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Review ArticleSYSTEMATIC REVIEW/META-ANALYSIS

Transvenous Embolization vs. Surgical Intervention for cerebrospinal fluid Venous Fistulas: A Systematic Review and Meta-analysis

Seyed Behnam Jazayeri, Mohammad Mirahmadi Eraghi, Julien Ognard, Sherief Ghozy, Ramanathan Kadirvel, Waleed Brinjikji and David F. Kallmes
American Journal of Neuroradiology May 2025, ajnr.A8839; DOI: https://doi.org/10.3174/ajnr.A8839
Seyed Behnam Jazayeri
From the Tehran University of Medical Sciences, Tehran, Iran (S.B.J), Student Research Committee, School of Medicine, Islamic Azad University, Qeshm International Branch, Qeshm, Iran (M.M.E), Department of Radiology (J.O., S.G., R.K., W.B. and D.F.K.), Mayo Clinic, Rochester, MN, United States, Department of Neurologic Surgery (S.G. and W.B.), Mayo Clinic, Rochester, MN, United States
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Mohammad Mirahmadi Eraghi
From the Tehran University of Medical Sciences, Tehran, Iran (S.B.J), Student Research Committee, School of Medicine, Islamic Azad University, Qeshm International Branch, Qeshm, Iran (M.M.E), Department of Radiology (J.O., S.G., R.K., W.B. and D.F.K.), Mayo Clinic, Rochester, MN, United States, Department of Neurologic Surgery (S.G. and W.B.), Mayo Clinic, Rochester, MN, United States
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Julien Ognard
From the Tehran University of Medical Sciences, Tehran, Iran (S.B.J), Student Research Committee, School of Medicine, Islamic Azad University, Qeshm International Branch, Qeshm, Iran (M.M.E), Department of Radiology (J.O., S.G., R.K., W.B. and D.F.K.), Mayo Clinic, Rochester, MN, United States, Department of Neurologic Surgery (S.G. and W.B.), Mayo Clinic, Rochester, MN, United States
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Sherief Ghozy
From the Tehran University of Medical Sciences, Tehran, Iran (S.B.J), Student Research Committee, School of Medicine, Islamic Azad University, Qeshm International Branch, Qeshm, Iran (M.M.E), Department of Radiology (J.O., S.G., R.K., W.B. and D.F.K.), Mayo Clinic, Rochester, MN, United States, Department of Neurologic Surgery (S.G. and W.B.), Mayo Clinic, Rochester, MN, United States
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Ramanathan Kadirvel
From the Tehran University of Medical Sciences, Tehran, Iran (S.B.J), Student Research Committee, School of Medicine, Islamic Azad University, Qeshm International Branch, Qeshm, Iran (M.M.E), Department of Radiology (J.O., S.G., R.K., W.B. and D.F.K.), Mayo Clinic, Rochester, MN, United States, Department of Neurologic Surgery (S.G. and W.B.), Mayo Clinic, Rochester, MN, United States
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Waleed Brinjikji
From the Tehran University of Medical Sciences, Tehran, Iran (S.B.J), Student Research Committee, School of Medicine, Islamic Azad University, Qeshm International Branch, Qeshm, Iran (M.M.E), Department of Radiology (J.O., S.G., R.K., W.B. and D.F.K.), Mayo Clinic, Rochester, MN, United States, Department of Neurologic Surgery (S.G. and W.B.), Mayo Clinic, Rochester, MN, United States
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David F. Kallmes
From the Tehran University of Medical Sciences, Tehran, Iran (S.B.J), Student Research Committee, School of Medicine, Islamic Azad University, Qeshm International Branch, Qeshm, Iran (M.M.E), Department of Radiology (J.O., S.G., R.K., W.B. and D.F.K.), Mayo Clinic, Rochester, MN, United States, Department of Neurologic Surgery (S.G. and W.B.), Mayo Clinic, Rochester, MN, United States
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ABSTRACT

BACKGROUND: The efficacy and safety profiles of surgical and embolization techniques for cerebrospinal venous fistulas (CVFs) in patients with spontaneous intracranial hypotension (SIH) are not well-defined due to limited data and a lack of randomized trials.

PURPOSE: This systematic review and meta-analysis aims to compare the efficacy and safety of surgical treatment and transvenous embolization for CVFs in patients with SIH.

