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Feasibility, safety, and efficacy of endovascular treatment of anterior cranial fossa dural arteriovenous fistulas: a systematic review and meta-analysis with a subanalysis for Onyx

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Abstract

Dural Arteriovenous Fistulas (dAVFs) of the anterior cranial fossa (ACF) are uncommon but carry a high risk of hemorrhage and pose substantial treatment challenges. Recent advancements in endovascular treatment (EVT), including the introduction of novel liquid embolic agents, have markedly bolstered EVT’s role in managing ACF-dAVFs, with notable series published in the last five years. We aimed to assess the feasibility, safety, and efficacy of EVT for ACF-dAVFs. We searched Medline, Scopus, Web of Science, and Cochrane Library databases following PRISMA guidelines. Eligible studies included those with ≥ 5 patients undergoing embolization of ACF-dAVFs, detailing both angiographic and clinical outcomes. We used single proportion analysis with 95% confidence intervals under a random-effects model, I2 to assess heterogeneity, and Baujat and sensitivity analysis to address high heterogeneity. Publication bias was assessed by funnel-plot analysis and Egger’s test. Outcomes included complete occlusion following embolization, unsuccessful endovascular embolization attempts, incomplete occlusion following embolization, symptom resolution or clinical improvement following embolization, recurrence; procedure-related complications, morbidity, and mortality. Additionally, a subanalysis for studies exclusively utilizing Onyx™ embolic system was done. Eighteen studies comprising 231 ACF-dAVF were included. Unsuccessful endovascular embolization attempts rate was 2%. Complete occlusion rate was 85%, with 4% of complications. Incomplete occlusion rate was 10%. Successfully embolized patients experienced either symptom resolution or clinical improvement in 94% of cases. Morbidity and mortality rates were 1% and 0%, respectively. Onyx subanalyses showed an overall rate of 0% for unsuccessful attempts, 95% for complete occlusion, and 5% for incomplete occlusion. Symptom resolution or clinical improvement was 98% and recurrence rate was 0%. EVT for ACF-dAVF is highly feasible, effective, and safe, with a low rate of complications, morbidity, and mortality. The subanalyses focusing on Onyx embolizations revealed superior efficacy and safety outcomes compared to the findings of the primary analyses involving all included studies.

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References

  1. Abrahams JM, Bagley LJ, Flamm ES et al (2002) Alternative management considerations for ethmoidal dural arteriovenous fistulas. Surg Neurol 58(6):410–416. https://doi.org/10.1016/s0090-3019(02)00871-6

    Article  PubMed  Google Scholar 

  2. Gross BA, Du R (2012) The natural history of cerebral dural arteriovenous fistulae. Neurosurgery 71(3):594–603. https://doi.org/10.1227/NEU.0b013e31825eabdb

    Article  PubMed  Google Scholar 

  3. Agid R, Terbrugge K, Rodesch G et al (2009) Management strategies for anterior cranial fossa (ethmoidal) dural arteriovenous fistulas with an emphasis on endovascular treatment. J Neurosurg 110(1):79–84. https://doi.org/10.3171/2008.6.17601

    Article  PubMed  Google Scholar 

  4. Li C, Wu Z, Yang X, Li Y et al (2014) Transarterial treatment with Onyx of Cognard type IV anterior cranial fossa dural arteriovenous fistulas. J Neurointerv Surg 6(2):115–120. https://doi.org/10.1136/neurintsurg-2012-010641

    Article  PubMed  Google Scholar 

  5. Gross BA, Moon K, Kalani MY et al (2016) Clinical and anatomic insights from a series of Ethmoidal Dural Arteriovenous Fistulas at Barrow Neurological Institute. World Neurosurg 93:94–99. https://doi.org/10.1016/j.wneu.2016.05.052

    Article  PubMed  Google Scholar 

  6. Su X, Gao Z, Ma Y et al (2023) Transarterial embolization for anterior cranial fossa dural arteriovenous fistulas: a retrospective single-center study. J Neurointerv Surg published online July 12, 2023. https://doi.org/10.1136/jnis-2023-020408

  7. Li Q, Fang YB, Huang QH et al (2013) Transarterial embolization of dural arteriovenous fistulas of the anterior cranial fossa with Onyx. J Clin Neurosci 20(2):287–291. https://doi.org/10.1016/j.jocn.2012.03.031

    Article  PubMed  Google Scholar 

  8. Hayreh SS (2006) Orbital vascular anatomy. Eye (Lond) 20(10):1130–1144. https://doi.org/10.1038/sj.eye.6702377

    Article  CAS  PubMed  Google Scholar 

  9. Deng JP, Li J, Zhang T et al (2014) Embolization of dural arteriovenous fistula of the anterior cranial fossa through the middle meningeal artery with Onyx. Clin Neurol Neurosurg 117:1–5. https://doi.org/10.1016/j.clineuro.2013.11.013

