Purpose To present our experience with the presentation, therapy and outcomes of patients with low- and high- grade non-cavernous dural arteriovenous fistulas (DAVF)

Methods/materials IRB approval was obtained for this retrospective analysis. All patients presenting with non-cavernous DAVF between 1/1/1996 and 5/5/2014 at a single institution were reviewed (N=60; 30 males, 30 females). Clinical and operative records, imaging, and post-operative course of patients were identified through a search of the electronic medical record system. The primary outcomes evaluated were technical success rate and complication rate for low-grade and high-grade DAVF. Categorical differences between low- and high-grade DAVF in the series were compared using the χ² test.

Results Mean age was 58 years. 27/60 patients (45%) presented with tinnitus, 22/60 patients (37%) presented with headache, and 12/60 patients (20%) presented with intracranial hemorrhage. Less common presentations included visual changes (n = 6) and altered mental status (n = 6). There were 34 (57%) high-grade and 26 (43%) low-grade DAVF. A significantly greater proportion of patients with low-grade DAVF presented with tinnitus (81% vs. 17%; p < 0.001). A significantly greater proportion of patients with high grade DAVF presented with intracranial hemorrhage (30% vs. 8%; p = 0.037) and headache (50% vs. 19%; p = 0.014). Endovascular therapy alone or in combination with surgery and/or stereotactic radiosurgery (SRS) was used in 29/34 high-grade DAVF. In high-grade DAVF treated only endovascularly, complete fistula obliteration or cure of cortical venous reflux (CVR) was achieved in 22/29 cases (76%). With the addition of surgery and/or SRS, this rate increased to 28/29 cases (97%). One patient was lost to follow up after incomplete staged therapy. Angiographic follow up of greater than 1 month was available in 18 high-grade DAVF. There was no evidence of angiographic recurrence at an average follow up of 11.6 months. 23/26 low-grade DAVF were treated endovascularly. 22/23 of these patients (96%) had cured or improved symptoms at short term follow up after their final procedure. One patient did not pursue further therapy after the first stage. Clinical follow up of greater than 1 month was available in 19 cases. 17/19 (89%) had no recurrence or progression of their symptoms at an average follow up of 30 months. One patient (5%) noted unchanged presenting symptoms and 1 patient (5%) had worsening of their symptoms. There were 4 significant complications in a total of 79 procedures (5% procedural complication rate). Significant complications included cranial nerve neuropathy, intracranial hemorrhage, delayed extremity weakness without correlative imaging finding, and occipital scalp necrosis (n = 1 of each).

Conclusions High-grade non-cavernous DAVF more commonly present with intracranial hemorrhage and headache, while low-risk DAVF more commonly present with tinnitus. Endovascular therapy has a high success rate in curing CVR and improving patient symptoms both at immediate and long-term follow-up with low rates of significant complications. The addition of surgery and/or stereotactic radiosurgery in persistent high-grade fistulas provides further therapeutic benefit.

Disclosures J. Griauzde: None. J. Gemmete: None. A. Pandey: None. N. Chaudhary: None.