Endovascular treatment of superior petrosal sinus dural arteriovenous fistulas via combined transarterial and transvenous approach: Lessons from 2 cases

Superior petrosal sinus (SPS) dural arteriovenous fistulas (DAVFs) often require endovascular treatment (EVT), with a combined transarterial/transvenous approach being a rare alternative. Case 1 involved a 61-year-old male with subarachnoid hemorrhage (SAH) diagnosed with a non-sinus-type SPS DAVF. The endovascular treatment utilized a combined transarterial/transvenous approach: A transvenous dual-lumen mini-balloon catheter was advanced into the SPS origin via the internal jugular vein (IJV) and sigmoid sinus (SS), while a transarterial balloon catheter was positioned in the external carotid artery (ECA). After temporary occlusion of the external carotid artery, transvenous Onyx injection failed to penetrate the fistula, the patient experienced a new postoperative subarachnoid hemorrhage, which resolved spontaneously, and follow-up angiography at 2 months confirmed complete DAVF obliteration. Case 2 involved a 63-year-old male diagnosed with a sinus-type SPS DAVF, where a combined transarterial/transvenous approach was employed: The carotid artery feeding arteries were embolized, the dilated SPS origin was catheterized via the internal jugular vein and sigmoid sinus, and the DAVF-feeding aneurysm on the basilar artery perforating artery was catheterized, followed by coiling of both the dilated SPS origin and the aneurysm, resulting in complete DAVF obliteration. Postoperatively, the patient reported facial numbness, which resolved after a 1-month course of mecobalamin tablet therapy. These cases demonstrate that for non-sinus-type SPS DAVF, occlusion of the SPS alone may carry a risk of hemorrhagic complications due to lack of fistula-site embolization. In contrast, for sinus-type SPS DAVF, embolizing the dilated SPS origin (as the fistula site) and the feeding artery may suffice for effective treatment.