Journal of the Neurological Sciences 341 (2014) 175
Contents lists available at ScienceDirect
Journal of the Neurological Sciences journal homepage: www.elsevier.com/locate/jns
Response to Letter to the Editor Treatment options for symptomatic dural arteriovenous fistulas
or AVMs may require multimodality approach combining surgery, stereotactic radiosurgery, and endovascular embolization.
We thank Dr. Dale Ding for his thoughtful comments regarding our article entitled ‘Dural arteriovenous fistula presenting with exophthalmos and seizures’, in which we described a unique case of a Cognard type IIa dural arteriovenous fistula (DAVF) in the temporal lobe that manifested clinically with complex partial seizures and ipsilateral ocular symptoms [1]. Dr. Ding adds his experience in managing a 42-year-old man with a large, complex arteriovenous (AVM) who was treated with a volume staged gamma knife radiosurgery [2]. In their patient, the location and grade of the AVM caused Drs. Ding and Liu to choose gamma knife radiosurgery instead of an endovascular embolization or a surgical therapy. Endovascular embolization is an expedient means of DAVF therapy that has become the preferred option; however, it can be limited by inadequate access to the fistula point, non-target embolization, and the potential for recanalization [3]. When anatomic features prevent endovascular access, or embolization fails to obliterate the lesion, definitive cure can be achieved by surgical interruption of leptomeningeal venous drainage. Following surgical obliteration of DAVF feeding vessels, our patient had dramatic improvement in presenting symptoms without any significant surgical complication [1]. Indeed, several reports have demonstrated that surgical obliteration of a high grade cerebral DAVF is associated with a high angiographic cure rate with acceptable morbidity and mortality [3,4]. Given their success in a cohort of 24 patients, Gross and Du recommend surgical treatment as a first line therapy for high grade cerebral DAVFs, in the absence of a medical contraindication [3]. However, as Dr. Ding points out, high-grade complex AVMs and DAVFs may not be amenable to surgical obliteration or endovascular embolization due to the high risk of rupture and surgical morbidity and mortality. For these cases, stereotactic radiosurgery has been previously attempted, albeit with a lower success rate [5]. Taken together, surgical therapy and stereotactic radiosurgery can be reasonable options for the management of symptomatic DAVFs and AVMs when endovascular embolization is not feasible. Furthermore, the decision regarding which treatment modality to employ should be based on the size, grade, and location of the cerebrovascular malformation as well as the risk of the procedure under consideration. Lastly, as Dr. Ding alludes to complete obliteration of complex and large DAVFs
Conflict of interest
http://dx.doi.org/10.1016/j.jns.2014.03.055 0022-510X/Published by Elsevier B.V.
None of the authors have any conflicts of interest to state. Disclosures None. References [1] Feyissa AM, Ponce LL, Patterson JT, Von Ritschl RH, Smith RG. Dural arteriovenous fistula presenting with exophthalmos and seizures. J Neurol Sci 2014;38:229–31. [2] Ding D, Liu KC. Orbital venous congestion: rare manifestation of an intracranial arteriovenous malformation. J Clin Neurosci 2014;21:522–4. [3] Gross BA, Du R. Surgical treatment of high grade dural arteriovenous fistulae. J Clin Neurosci 2013;20:1527–32. [4] Kakarla UK, Deshmukh VR, Zabramski JM, Albuquerque FC, McDougall CG, Spetzler RF. Surgical treatment of high-risk intracranial dural arteriovenous fistulae: clinical outcomes and avoidance of complications. Neurosurgery 2007;61:447–57. [5] Cifarelli CP, Kaptain G, Yen CP, Schlesinger D, Sheehan JP. Gamma knife radiosurgery for dural arteriovenous fistulas. Neurosurgery 2010;67:1230–5.
Anteneh M. Feyissa⁎ Department of Neurology, University of Texas Medical Branch at Galveston, 301 University Blvd, JSA 9.128, Galveston, TX 77555, United States ⁎Corresponding author. Tel.: +1 409 772 8053; fax: +1 409 772 6940. E-mail addresses: [email protected], [email protected]. Joel T. Patterson Division of Neurosurgery, Division of Neurosurgery, University of Texas Medical Branch at Galveston, Galveston, TX 77555, United States Robert G. Smith Department of Neurology, University of Texas Medical Branch at Galveston, 301 University Blvd, JSA 9.128, Galveston, TX 77555, United States
25 March 2014
Contents lists available at ScienceDirect
Journal of the Neurological Sciences journal homepage: www.elsevier.com/locate/jns
Response to Letter to the Editor Treatment options for symptomatic dural arteriovenous fistulas
or AVMs may require multimodality approach combining surgery, stereotactic radiosurgery, and endovascular embolization.
