Microsurgical treatment for superior petrosal sinus dural arteriovenous fistulas

Abstract Background and Objectives: Superior petrosal sinus (SPS) dural arteriovenous fistulas (DAVFs), is a relatively common type of tentorial DAVF that sometimes need to be treated microsurgically. The purpose of this study is to analyze the superior petrosal vein (SPV) tributaries observed during surgery, as well as their relationship with clinical symptoms and venous drainage patterns. Methods This retrospective study examined a consecutive series of 34 patients with SPS DAVFs who underwent microsurgical treatment at a single institution from 2014 to 2022. Expected Outcomes: 34 patients had an average age of 52.8 ± 11.8 years (range, 25–73), with 85.3% (29/34) being men. The most common symptoms were venous hypertensive myelopathy (VHM) (55.9%, 19/34) and intracranial hemorrhage or subarachnoid hemorrhage (23.5%, 8/34). 94.1% (32/34) of the lesions were ligated using the standard retrosigmoid approach. Immediate complete occlusion of the fistulas was achieved in all patients. A higher frequency of subarachnoid hemorrhage or intracerebral haemorrhage and venous varix was observed in supratentorial venous drainage pattern (P = 0.047). VHM-related symptoms are more common in infratentorial venous drainage patterns (P<0.001). 90% of SPS DAVFs drained supratentorially via the pontotrigeminal vein. 61.5% of SPS DAVFs drained infratentorially via the vein of the cerebellopontine fissure (VCPF). 90% of cases drained into the perimedullary venous system via the VCPF or TPV, and lateral anterior medullary veins, while the remaining cases drained infratentorially into cerebellar cortical veins. Discusssion: Endovascular treatment for SPS DAVFs can be risky, even though most tentorial DAVFs can be effectively treated via TAE. SPS DAVFs can be managed through a standard retrosigmoid craniotomy, leading to favorable clinical outcomes and high cure rates. In cases with supratentorial venous drainage, the most common arterialized tributary of the SPV is the VCPF, whereas in cases with infratentorial venous drainage, the most common arterialized SPV tributary is the PTV.