Background Dural arteriovenous fistulas (AVF) of the foramen magnum region (FMR) are technically challenging lesions to treat. Transvenous (TV), transarterial (TA), and surgical approaches have been described, but the optimum treatment strategy is not defined.
Objective To report treatment strategies and outcomes for FMR-AVF at a single, high-volume referral center.
Methods A retrospective review from January 2010 to August 2020 identified patients with FMR-AVF at a single referral center. Angiographic features, treatment (observation, endovascular, surgical), and follow-up of angiographic and clinical results were recorded. The technical aspects of TV embolization are then presented in detail.
Results 29 FMR-AVF were identified in 28 patients. Of these, 24/29 (82.8%) were treated and 5/29 (17.2%) were observed. Treatment was endovascular in 21/24 (87.5%), combined (endovascular+surgical) in 2/24 (8.3%), and surgical in 1/24 (4.2%). Endovascular treatments were 76.2% TV, 14.3% TA, and 9.5% combined TV/TA. Sufficient follow-up data were available for 20/28 (71.4%) with mean follow-up of 16.8 months. No AVF recurrence was seen for TA/TV, combined endovascular/surgical, or surgical groups, and there was one recurrence (7.1%) in the TV group. Symptomatic improvement was seen in all groups: TV (71.4% complete, 28.6% partial), TA (66.7% complete, 33.3% no follow-up), TV+TA (100% partial), endovascular/surgical (100% complete), and surgical (100% partial). Minor non-neurologic complications included 1/14 (7.1%) in the TV group and 1/3 (33.3%) in the TA/TV group.
Conclusion Endovascular treatment is safe and effective for most FMR-AVF. TV embolization has a high cure rate with few complications.
- liquid embolic material
- posterior fossa
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Contributors MTC and MRA: conception and design of the work; initial drafting of the work. KHN, AB, SWH, DLC, CFD, RTH, VVH: substantial contributions to the conception or design of the work; or the acquisition and interpretation of data for the work; revising the work critically for important intellectual content. All authors: Final approval of the version submitted. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Funding This work was supported in part by National Heart Lung, and Blood Institute of the National Institutes of Health under award No. R56HL149124-01.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.