Background Anterior cranial fossa dural arteriovenous fistulas (ACF-dAVFs) are aggressive vascular lesions. The pattern of venous drainage is the most important determinant of symptoms. Due to the absence of a venous sinus in the anterior cranial fossa, most ACF-dAVFs have some degree of drainage through small cortical veins. We describe the natural history, angiographic presentation and outcomes of the largest cohort of ACF-dAVFs.
Methods The CONDOR consortium includes data from 12 international centers. Patients included in the study were diagnosed with an arteriovenous fistula between 1990–2017. ACF-dAVFs were selected from a cohort of 1077 arteriovenous fistulas. The presentation, angioarchitecture and treatment outcomes of ACF-dAVF were extracted and analyzed.
Results 60 ACF-dAVFs were included in the analysis. Most ACF-dAVFs were symptomatic (38/60, 63%). The most common symptomatic presentation was intracranial hemorrhage (22/38, 57%). Most ACF-dAVFs drained through cortical veins (85%, 51/60), which in most instances drained into the superior sagittal sinus (63%, 32/51). The presence of cortical venous drainage predicted symptomatic presentation (OR 9.4, CI 1.98 to 69.1, p=0.01). Microsurgery was the most effective modality of treatment. 56% (19/34) of symptomatic patients who were treated had complete resolution of symptoms. Improvement of symptoms was not observed in untreated symptomatic ACF-dAVFs.
Conclusion Most ACF-dAVFs have a symptomatic presentation. Drainage through cortical veins is a key angiographic feature of ACF-dAVFs that accounts for their malignant course. Microsurgery is the most effective treatment. Due to the high risk of bleeding, closure of ACF-dAVFs is indicated regardless of presentation.
Data availability statement
Data are available upon reasonable request.
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Contributors Study conception and design: EAS. Acquisition of data: all authors. Analysis and interpretation of data: EAS, SS, and LW. Critically revising the article: all authors. EAS is the guarantor of the study.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests LJK is a co-founder of Spi Surgical and reports compensation for consultant services from Microvention. IJA reports stock options in Remedy Robotics and compensation from Remedy Robotics and InNeuroCo for consultant services. MRL reports equity interest in Propio, Cerebrotech and Synchron, and grants from Stryker, Volcano Philips and Medtronic. MRL is part of the editorial board of JNIS. APK reports compensation from Penumbra and Microvention for consultant services. WB reports compensation for consultant services from Johnson & Johnson, Stryker, Medtronic Vascular and Microvention; compensation from MIVI Neurovascular for data and safety monitoring services; stock holdings from Marblehead Medical LLC. AJP reports compensation from DePuy Synthes Spine for consultant services. BG reports compensation from Microvention and Medtronic for consultant services. AA reports compensation from Johnson & Johnson and Cerenovous for consultant services. RMS reports consulting and teaching agreements with Penumbra, Abbott, Medtronic, InNeuroCo and Cerenovous. RD reports compensation from Grand Rounds for consultant services and compensation from NIH for other services. CD reports stock options from Euphrates Vascular; compensation from noNO and Penumbra, Inc for data and safety monitoring services. EAS is a proctor with Microvention and reports compensation from Medtronic and Rapid Medical for consultant services.
Provenance and peer review Not commissioned; externally peer reviewed.
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