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

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.