Superior petrosal sinus dural arteriovenous fistulas: endovascular treatment strategies with special emphasis on transvenous route selection

BACKGROUND AND OBJECTIVE: Superior petrosal sinus dural arteriovenous fistulas (SPSdAVFs) are uncommon tentorial fistulas with aggressive venous drainage and complex anatomy. We evaluated endovascular treatment outcomes in our cohort and propose an anatomy-driven framework for treatment selection, with particular emphasis on transvenous route selection. METHODS: We retrospectively reviewed consecutive SPSdAVFs treated endovascularly at two tertiary centers (January 2005-March 2024). Clinical, angiographic, procedural, and follow-up data were analyzed, including arterial supply, venous outflow, superior petrosal sinus (SPS) patency, embolic agent, and access route. Transvenous access to the junction of the SPS and superior petrosal venous confluence was categorized as duro-pial, anteromedial dural, or posterolateral dural. RESULTS: Twenty-two patients (20 men; mean age, 51.7 years) were included; 6 (27.3%) presented with infratentorial hemorrhage. Ten underwent transvenous embolization (TVE) and 12 underwent transarterial embolization (TAE). TVE was achieved via a duro-pial route in four cases, anteromedial dural in four, and posterolateral dural in two. All anteromedial cases required recanalization of a thrombosed SPS segment; one posterolateral case required adjunctive snare-assisted pull-through. Complete angiographic occlusion was achieved in all patients after a single session. Periprocedural complications occurred in three patients (13.6%): one localized subarachnoid hemorrhage after TVE and two transient facial pareses after TAE. There were no procedure-related deaths or radiologic recurrences. Mean modified Rankin Scale score improved from 1.5 to 0.3 at last follow-up (mean, 6.5 years). CONCLUSIONS: TVE is a viable curative option for SPSdAVFs. An anatomy-driven strategy centered on venous foot access may facilitate route selection and durable occlusion.