Endovascular and Surgical Treatment of Tentorial Dural Arteriovenous Fistulas: A Meta-Analysis

Introduction: Tentorial dural arteriovenous fistulas (TDAVF) are characterized by a high hemorrhagic risk. The traditional therapeutic option was surgical resection however endovascular therapy and combined surgical/endovascular therapy have emerged as primary therapeutic options. In this study, we evaluated trends in outcomes and management of TDAVF and performed a meta-analysis evaluating clinical and angiographic outcomes by treatment modality.

Methods: We performed a comprehensive literature search for studies on surgical and endovascular treatment of TDAVF. We compared the proportion of patients undergoing endovascular, surgical, and combined endovascular/surgical management across three time periods: 1980 to 1995, 1996 to 2005, and 2006 to 2014. We also compared the proportion of patients presenting with ruptured TDAVF across these time periods and the proportion of treated patients with a good neurological outcome. We performed a random effects meta-analysis evaluating rates of occlusion, long-term neurological morbidity, perioperative morbidity, and resolution of symptoms for the three treatment modalities.

Results: A total of 29 studies with 283 patients were included. The proportion of patients treated with surgical treatment alone decreased from 38.7 to 20.4% between 1980 and 1995 and 2006 and 2014. The proportion of patients treated with endovascular therapy along increased from 16.1 to 48.0%. The proportion of patients presenting with ruptured TDAVF decreased from 64.4 to 43.6%. The rate of good neurological outcome increased from 80.7 to 92.9%. Complete occlusion rates were highest for patients receiving multimodality treatment (84.0%, 95%CI = 72.0–91.0) and lowest for endovascular treatment (71.0%, 95%CI = 56.0–83.0). Long-term neurological morbidity was highest in the surgical group (8.0%, 95%CI = 2.0–21.0) and lowest for the endovascular group (5.0%, 95%CI = 2.0–11.0).

Conclusion: Over the past 35 years, TDAVF patients are increasingly presenting with unruptured lesions, receiving endovascular treatment and experiencing higher rates of good neurological outcomes. Endovascular treatment was associated with the best long-term neurological outcomes but lower occlusion rates. Combined endovascular and surgical treatment was associated with high occlusion rates and low morbidity.