age at presentation is fifties Rare in children 5

6. © 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Pathogensis Not completely understood Most popular theory is collateral revascularication (i.e. sinus thrombosis followed by recanalization of the dura) Precipitating factors include…trauma, hypercoagulable states, and infection 6

7. © 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Presentation Highly variable Location, location, location Pulsatile tinnitus, Bruit, Headache Opthalmoplegia, Chemosis, Proptosis Papilledema Focal or Global Neurologic Deficit Intracranial hemorrhage 7

8. © 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Radiographic Evaluation CT/CT Angiogram, MR/MR Angiogram Initial investigation Abnormal blood vessels, white matter edema, hemorrhage Cannot exclude DAVF Intracranial Angiography The Gold Standard Accurate classification 8

9. © 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Hallmark Angiographic Feature Premature appearance of venous structures Within or next to the dura during the arterial phase 9

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11. © 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Arterial Supply Arterial branches that supply the dura Middle menigeal artery Anterior Fossa: Ethmodial branches of the opthalmic artery Cavernous Sinus: Dural branches from ICA and accessory menigeal branch of the maxillary artery Posterior Fossa: Dural branches of vertebral, occipital, and ascending Pharyngeal Arteries 11

12. © 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Location of DAVF AWAD and Little: J Neurosurgery 1990; 72: 839-850 Review of Literature with 377 DAVF cases 12 Aggressive / Benign Transverse/ Sigmoid Sinus62.6%1:8.8 Cavernous Sinus11.9%1:6.5 Tentorial Incisura8.4%31:1 Convexity Sagittal Sinus7.4%1:1 Anterior Cranial Fossa3.7%2.1:1 Sylvian – Middle Fossa3.7%2.5:1

13. © 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Classification Anatomic Location Associated Dural Sinus Hemodynamics Venous Drainage Pattern Aggressive / Benign 13

14. © 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Angiographic Classifaction Borden 3 types based on cortical venous reflux and sinus drainage Cognard 5 types based on cortical venous reflux, sinus drainage and direction of flow with involved sinus Barrow Used for Cavernous sinus fistulas 14

15. © 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Borden Classification (Journal of Neurosurgery 1995; 82:166-179) Type 1:Anterograde sinus flow and no cortical venous reflux Type 2:Retrograde sinus flow and cortical venous reflux Type 3:No flow inside the sinus and exclusive cortical venous reflux 15

16. © 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Cognard Classification (Radiology 194(3): 671-680, 1995 Type 1: Drainage into venous sinus only; anterograde flow Type 2A:Draining into dural sinus with retrograde flow Type 2B:Anterograde drainage into sural sinus and CVR Type 2A & B:Retrograde drainage into dural sinus and CVR Type 3:CVR only without venous ectasia Type 4:CVR only with venous ectasia Type 5:Drainage into spinal perimedullary veins 16

17. © 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Natural History (Interventional Neuroradiology 1997; 3:295-302) Aggressive presentation Intracranial Hemorrhage, Focal Neurologic Deficit or Death Borden Type 12% Borden Type 239% Borden Type 379% Borden Type 2 & 319.2% / patient-year ICH 17

18. © 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Bottom Line Presence of retrograde cortical venous drainage is significant prognostic factor for aggressive or unfavorable natural history 18

19. © 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Treatment Options Observation Medical Management Endovascular Transarterial Transvenous Liquid Embolic, Coils, Stents 19

20. © 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Treatment Options Continued Surgery Exposure Ligation, Resection or Disconnection of DAVF Stereotactic Radiosurgery Gamma Knife Cyber Knife Novalis Combination Endovascular, Surgery, Radiosurgery 20

21. © 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Management Goals Identify which DAVFs are potentially aggressive Determine when to treat and which treatment method to use Partial vs. Complete obliteration 21

22. © 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Cases 22

23. © 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Case 1 Type 1 DAVF Sigmoid Sinus DAVF 52 year old male presents with pulsatile tinnitus and occipital bruit Past medical history significant for Nephrotic Syndrome, Antithrombin III deficiency and dural sinus thrombosis 23

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26. © 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Case 2 High Flow Indirect Carotid Cavernous Fistula with Exclusive Cortical Venous Drainage 71 year old presents with progressively worsening diplopia, left eye chemosis and blurred vision Had seen several ophthalmologists Increased intraocular pressure 26

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29. © 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Case 2 - Outcome High Flow Indirect Carotid Cavernous Fistula with Exclusive Cortical Venous Drainage Full Recovery 29

30. © 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Case 3 High Flow DAVF at the Sinus Torcula 21 year old female presents with severe medically recalcitrant headaches and progressive blindness Previously diagnosed and treated for pseudotumor cerebri Bilateral optic nerve fenestrations 30

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33. © 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Case 3 - Treatment High Flow DAVF at the Sinus Torcula Staged 3 preop embolizations Bilateral Occipital and Suboccipital Craniotomies and intraoperative angiograms Gamma Knife Radiosurgery 33

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36. © 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Case 3 - Outcome High Flow DAVF at the Sinus Torcula Overall excellent Developed radiation necrosis 3 years later and lost some vision Completed college and now 5 years later, is engaged and in the working world 36

37. © 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Case 4 Left Transverse Sinus DAVF with CVR 60 year old male presenting to outside hospital with severe headache and visual loss MRI: Left Occipital hemorrhage and abnormal flow voids 37

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40. © 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Case 4 – Treatment & Outcome Left Transverse Sinus DAVF with CVR Transvenous embolization Full Recovery 40

41. © 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Case 5 High Flow Direct CCF 27 year old female presents with headache, right eye proptosis and ecchymosis and right temporal bruit Patients medical history significant for motor vehicle collision and craniotomy at outside hospital one month before 41

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46. © 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Case 6 High Flow DAVF with CVR 37 year old female presents with right sided weakness and expressive aphasia for one day duration Patient’s medical history: Diabetes 46

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48. © 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas 48