Results of combined stereotactic radiosurgery and transarterial embolization for dural arteriovenous fistulas of the transverse and sigmoid sinuses

Object. Most dural arteriovenous fistulas (DAVFs) of the transverse and sig moid sinuses do not have angiographically demonstrated features associated with intracranial hemorrhage and, therefore, may be treated nonsurgically. The authors report their experience using a staged combination of radiosurg ery and transarterial embolization for treating DAVFs involving the transve rse and sigmoid sinuses. Methods. Between 1991 and 1998, 25 patients with DAVFs of the transverse an d/or sigmoid sinuses were treated using stereotactic radiosurgery; 22 of th ese patients also underwent transarterial embolization. Two patients were l ost to follow-up review. Clinical data, angiographic findings, and follow-u p records for the remaining 23 patients were collected prospectively. The m ean duration of clinical follow up after radiosurgery was 50 months (range 20-99 months). The 18 women and five men included in this series had a mean age of 57 year s (range 33-79 years). Twenty-two (96%) of 23 patients presented with pulsa tile tinnitus as the primary symptom; two patients had experienced an earli er intracerebral hemorrhage (ICH). Cognard classifications of the DAVFs inc luded the following: I in 12 patients (52%), IIa in seven patients (30%), a nd LII in four patients (17%). After treatment, symptoms resolved (20 patie nts) or improved significantly (two patients) in 96% of patients. One patie nt was clinically unchanged. No patient sustained an ICH or irradiation-rel ated complication during the follow-up period. Seventeen patients underwent follow-up angiographic studies at a mean of 21 months after radiosurgery ( range 11-38 months). Total or near-total obliteration (> 90%) was seen in 1 1 patients (65%), and more than a 50% reduction in six patients (35%). Two patients experienced recurrent tinnitus and underwent repeated radiosurgery and embolization at 21 and 38 months, respectively, after the first proced ure. Conclusions. A staged combination of radiosurgery and transarterial emboliz ation provides excellent symptom relief and a good angiographically verifie d cure rate for patients harboring low-risk DAVFs of the transverse and sig moid sinuses. This combined approach is a safe and effective treatment stra tegy for patients without angiographically determined risk factors for hemo rrhage and for elderly patients with significant comorbidities.