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A Proposed Grading Scale for Predicting Outcomes After Stereotactic Radiosurgery for Dural Arteriovenous Fistulas.

  • Mohammed, Nasser1
  • Hung, Yi-Chieh1
  • Chen, Ching-Jen1
  • Xu, Zhiyuan1
  • Schlesinger, David1
  • Kano, Hideyuki2
  • Chiang, Veronica3
  • Hess, Judith3
  • Lee, John4
  • Mathieu, David5
  • Kaufmann, Anthony M6
  • Grills, Inga S7
  • Cifarelli, Christopher P8
  • Vargo, John A8
  • Chytka, Tomas9
  • Janouskova, Ladislava9
  • Feliciano, Caleb E10
  • Mercado, Rafael Rodriguez10
  • Lunsford, L Dade4
  • Sheehan, Jason P1
  • 1 Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia.
  • 2 Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.
  • 3 School of Medicine, Yale University, New Haven, Connecticut.
  • 4 Department of Neurological Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
  • 5 Department of Neurological Surgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke, Canada. , (Canada)
  • 6 Department of Neurological Surgery, University of Manitoba, Winnipeg, Canada. , (Canada)
  • 7 Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan.
  • 8 Department of Neurological Surgery, West Virginia University, Morgantown, West Virginia.
  • 9 Department of Neurological Surgery, Na Homolce Hospital, Prague, Czech Republic. , (Czechia)
  • 10 Department of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico. , (Puerto Rico)
Published Article
Publication Date
Aug 01, 2020
DOI: 10.1093/neuros/nyz401
PMID: 31584074


There are presently no grading scales that specifically address the outcomes of cranial dural arteriovenous fistula (dAVF) after stereotactic radiosurgery (SRS). To design a practical grading system that would predict outcomes after SRS for cranial dAVFs. From the International Radiosurgery Research Foundation (University of Pittsburgh [41 patients], University of Pennsylvania [6 patients], University of Sherbrooke [2 patients], University of Manitoba [1 patient], West Virginia University [2 patients], University of Puerto Rico [1 patient], Beaumont Health System 1 [patient], Na Homolce Hospital [13 patients], the University of Virginia [48 patients], and Yale University [6 patients]) centers, 120 patients with dAVF treated with SRS were included in the study. The factors predicting favorable outcome (obliteration without post-SRS hemorrhage) after SRS were assessed using logistic regression analysis. These factors were pooled with the factors that were found to be predictive of obliteration from 7 studies with 736 patients after a systematic review of literature. These were entered into stepwise multiple regression and the best-fit model was identified. Based on the predictive model, 3 factors emerged to develop an SRS scoring system: cortical venous reflux (CVR), prior intracerebral hemorrhage (ICH), and noncavernous sinus location. Class I (score of 0-1 points) predicted the best favorable outcome of 80%. Class II patients (2 points score) had an intermediate favorable outcome of 57%, and class III (score 3 points) had the least favorable outcome at 37%. The ROC analysis showed better predictability to prevailing grading systems (AUC = 0.69; P = .04). Kaplan-Meier analysis showed statistically significant difference between the 3 subclasses of the proposed grading system for post-SRS dAVF obliteration (P = .001). The proposed dAVF grading system incorporates angiographic, anatomic, and clinical parameters and improves the prediction of the outcomes following SRS for dAVF as compared to the existing scoring systems. Copyright © 2019 by the Congress of Neurological Surgeons.

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