Anyone who has ever faced a run-of-the mill tangle—in headphone wires, knitting yarn or a child’s hair—knows that a tangle can mean a headache. But for neurosurgeons and some of their patients, an unusual type of tangle presents some very particular headaches.
A new paper by Dr. Philip Meyers and others* (full list below) aims to help.
The condition in question is known as a dural arteriovenous shunt. It is an abnormal tangle of small blood vessels in the lining of the brain. One symptom of a dural arteriovenous shunt can be a headache.
But beyond that, getting one of these tangles diagnosed correctly can also be a headache. The condition is rare and does not always show up on Computed Tomography (CT) or Magnetic Resonance (MR) scans. Instead, it is usually diagnosed with an angiogram, a specialized test in which a dye injected into the bloodstream can reveal the architecture of blood vessels in the brain.
And once the condition is diagnosed, the next steps are not always clear. Brain procedures always carry some amount of risk, and our Columbia neurosurgeons do not take that risk lightly. So if a dural arteriovenous shunt can exist without causing a problem—as many of them do—it does not necessarily need surgical treatment. Instead, it can be periodically watched for any changes.
But surgical treatment is required for arteriovenous shunts prone to hemorrhaging (leaking blood) or causing other problems with blood flow in the brain. These risks tend to be related to vessel anatomy and blood flow where blood leaves the tangle. Neurosurgeons treating this condition face two big questions: How to determine the cases that are best treated surgically? And which treatment is best for each case?
Dr. Meyers is an expert in dural arteriovenous shunts and other disorders of blood vessels in the brain and spinal cord. Last November, he joined 30 other top neurosurgeons, neuroradiologists, radiologists and neurologists in formulating the best possible answers to those questions.
The resulting paper, published in the Journal of NeuroInterventional Surgery, will help neurosurgeons everywhere evaluate and treat individuals affected by dural arteriovenous shunts. A final list of six easy-to-use recommendations summarizes the group’s findings on the best ways to diagnose, classify and treat the condition.
For example, the group lays out different recommendations for cases in which the shunt actively causes symptoms or is simply found in passing, and presents considerations for shunts with high-risk or low-risk features to their blood flow.
The recommendations discuss the relative strengths of treatment options such as open surgery, endovascular treatment (treatment delivered with thin, flexible catheters that can travel through blood vessels) and stereotactic radiosurgery (a procedure that delivers precise beams of radiation from different angles to the vascular tangle).
Just as important, the authors note the type and quality of the evidence upon which each of their recommendations is based. Dural arteriovenous shunts are complex and relatively rare lesions, and researchers are continually evaluating new information about them.
In that context, it is important for neurosurgeons to always be aware of the current state of the knowledge behind each recommendation as they create treatment plans for individual patients.
Dr. Meyers and the other authors hope their work erases some headaches for neurosurgeons and patients alike.
*Full list of authors:
Standard and Guidelines: Intracranial Dural Arteriovenous Shunts. Lee SK, Hetts SW, Halbach V, terBrugge K, Ansari SA, Albani B, Abruzzo T, Arthur A, Alexander MJ, Albuquerque FC, Baxter B, Bulsara KR, Chen M, Delgado Almandoz JE, Fraser JF, Frei D, Gandhi CD, Heck D, Hussain MS, Kelly M, Klucznik R, Leslie-Mazwi T, McTaggart RA, Meyers PM, Patsalides A, Prestigiacomo C, Pride GL, Starke R, Sunenshine P, Rasmussen P, Jayaraman MV; on behalf of the Standard and Guidelines Committee for the Society of Neurointerventional Surgery.
Photo Credit: © [pixelrobot]/Adobe Stock
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