Efficacy and safety of radiosurgery in patients with intracranial dural arteriovenous fistulae

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