BACKGROUND: The quoted risk of hemorrhage from dural arteriovenous fistulae with cortical venous reflux varies widely, and the influence of angiographic grade on clinical course has not previously been reported.
OBJECTIVE: To assess the risk of hemorrhage and the influence of angiographic grade on this, compared to known predictors of hemorrhage such as presentation.
METHODS: 75 fistulae with cortical venous reflux identified in our AVM clinic between 1992 and 2007 were followed up clinically, and their angiograms reviewed.
RESULTS: There were 8 hemorrhages in 90 years of follow up. The annual incidence of hemorrhage before any treatment was 13%, and 4.7% after partial treatment, giving an overall incidence of 8.9% before definitive treatment. Borden and Cognard grades were poor discriminators of risk for lesions with the exception of Cognard type IV lesions. These lesions, characterized by venous ectasia, had a seven-fold increase in the incidence of hemorrhage (3.5% no ectasia versus 27% with ectasia). Patients presenting with hemorrhage (20%) or non-hemorrhagic neurological deficit (22%) had a higher incidence of hemorrhage than those with a benign presentation (4.3%), but this may be directly linked to the presence of venous ectasia.
CONCLUSION: In this series untreated DAVF with CVR had a 13% annual incidence of hemorrhage after diagnosis. There was a significant difference between those with and without venous ectasia. This should be confirmed by further studies but probably defines a high-risk sub-group of patients that requires rapid intervention.
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