We thank Dr. Dale Ding for his thoughtful comments regarding our article entitled ‘Dural arteriovenous fistula presenting with exophthalmos and seizures’, in which we described a unique case of a Cognard type IIa dural arteriovenous fistula (DAVF) in the temporal lobe that manifested clinically with complex partial seizures and ipsilateral ocular symptoms [1]. Dr. Ding adds his experience in managing a 42-year-old man with a large, complex arteriovenous (AVM) who was treated with a volume staged gamma knife radiosurgery [2]. In their patient, the location and grade of the AVM caused Drs. Ding and Liu to choose gamma knife radiosurgery instead of an endovascular embolization or a surgical therapy. Endovascular embolization is an expedient means of DAVF therapy that has become the preferred option; however, it can be limited by inadequate access to the fistula point, non-target embolization, and the potential for recanalization [3]. When anatomic features prevent endovascular access, or embolization fails to obliterate the lesion, definitive cure can be achieved by surgical interruption of leptomeningeal venous drainage. Following surgical obliteration of DAVF feeding vessels, our patient had dramatic improvement in presenting symptoms without any significant surgical complication [1]. Indeed, several reports have demonstrated that surgical obliteration of a high grade cerebral DAVF is associated with a high angiographic cure rate with acceptable morbidity and mortality [3,4]. Given their success in a cohort of 24 patients, Gross and Du recommend surgical treatment as a first line therapy for high grade cerebral DAVFs, in the absence of a medical contraindication [3]. However, as Dr. Ding points out, high-grade complex AVMs and DAVFs may not be amenable to surgical obliteration or endovascular embolization due to the high risk of rupture and surgical morbidity and mortality. For these cases, stereotactic radiosurgery has been previously attempted, albeit with a lower success rate [5]. Taken together, surgical therapy and stereotactic radiosurgery can be reasonable options for the management of symptomatic DAVFs and AVMs when endovascular embolization is not feasible. Furthermore, the decision regarding which treatment modality to employ should be based on the size, grade, and location of the cerebrovascular malformation as well as the risk of the procedure under consideration. Lastly, as Dr. Ding alludes to complete obliteration of complex and large DAVFs
Conflict of interest
http://dx.doi.org/10.1016/j.jns.2014.03.055 0022-510X/Published by Elsevier B.V.
None of the authors have any conflicts of interest to state. Disclosures None. References [1] Feyissa AM, Ponce LL, Patterson JT, Von Ritschl RH, Smith RG. Dural arteriovenous fistula presenting with exophthalmos and seizures. J Neurol Sci 2014;38:229–31. [2] Ding D, Liu KC. Orbital venous congestion: rare manifestation of an intracranial arteriovenous malformation. J Clin Neurosci 2014;21:522–4. [3] Gross BA, Du R. Surgical treatment of high grade dural arteriovenous fistulae. J Clin Neurosci 2013;20:1527–32. [4] Kakarla UK, Deshmukh VR, Zabramski JM, Albuquerque FC, McDougall CG, Spetzler RF. Surgical treatment of high-risk intracranial dural arteriovenous fistulae: clinical outcomes and avoidance of complications. Neurosurgery 2007;61:447–57. [5] Cifarelli CP, Kaptain G, Yen CP, Schlesinger D, Sheehan JP. Gamma knife radiosurgery for dural arteriovenous fistulas. Neurosurgery 2010;67:1230–5.
Anteneh M. Feyissa⁎ Department of Neurology, University of Texas Medical Branch at Galveston, 301 University Blvd, JSA 9.128, Galveston, TX 77555, United States ⁎Corresponding author. Tel.: +1 409 772 8053; fax: +1 409 772 6940. E-mail addresses: [email protected], [email protected]. Joel T. Patterson Division of Neurosurgery, Division of Neurosurgery, University of Texas Medical Branch at Galveston, Galveston, TX 77555, United States Robert G. Smith Department of Neurology, University of Texas Medical Branch at Galveston, 301 University Blvd, JSA 9.128, Galveston, TX 77555, United States
25 March 2014