    Article  PubMed  Google Scholar 

  10. Voldřich R, Charvát F, Netuka D (2023) Copolymer liquid embolization of dural arteriovenous fistulas: a 20-year single-center experience. J Neuroimaging 33(6):926–932. https://doi.org/10.1111/jon.13148

    Article  PubMed  Google Scholar 

  11. Kular S, Tse G, Pahwa B et al (2022) Micro-balloon-assisted embolization of anterior cranial fossa dural arteriovenous fistula via a trans-ophthalmic approach - a technical report and case series. Neuroradiology 64(6):1269–1274. https://doi.org/10.1007/s00234-022-02929-6

  12. Piergallini L, Tardieu M, Cagnazzo F et al (2021) Anterior cranial fossa dural arteriovenous fistula: transarterial embolization from the ophthalmic artery as first-line treatment. J Neuroradiol 48(3):207–214. https://doi.org/10.1016/j.neurad.2019.05.009

    Article  PubMed  Google Scholar 

  13. Xu K, Ji T, Li C, Yu J (2019) Current status of endovascular treatment for dural arteriovenous fistulae in the anterior cranial fossa: a systematic literature review. Int J Med Sci 16(2):203–211 Published 2019 Jan 1. https://doi.org/10.7150/ijms.29637

    Article  PubMed  PubMed Central  Google Scholar 

  14. Zhao B, Yin R, Lanzino G et al (2016) Endovascular coiling of wide-Neck and wide-Neck Bifurcation aneurysms: a systematic review and Meta-analysis. AJNR Am J Neuroradiol 37(9):1700–1705. https://doi.org/10.3174/ajnr.A4834

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Page MJ, McKenzie JE, Bossuyt PM et al (2021) The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 372:n71. Published 2021 Mar 29. https://doi.org/10.1136/bmj.n71

  16. Cannizzaro D, Peschillo S, Cenzato M et al (2018) Endovascular and surgical approaches of ethmoidal dural fistulas: a multicenter experience and a literature review. Neurosurg Rev 41(2):391–398. https://doi.org/10.1007/s10143-016-0764-1

    Article  CAS  PubMed  Google Scholar 

  17. Kulanthaivelu K, Pendharkar H, Prasad C et al (2021) Anterior cranial Fossa Dural Arteriovenous Fistulae - Angioarchitecture and intervention. Clin Neuroradiol 31(3):661–669. https://doi.org/10.1007/s00062-020-00932-z

    Article  PubMed  Google Scholar 

  18. Mayercik VA, Sussman ES, Pulli B et al (2021) Efficacy and safety of embolization of dural arteriovenous fistulas via the ophthalmic artery. Interv Neuroradiol 27(3):444–450. https://doi.org/10.1177/1591019920969270

    Article  PubMed  Google Scholar 

  19. Dabus G, Kan P, Diaz C et al (2021) Endovascular treatment of anterior cranial fossa dural arteriovenous fistula: a multicenter series. Neuroradiology 63(2):259–266. https://doi.org/10.1007/s00234-020-02536-3

    Article  PubMed  Google Scholar 

  20. Trivelato FP, Smajda S, Saleme S et al (2022) Endovascular treatment of anterior cranial base dural arteriovenous fistulas as a first-line approach: a multicenter study. J Neurosurg 137(6):1758–1765 Published 2022 Apr 8. https://doi.org/10.3171/2022.2.JNS212588

    Article  PubMed  Google Scholar 

  21. Sanchez S, Raghuram A, Wendt L et al (2023) Natural history, angiographic presentation and outcomes of anterior cranial fossa dural arteriovenous fistulas. J Neurointerv Surg 15(9):903–908. https://doi.org/10.1136/jnis-2022-019160

    Article  PubMed  Google Scholar 

  22. Zhang Y, Na S, Liu T et al (2023) Therapeutic effect analysis of embolization of dural arteriovenous fistula at anterior cranial fossa base using Onyx-18 via different approaches. Chin J Neurosurg 139(5):456–461. https://doi.org/10.3760/cma.j.cn112050-20220621-00315

    Article  Google Scholar 

  23. Puylaert CAJ, van den Berg R, Coert BA et al (2024) Transarterial embolization of Anterior Cranial Fossa Dural AVFs as a First-Line Approach: a single-center study. AJNR Am J Neuroradiol 45(2):171–175. https://doi.org/10.3174/ajnr.A8092

    Article  PubMed  Google Scholar 

  24. Abud TG, Nguyen A, Saint-Maurice JP et al (2011) The use of Onyx in different types of intracranial dural arteriovenous fistula. AJNR Am J Neuroradiol 32(11):2185–2191. https://doi.org/10.3174/ajnr.A2702

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  25. Sim SY (2022) Pathophysiology and classification of intracranial and spinal dural AVF. J Cerebrovasc Endovasc Neurosurg 24(3):203–209. https://doi.org/10.7461/jcen.2022.E2021.04.001

