Is acetazolamide (carbonic anhydrase inhibitor) effective in managing symptoms of dural fistula?

From the Guidelines

Acetazolamide is not recommended as a primary treatment for dural fistula due to the lack of evidence supporting its effectiveness in managing symptoms and the potential for worsening symptoms over time. When considering treatment options for dural fistula, it is essential to prioritize interventions that can provide a cure or significant improvement in symptoms. According to the American Heart Association council on cardiovascular radiology and intervention, stroke council, council on cardiovascular surgery and anesthesia, interdisciplinary council on peripheral vascular disease, and interdisciplinary council on quality of care and outcomes research 1, dural arteriovenous fistulas are often amenable to curative endovascular treatment with contemporary transvenous or transarterial embolization techniques. Some key points to consider in the management of dural fistula include:

• The location of the fistula and its associated symptoms, which can range from pulse-synchronous tinnitus and exophthalmos to cranial nerve deficits, dementia, venous infarct, intracranial hemorrhage, and even death 1
• The availability of curative endovascular treatment options, which can provide good to excellent functional outcomes in up to 80% of cases 1
• The importance of monitoring for side effects and potential complications associated with any treatment, including acetazolamide
• The need for a comprehensive treatment plan that takes into account the individual patient's symptoms, medical history, and overall health status. Given the lack of evidence supporting the use of acetazolamide in managing symptoms of dural fistula, endovascular embolization or surgery should be considered as the primary treatment options.

From the Research

Effectiveness of Acetazolamide in Managing Dural Fistula Symptoms

• Acetazolamide, a carbonic anhydrase inhibitor, has been studied for its potential in managing symptoms of dural fistula, particularly in relation to intracranial venous hypertension 2.
• The study published in 2005 found that acetazolamide can help quantify intracranial venous hypertension and indicate the need for treatment of the dural arteriovenous fistula (DAVF) 2.
• However, the same study also noted that cerebral venous hypertension in DAVF reduced the response to acetazolamide, suggesting that its effectiveness may be limited in certain cases 2.

Temporary Relief and Potential Long-term Effects

• There is evidence to suggest that acetazolamide can provide temporary relief from symptoms associated with high intracranial pressure, including those related to dural fistula 3, 4.
• A study published in 2014 found that acetazolamide significantly decreased intracranial pressure in patients with high intracranial pressure cerebrospinal fluid leaks 3.
• Another study published in 2017 found that acetazolamide lowered intracranial pressure and modulated the cerebrospinal fluid secretion pathway in healthy rats 4.
• However, there is limited research on the long-term effects of acetazolamide on dural fistula symptoms, and it is unclear whether its use can lead to worsening of symptoms over time.

Comparison with Other Treatment Options

• Endovascular embolization is considered the primary therapeutic modality for intracranial dural arteriovenous fistulae, with a high degree of cure and a reasonably low complication rate 5, 6.
• The choice of treatment approach depends on various factors, including the angioarchitecture of the fistula, pattern of venous drainage, clinical presentation, and location 5, 6.
• Acetazolamide may be considered as an adjunctive treatment or for temporary relief of symptoms, but its role in the overall management of dural fistula is still being studied and debated.