DATA SOURCES: PubMed, Embase, and Scopus were searched from inception to September 2024.

STUDY SELECTION: Clinical studies involving adults with confirmed CVFs, treated either surgically or through transvenous embolization, were included. Endpoints analyzed included headache response, overall symptom resolution, radiologic treatment response, and complications. Meta-analyses were performed using R software, applying random effects models to calculate prevalence rates and their 95% confidence intervals (CIs). Subgroups of surgery and embolization were compared using Chi-square test. The quality of the studies was assessed using appropriate checklists.

DATA ANALYSIS: Fifteen studies involving 321 patients and 354 CVFs were included, all of good quality. Both treatment modalities led to over 90% partial or complete headache response, with no significant difference between embolization (93.9%; 95% CI 88.3% to 96.9%) and surgery (90.1%; 95% CI 75.6% to 96.4%) (p=0.43). Overall symptom resolution (complete response) was also comparable between embolization (59.1%; 95% CI 50.5% to 67.1%) and surgery (70.7%; 95% CI 44.7% to 87.8%) (p=0.38). Radiologic response, measured by the Bern score, showed significant improvement post-embolization, with no corresponding data from surgical literature. The retreatment/recurrence rate was 14% (95% CI: 9.9% to 19.3%), with no significant difference between embolization (15.3%; 95% CI 10.3% to 22.1%) and surgery (11.3%; 95% CI 5.7% to 20.9%) (p=0.63). There was no publication bias among the reported endpoints.

LIMITATIONS: Lack of direct comparative effectiveness and small sample sizes heighten the risk of selection and confounding bias.

CONCLUSIONS: In conclusion, our systematic review and meta-analysis indicate that both surgical treatment and transvenous embolization for CVFs in patients with SIH provide comparable efficacy and safety profiles. Future research should employ uniform definitions, standardized radiologic and clinical endpoints, and long-term follow-up to more rigorously evaluate the relative efficacy and safety of these approaches.

ABBREVIATIONS: SIH =Spontaneous intracranial hypotension; CVF =CSF-venous fistulas; EBP =Epidural blood patching.

Footnotes

  • Disclosure of potential conflicts of interest: J.O. received research grants from SFNR, GIRCI-GO, INNOVEO-Chu De Brest, Medtronic, Phenox, Institut Servier, Philippe Foundation, Philips, and receives consulting fees from Balt. D.F.K. holds equity in Nested Knowledge, Superior Medical Editors, and Conway Medical, Marblehead Medical and Piraeus Medical. He receives grant support from Micro-Vention, Medtronic, Balt, and Insera Therapeutics; has served on the Data Safety Monitoring Board for Vesalio; and received royalties from Medtronic. W.B. holds equity in Nested Knowledge, Superior Medical Editors, Piraeus Medical, Sonoris Medical, and MIVI Neurovascular. He receives royalties from Medtronic and Balloon Guide Catheter Technology. He receives consulting fees from Medtronic, Stryker, Imperative Care, Microvention, MIVI Neurovascular, Cerenovus, Asahi, and Balt. He serves in a leadership or fiduciary role for MIVI Neurovascular, Marblehead Medical LLC, Interventional Neuroradiology (Editor in Chief), Piraeus Medical, and WFITN. Other authors declare no competing interests.

  • © 2025 by American Journal of Neuroradiology

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Accepted Manuscript
Seyed Behnam Jazayeri, Mohammad Mirahmadi Eraghi, Julien Ognard, Sherief Ghozy, Ramanathan Kadirvel, Waleed Brinjikji, David F. Kallmes
Transvenous Embolization vs. Surgical Intervention for cerebrospinal fluid Venous Fistulas: A Systematic Review and Meta-analysis
American Journal of Neuroradiology May 2025, ajnr.A8839; DOI: 10.3174/ajnr.A8839

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Accepted Manuscript
Transvenous Embolization vs. Surgical Intervention for cerebrospinal fluid Venous Fistulas: A Systematic Review and Meta-analysis
Seyed Behnam Jazayeri, Mohammad Mirahmadi Eraghi, Julien Ognard, Sherief Ghozy, Ramanathan Kadirvel, Waleed Brinjikji, David F. Kallmes
American Journal of Neuroradiology May 2025, ajnr.A8839; DOI: 10.3174/ajnr.A8839
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