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AJNR Am J Neuroradiol. 2014 Sep;35(9):1793-7. doi: 10.3174/ajnr.A3938. Epub 2014 Apr 17.

Transarterial onyx embolization of cranial dural arteriovenous fistulas: long-term follow-up.

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  • 1From the Neuroradiology and Neurovascular Surgery Services, Departments of Diagnostic Imaging and Surgery (R.V.C.), Monash University, Melbourne, Victoria, Australia.
  • 2Neuroendovascular Service (T.M.L.-M., B.P.M., A.J.Y., J.D.R., J.A.H.) Department of Neurology (T.M.L.-M., B.P.M.).
  • 3Neuroendovascular Service (T.M.L.-M., B.P.M., A.J.Y., J.D.R., J.A.H.) Department of Radiology (A.J.Y., J.D.R., J.A.H.), Division of Diagnostic Neuroradiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
  • 4Department of Interventional Neuroradiology (J.C.P.), Boston University, Boston, Massachusetts.
  • 5Neuroendovascular and Neurocritical Care Services and Neurology, Neurosurgery, and Radiology (R.G.N.), Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia.



Endovascular therapy with liquid embolic agents is a common treatment strategy for cranial dural arteriovenous fistulas. This study evaluated the long-term effectiveness of transarterial Onyx as the single embolic agent for curative embolization of noncavernous cranial dural arteriovenous fistulas.


We performed a retrospective review of 40 consecutive patients with 41 cranial dural arteriovenous fistulas treated between March 2006 and June 2012 by using transarterial Onyx embolization with intent to cure. The mean age was 57 years; one-third presented with intracranial hemorrhage. Most (85%) had cortical venous drainage. Once angiographic cure was achieved, long-term treatment effectiveness was assessed with DSA and clinical follow-up.


Forty-nine embolization sessions were performed; 85% of cranial dural arteriovenous fistulas were treated in a single session. The immediate angiographic cure rate was 95%. The permanent neurologic complication rate was 2% (mild facial palsy). Thirty-five of the 38 patients with initial cure underwent short-term follow-up DSA (median, 4 months). The short-term recurrence rate was only 6% (2/35). All patients with occlusion at short-term DSA undergoing long-term DSA (median, 28 months) had durable occlusion. No patient with long-term clinical follow-up (total, 117 patient-years; median, 45 months) experienced hemorrhage.


Transarterial embolization with Onyx as the single embolic agent results in durable long-term cure of noncavernous cranial dural arteriovenous fistulas. Recurrence rates are low on short-term follow-up, and all patients with angiographic occlusion on short-term DSA follow-up have experienced a durable long-term cure. Thus, angiographic cure should be defined at short-term follow-up angiography instead of at the end of the final embolization session. Finally, long-term DSA follow-up may not be necessary if occlusion is demonstrated on short-term angiographic follow-up.

© 2014 by American Journal of Neuroradiology.

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