{
  "abstract": "Background Given the low haemorrhagic risk of intracranial low-grade dural arteriovenous fistulas (dAVFs), the benefits of routine intervention remain controversial. This study compares patient outcomes treated with stereotactic radiosurgery (SRS) versus conservative management.Method Multicentre retrospective analysis of the Consortium for Dural Arteriovenous Fistula Outcomes Research and the International Radiosurgery Research Foundation data. Inclusion criteria were (1) intracranial low-grade dAVF diagnosed by catheter-based angiography, (2) no prior dAVF-related haemorrhage and (3) management with upfront SRS (intervention group) or conservative management (observation group). The primary outcome was symptomatic improvement. Secondary outcomes included dAVF obliteration, up-conversion, haemorrhage, improvement and favourable modified Rankin Scale (mRS) at follow-up.Results 304 patients with a mean age of 56 years (SD 13.5) and a follow-up of 46.7 months (SD 45.5) were included. 135 (44.4%) were managed conservatively and 169 (55.6%) had upfront SRS. Compared with the observation group, symptomatic and mRS Score improvement (≥1-point decrease in baseline score) was more likely in the intervention group (95.1% vs 58.5%; OR=13.75 (5.61–33.69) and 37.0% vs 24.0%; OR=1.85 (1.09–3.15), respectively). These findings remained significant after multiple imputation and propensity score matching. Remaining outcomes were similar between groups. The all-cause mortality rate was 5.4% (n=16), unrelated to the dAVF or treatment. Five (3.0%) SRS-related complications were reported and resolved during the follow-up period.Conclusions SRS was associated with increased symptomatic and mRS Score improvement for low-grade dAVFs compared with conservative management. SRS had a low complication risk and did not appear to alter dAVF obliteration or haemorrhage. Future prospective trials on SRS as a first-line intervention for symptomatic low-grade dAVFs should be considered.",
  "authors": [
    {
      "affiliations": [
        "Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA"
      ],
      "name": "Andrea Becerril-Gaitan"
    },
    {
      "affiliations": [
        "Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA"
      ],
      "name": "Pedram Peesh"
    },
    {
      "affiliations": [
        "Neurosurgery, University at Buffalo, Buffalo, New York, USA"
      ],
      "name": "Collin Liu"
    },
    {
      "affiliations": [
        "Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Japan",
        "School of Medicine, National Yang-Ming University, Hsinchu, Taiwan Province, Taiwan"
      ],
      "name": "Cheng-Chia Lee"
    },
    {
      "affiliations": [
        "Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan"
      ],
      "name": "Huai-Che Yang"
    },
    {
      "affiliations": [
        "Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA"
      ],
      "name": "Ajay Niranjan"
    },
    {
      "affiliations": [
        "Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA",
        "Radiation Oncology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA"
      ],
      "name": "Lawrence Dade Lunsford"
    },
    {
      "affiliations": [
        "Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA"
      ],
      "name": "Zhishuo Wei"
    },
    {
      "affiliations": [
        "Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA"
      ],
      "name": "Andrew Hoang"
    },
    {
      "affiliations": [
        "Neurosurgery, University of Virginia, Charlottesville, Virginia, USA"
      ],
      "name": "Jason Sheehan"
    },
    {
      "affiliations": [
        "Neurosurgery, University of Virginia, Charlottesville, Virginia, USA"
      ],
      "name": "Samantha Dayawansa"
    },
    {
      "affiliations": [
        "Department of Neurosurgery, Koç University Graduate School of Health Sciences, Istanbul, İstanbul, Turkey"
      ],
      "name": "Selçuk Peker"
    },
    {
      "affiliations": [
        "Department of Neurosurgery, Koç University Graduate School of Health Sciences, Istanbul, İstanbul, Turkey"
      ],
      "name": "Yavuz Samanci"
    },
    {
      "affiliations": [
        "Neurosurgery, University of Miami Health System, Miami, Florida, USA"
      ],
      "name": "Robert M Starke"
    },
    {
      "affiliations": [
        "Neurosurgery, University of Miami Health System, Miami, Florida, USA"
      ],
      "name": "Ahmed Abdelsalam"
    },
    {
      "affiliations": [
        "Neurosurgery, NYU Langone Medical Center, New York, New York, USA"
      ],
      "name": "Douglas Kondziolka"
    },
    {
      "affiliations": [
        "Radiation Oncology, NYU Langone Medical Center, New York, New York, USA"
      ],
      "name": "Kenneth Bernstein"
    },
    {
      "affiliations": [
        "Neurosurgery, NYU Langone Medical Center, New York, New York, USA"
      ],
      "name": "Ying Ming"
    },
    {
      "affiliations": [
        "Neurosurgery, Dokkyo Medical University, Shimotsuga District, Japan"
      ],
      "name": "Go Ikeda"
    },
    {
      "affiliations": [
        "Neurosurgery, Dokkyo Medical University, Shimotsuga District, Japan"
      ],
      "name": "Hideyuki Kano"
    },
    {
      "affiliations": [
        "Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, Delhi, India"
      ],
      "name": "Manjul Tripathi"
    },
    {
      "affiliations": [
        "Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic"
      ],
      "name": "Roman Liscak"
    },
    {
      "affiliations": [
        "Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic"
      ],
      "name": "Jaromir May"
    },
    {
