EBS presentation 1

“ Efficacy and safety of radiosurgery in patients with intracranial dural arteriovenous fistulae”

Santhosh George Thomas

Evidence Based Surgery presentation

11/08/2014

EBS presentation 2

Background

• 41 year old doctor diagnosed to have a right transverse sigmoid junction dural AV fistula

• Options of treatment explained • Question of efficacy of SRS

EBS presentation 3

Searchable question (PICO format)

• P – Patients with intracranial dural av fistulae,• I – Radiosurgery• C - • O –Safety and efficacy

Question:

What is the efficacy and safety of radiosurgery in patients with intracranial dural arteriovenous fistulae?

EBS presentation 4

Search strategy

• Ovid Medline• Embase• Scopus• Cochrane Reviews

EBS presentation 5

Medline

EBS presentation 6

Embase

EBS presentation 7

EBS presentation 8

PRISMA flow diagramEmbase 65Medline 43

After duplicates removed in end note, 165 articles

13 articles for review

- Not relevant after title and/ or abstract screening-Excluded case reports/reviews/letter to the editor (4)- Excluded 4 articles by the same group from 2002-2013

Scopus 98Cochrane 0

EBS presentation 9

Summary of papers

• Only 13 studies with reqd data (N=821)

with Cortical venous drainage (N=299, ~37% of the total)

• 4 were prospective and 9 retrospective• 3 Linac systems and 10 GKS

• Mean and 95% CI calculated using the modified Wald’s method

EBS presentation 10

ClinicalPresentation

Mean (%) 95% CI Lower limit

95% CI Upper limit

Tinnitus/Bruit 42.57% 35.96 49.47

Hemorrhage 26.24 % 20.64 32.72

Chemosis/headache

21.29 % 16.18 27.47

Neurological Deficit

4.95% 2.6 8.98

Acute Hydrocephalus

1.98% 0.59 5.16

EBS presentation 11

• Previous Craniotomy in 5.22% (95% CI 3.68-7.64)

• Previous / Immediate post SRS embolisation in 28.79% (95% CI 25.29 -32.56)

• Mean follow up 40.72 months

• Mean prescribed dose was 19.7 GY

EBS presentation 12

64.62%

EBS presentation 13

4.51% (Hemorrhage/ Radiation necrosis/ Neurological deficit)

EBS presentation 14

• Mortality was 0.24% (only 2 cases, 95% CI 0.01-0.94)

• ~37% of the group had CVD

EBS presentation 15

Conclusions

• Difficult condition to treat effectively• Though a total of ~33% pts had received

some previous modality of treatment, the three and half year complete obliteration rate was only 64%

• This came with a morbidity of ~4.5%• May not suitable as a first line treatment

strategy• Not very effective in fistulae with CVD