Dural Arteriovenous Malformations

Advances in endovascular therapy have established this modality as the primary treatment option for a majority of dural arteriovenous malformations (DAVMs). Transvenous embolization is the preferred route (Fig. 3). For those lesions that are not amenable to endovascular therapy, surgical interruption of the venous drainage provides immediate elimination of the lesion.

The treatment of DAVMs with radiosurgery is highly controversial. Link et al. (41) have recently reported on the use of stereotactic radiosurgery for the treatment of DAVMs as the primary treatment modality. The protocol involved radiosurgery followed by transarterial embolization 48 h after the radiation. The authors reported good results in their short-term follow-up (1 yr) of the 105 patients with various DAVMs. Although knowledge of the natural history of DAVMs is incomplete, it is well known that those lesions associated with lep-tomeningeal venous drainage have a very aggressive clinical course compared to those draining into a dural sinus (42,43). The former are associated with rates of intracranial hemorrhage, nonhemorrhagic neurological deficit, and mortality of 14.2, 10.9, and 19.3% per lesion per year, respectively (43). In these cases, the use of stereotactic radiosurgery, with its long interval to therapeutic benefit, exposes the patient to unnecessary risks, especially when the fistulae can be immediately obliterated by endovascular or surgical interruption of the venous drainage. In addition, partial treatment of these lesions may turn them into more aggressive ones by altering the venous drainage pattern. Although radio-surgery is a less invasive treatment modality, its efficacy in the treatment of DAVMs has not been established.

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