      "affiliations": [
        "Biostatistics and Data Science, The University of Texas Health Science Center at Houston, Houston, Texas, USA"
      ],
      "name": "Qian Wang"
    },
    {
      "affiliations": [
        "Internal Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, USA"
      ],
      "name": "Wen Li"
    },
    {
      "affiliations": [
        "Neurosurgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA"
      ],
      "name": "Babu Welch"
    },
    {
      "affiliations": [
        "Neurosurgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA"
      ],
      "name": "Jennifer O’Con"
    },
    {
      "affiliations": [
        "University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA",
        "Case Western Reserve University School of Medicine, Cleveland, Ohio, USA"
      ],
      "name": "Sepideh Amin-Hanjani"
    },
    {
      "affiliations": [
        "University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA"
      ],
      "name": "Quang Nguyen"
    },
    {
      "affiliations": [
        "Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA"
      ],
      "name": "Guiseppe Lanzino"
    },
    {
      "affiliations": [
        "Radiology, Mayo Clinic, Rochester, Minnesota, USA"
      ],
      "name": "Waleed Brinjikji"
    },
    {
      "affiliations": [
        "Department of Neurology, University of Iowa Health Care, Iowa City, Iowa, USA"
      ],
      "name": "Minako Hayakawa"
    },
    {
      "affiliations": [
        "Neurology and Neurointerventional Radiology, University of Iowa Health Care, Iowa City, Iowa, USA"
      ],
      "name": "Edgar Samaniego"
    },
    {
      "affiliations": [
        "Neurosurgery, Brigham and Women’s Hospital, Boston, Massachusetts, USA"
      ],
      "name": "Rose Du"
    },
    {
      "affiliations": [
        "Neurosurgery, Brigham and Women’s Hospital, Boston, Massachusetts, USA"
      ],
      "name": "Rosalind Lai"
    },
    {
      "affiliations": [
        "Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, Virginia, USA"
      ],
      "name": "Colin Derdeyn"
    },
    {
      "affiliations": [
        "Neurosurgery, University of Miami Health System, Miami, Florida, USA"
      ],
      "name": "Adib Abla"
    },
    {
      "affiliations": [
        "Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA"
      ],
      "name": "Bradley Gross"
    },
    {
      "affiliations": [
        "Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA"
      ],
      "name": "Felipe Albuquerque"
    },
    {
      "affiliations": [
        "Barrow Neurological Institute, Phoenix, Arizona, USA"
      ],
      "name": "Michael Lawton"
    },
    {
      "affiliations": [
        "Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA"
      ],
      "name": "Louis Kim"
    },
    {
      "affiliations": [
        "Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA"
      ],
      "name": "Michael Levitt"
    },
    {
      "affiliations": [
        "Neurosurgery, University of Illinois Chicago, Chicago, Illinois, USA"
      ],
      "name": "Ali Alaraj"
    },
    {
      "affiliations": [
        "Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA"
      ],
      "name": "Ethan Winkler"
    },
    {
      "affiliations": [
        "Neurosurgery, University of Florida, Gainesville, Florida, USA"
      ],
      "name": "Nohra Chalouhi"
    },
    {
      "affiliations": [
        "University of Florida, Gainesville, Florida, USA"
      ],
      "name": "Brian Hoh"
    },
    {
      "affiliations": [
        "Neurosurgery, University Hospital Southampton NHS Foundation Trust, Wessex Neurological Centre, Southampton, England, UK"
      ],
      "name": "Diederik Bulters"
    },
    {
      "affiliations": [
        "Neurosurgery, University Hospital Southampton NHS Foundation Trust, Wessex Neurological Centre, Southampton, England, UK"
      ],
      "name": "Andrew Durnford"
    },
    {
      "affiliations": [
        "Neurosurgery, Tokushima University, Tokushima, Tokushima Prefecture, Japan"
      ],
      "name": "Junichiro Satomi"
    },
    {
      "affiliations": [
        "Neurosurgery, Tokushima University, Tokushima, Tokushima Prefecture, Japan"
      ],
      "name": "Yoshiteru Tada"
    },
    {
      "affiliations": [
        "Neurosurgery, University of Groningen, Groningen, GR, Netherlands"
      ],
      "name": "J Marc C van Dijk"
    },
    {
      "affiliations": [
        "Department of Neurology, University Medical Centre Groningen, Groningen, The Netherlands",
        "Neuroimaging Center, University Medical Centre Groningen, Groningen, The Netherlands"
      ],
      "name": "Adriaan R E Potgieser"
    },
    {
      "affiliations": [
        "Neurosurgery, Norton Healthcare, Louisville, Kentucky, USA"
      ],
      "name": "Dimitri Laurent"
    },
    {
      "affiliations": [
        "Neurosurgery, Washington University School of Medicine in Saint Louis, Saint Louis, Missouri, USA"
      ],
      "name": "Josh Osbun"
    },
    {
      "affiliations": [
        "Washington University School of Medicine in Saint Louis, St. Louis, Missouri, USA"
      ],
      "name": "Brigette Bahmani"
    },
    {
      "affiliations": [
        "Neurosurgery, Washington University School of Medicine in Saint Louis, Saint Louis, Missouri, USA"
      ],
      "name": "Gregory Zipfel"
    },
    {
      "affiliations": [
        "Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA"
      ],
      "name": "Ching-Jen Chen"
    }
  ],
  "title": "Stereotactic radiosurgery versus observation for intracranial low-grade dural arteriovenous fistulas",
  "uid": "f5eac302-f3b4-507f-aa78-84b15a1a400a"
}