Perspectives Commentary on: Surgical Disconnection of the Cortical Venous Reflux for High-Grade Intracranial Dural Arteriovenous Fistulas by Al-Mahfoudh et al. World Neurosurg 83:652-656, 2015
Treatment of Dural Arteriovenous Fistulas with Cortical Venous Reflux—Endovascular Therapy and Surgery Preferred Modality of Treatment Ajith J. Thomas and Christopher S. Ogilvy
I
n their article, the authors report their experience with the contemporaneous management of cranial dural arteriovenous fistulas (DAVFs) with cortical venous reflux (CVR). Carotid cavernous fistulas are excluded. In an era when endovascular techniques have evolved as the primary modality to treat DAVFs, this article rightly points out that when embolization cannot be performed safely, surgical disconnection rather than stereotactic radiosurgery is the treatment of choice.
DAVFs with CVR have a high incidence of hemorrhage and attendant morbidity, and disconnection of the draining vein through endovascular means or open surgery is efficacious in treating this disorder (3). The authors are to be commended on their excellent results as demonstrated by lack of recurrence of CVR or rehemorrhage. However, the article would have been more comprehensive if they had described the specific situations in which a surgical approach would be better. Was an endovascular attempt to disconnect the draining vein undertaken in all or some patients? Was there a specific subset of patients who failed endovascular therapy? In our institution, patients with ethmoidal or anterior cranial DAVFs are primarily treated by surgery. These fistulas are sup-
Key words Disconnection - Dural AVF - Embolization - Radiosurgery - Surgery -
Abbreviations and Acronyms CVR: Cortical venous reflux DAVF: Dural arteriovenous fistula
WORLD NEUROSURGERY 83 [6]: 1053-1054, JUNE 2015
plied by an anterior or posterior ethmoidal artery, which is a branch of the ophthalmic artery. Although some groups have attempted to perform catheterization and embolization of the ophthalmic arteries (1), this approach presents a risk of vision loss. We always attempt to treat other DAVFs through an endovascular transarterial route before attempting surgery. Embolization is considered incomplete as long as the fistula can be demonstrated even faintly. Incomplete embolization can be problematic because new vessels are recruited, which could result in alternative paths of venous drainage. The authors also emphasized this concept by performing reoperations in two patients who had continued evidence of fistulous communication after surgery. The addition of indocyanine green videofluorescence angiography has reduced the incidence of reoperation. Stereotactic radiosurgery should be reserved for situations in which embolization and surgery have failed or are not possible for two reasons. First, the latency of treatment effect of 2e4 years exposes patients to risk of hemorrhage or rehemorrhage when CVR is present. Second, the efficacy of radiosurgery for DAVFs with CVR in a meta-analysis was only 56%e60% (2).
Neurosurgery Service, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA To whom correspondence should be addressed: Christopher S. Ogilvy, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2015) 83, 6:1053-1054. http://dx.doi.org/10.1016/j.wneu.2015.01.024
www.WORLDNEUROSURGERY.org
1053
PERSPECTIVES
REFERENCES 1. Agid R, Terbrugge K, Rodesch G, Andersson T, Söderman M: Management strategies for anterior cranial fossa (ethmoidal) dural arteriovenous fistulas with an emphasis on endovascular treatment. J Neurosurg 110:79-84, 2009. 2. Chen CJ, Lee CC, Ding D, Starke RM, Chivukula S, Yen CP, Moosa S, Xu Z, Pan DH, Sheehan JP:
1054
www.SCIENCEDIRECT.com
Stereotactic radiosurgery for intracranial dural arteriovenous fistulas: a systematic review. J Neurosurg 122:353-362, 2015.
Citation: World Neurosurg. (2015) 83, 6:1053-1054. http://dx.doi.org/10.1016/j.wneu.2015.01.024 Journal homepage: www.WORLDNEUROSURGERY.org
3. Van Dijk JMC, TerBrugge KG, Willinsky RA, Wallace MC: Selective disconnection of cortical venous reflux as treatment for cranial dural arteriovenous fistulas. J Neurosurg 101:31-35, 2004.
Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2015 Elsevier Inc. All rights reserved.
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2015.01.024
Treatment of Dural Arteriovenous Fistulas with Cortical Venous Reflux—Endovascular Therapy and Surgery Preferred Modality of Treatment Ajith J. Thomas and Christopher S. Ogilvy
I
n their article, the authors report their experience with the contemporaneous management of cranial dural arteriovenous fistulas (DAVFs) with cortical venous reflux (CVR). Carotid cavernous fistulas are excluded. In an era when endovascular techniques have evolved as the primary modality to treat DAVFs, this article rightly points out that when embolization cannot be performed safely, surgical disconnection rather than stereotactic radiosurgery is the treatment of choice.
DAVFs with CVR have a high incidence of hemorrhage and attendant morbidity, and disconnection of the draining vein through endovascular means or open surgery is efficacious in treating this disorder (3). The authors are to be commended on their excellent results as demonstrated by lack of recurrence of CVR or rehemorrhage. However, the article would have been more comprehensive if they had described the specific situations in which a surgical approach would be better. Was an endovascular attempt to disconnect the draining vein undertaken in all or some patients? Was there a specific subset of patients who failed endovascular therapy? In our institution, patients with ethmoidal or anterior cranial DAVFs are primarily treated by surgery. These fistulas are sup-
Key words Disconnection - Dural AVF - Embolization - Radiosurgery - Surgery -
Abbreviations and Acronyms CVR: Cortical venous reflux DAVF: Dural arteriovenous fistula
WORLD NEUROSURGERY 83 [6]: 1053-1054, JUNE 2015
plied by an anterior or posterior ethmoidal artery, which is a branch of the ophthalmic artery. Although some groups have attempted to perform catheterization and embolization of the ophthalmic arteries (1), this approach presents a risk of vision loss. We always attempt to treat other DAVFs through an endovascular transarterial route before attempting surgery. Embolization is considered incomplete as long as the fistula can be demonstrated even faintly. Incomplete embolization can be problematic because new vessels are recruited, which could result in alternative paths of venous drainage. The authors also emphasized this concept by performing reoperations in two patients who had continued evidence of fistulous communication after surgery. The addition of indocyanine green videofluorescence angiography has reduced the incidence of reoperation. Stereotactic radiosurgery should be reserved for situations in which embolization and surgery have failed or are not possible for two reasons. First, the latency of treatment effect of 2e4 years exposes patients to risk of hemorrhage or rehemorrhage when CVR is present. Second, the efficacy of radiosurgery for DAVFs with CVR in a meta-analysis was only 56%e60% (2).
Neurosurgery Service, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA To whom correspondence should be addressed: Christopher S. Ogilvy, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2015) 83, 6:1053-1054. http://dx.doi.org/10.1016/j.wneu.2015.01.024
www.WORLDNEUROSURGERY.org
1053
PERSPECTIVES
REFERENCES 1. Agid R, Terbrugge K, Rodesch G, Andersson T, Söderman M: Management strategies for anterior cranial fossa (ethmoidal) dural arteriovenous fistulas with an emphasis on endovascular treatment. J Neurosurg 110:79-84, 2009. 2. Chen CJ, Lee CC, Ding D, Starke RM, Chivukula S, Yen CP, Moosa S, Xu Z, Pan DH, Sheehan JP:
1054
www.SCIENCEDIRECT.com
Stereotactic radiosurgery for intracranial dural arteriovenous fistulas: a systematic review. J Neurosurg 122:353-362, 2015.
Citation: World Neurosurg. (2015) 83, 6:1053-1054. http://dx.doi.org/10.1016/j.wneu.2015.01.024 Journal homepage: www.WORLDNEUROSURGERY.org
3. Van Dijk JMC, TerBrugge KG, Willinsky RA, Wallace MC: Selective disconnection of cortical venous reflux as treatment for cranial dural arteriovenous fistulas. J Neurosurg 101:31-35, 2004.
Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2015 Elsevier Inc. All rights reserved.
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2015.01.024