    Article  PubMed  PubMed Central  Google Scholar 

  26. Giannopoulos S, Texakalidis P, Mohammad Alkhataybeh RA et al (2019) Treatment of Ethmoidal Dural Arteriovenous fistulas: a Meta-analysis comparing endovascular versus Surgical Treatment. World Neurosurg 128:593–599e1. https://doi.org/10.1016/j.wneu.2019.04.227

    Article  PubMed  Google Scholar 

  27. Duffau H, Lopes M, Janosevic V et al (1999) Early rebleeding from intracranial dural arteriovenous fistulas: report of 20 cases and review of the literature. J Neurosurg 90(1):78–84. https://doi.org/10.3171/jns.1999.90.1.0078

    Article  CAS  PubMed  Google Scholar 

  28. Robert T, Blanc R, Smajda S et al (2016) Endovascular treatment of cribriform plate dural arteriovenous fistulas: technical difficulties and complications avoidance. J Neurointerv Surg 8(9):954–958. https://doi.org/10.1136/neurintsurg-2015-011956

    Article  PubMed  Google Scholar 

  29. Bhatia KD, Lee H, Kortman H et al (2022) Endovascular Management of Intracranial Dural Arteriovenous Fistulas: Transarterial Approach. AJNR Am J Neuroradiol 43(3):324–331. https://doi.org/10.3174/ajnr.A7296

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  30. Gross BA, Albuquerque FC, Moon K, McDougall CG (2017) Evolution of treatment and a detailed analysis of occlusion, recurrence, and clinical outcomes in an endovascular library of 260 dural arteriovenous fistulas. J Neurosurg 126(6):1884–1893. https://doi.org/10.3171/2016.5.JNS16331

    Article  PubMed  Google Scholar 

  31. Sadeh-Gonike U, Magand N, Armoiry X et al (2018) Transarterial Onyx Embolization of Intracranial Dural Fistulas: a prospective cohort, systematic review, and Meta-Analysis. Neurosurgery 82(6):854–863. https://doi.org/10.1093/neuros/nyx309

    Article  PubMed  Google Scholar 

  32. Sugiyama T, Nakayama N, Ushikoshi S et al (2021) Complication rate, cure rate, and long-term outcomes of microsurgery for intracranial dural arteriovenous fistulae: a multicenter series and systematic review. Neurosurg Rev 44(1):435–450. https://doi.org/10.1007/s10143-019-01232-y

    Article  PubMed  Google Scholar 

  33. Higgins JPT, Thomas J, Chandler J et al (2023) Cochrane Handbook for Systematic Reviews of Interventions version 6.4 (updated August 2023). Cochrane, 2023. Available via www.training.cochrane.org/handbook. Accessed 30 Jan 2024

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Authors and Affiliations

  1. Faculty of Medicine, Ninth July University, São Paulo, SP, Brazil

    Marcio Yuri Ferreira

  2. Department of Radiology, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey

    Ahmet Gunkan

  3. Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil

    Savio Batista & Raphael Camerotte

  4. Faculty of Medicine, Salvador University, Salvador, Bahia, Brazil

    Mauricio Porto

  5. State University of Ponta Grossa, Ponta Grossa, PR, Brazil

    Leonardo de Barros Oliveira

  6. Bahiana School of Medicine and Public Health, Salvador, BA, Brazil

    Silvio Porto Junior

  7. Sub-Saharan Africa Brain Health Initiative (SSABHI), Abuja, Nigeria

    Obiora Okoye

  8. Clinical Hospital of São Paulo State University, São Paulo, SP, Brazil

    Igor Oliveira da Fonseca

  9. Department of Neurosurgery, University of São Paulo, São Paulo, SP, Brazil

    Raphael Bertani

  10. Department of Endovascular Neurosurgery, Paulo Niemeyer State Brain Institute, Rio de Janeiro, RJ, Brazil

    Elias Antonio Tanus Machado

  11. Department of Neurosurgery, Lenox Hill Hospital, New York, NY, USA

    Christian Ferreira, David Langer & Yafell Serulle

  12. Department of Radiology, CHU de Saint Etienne, Saint Etienne, France

    Gabriele Ciccio

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Contributions

M.Y.F., A.G.: original idea, systematic search, data extraction, statistical analysis, and manuscript writing. M.P., R.C.: prepared tables, proofreading; L.B.O., S.P., I.O.F: prepared figures, writing initial draft, data extraction R.P., O.O: proofreading, manuscript structureS.B., E.A.T.M, C.F.: manuscript writing, editing.D.L., G.C., Y.S.: supervision, review, editing.All authors reviewed the manuscript.

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Correspondence to Ahmet Gunkan.

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Ferreira, M.Y., Gunkan, A., Batista, S. et al. Feasibility, safety, and efficacy of endovascular treatment of anterior cranial fossa dural arteriovenous fistulas: a systematic review and meta-analysis with a subanalysis for Onyx. Neurosurg Rev 47, 217 (2024). https://doi.org/10.1007/s10143-024-02446-5

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