2024 Volume 52 Issue 1 Pages 35-41
Background: A dural arteriovenous fistula (dAVF) with cortical reflux into the posterior fossa via the superior petrosal vein poses a risk of brainstem and cerebellar hemorrhage. Minimally invasive endovascular surgery and radiotherapy are preferred in several situations over open surgery. Even when these treatments are not curative, direct interruption of the superior petrosal vein remains useful, especially when it is the sole drainage route.
Case 1: A 69-year-old man presented with a gait disturbance. Upon examination, a left-sided tentorial dAVF fed by the tentorial artery was observed to reflux into the pontine vein via the superior petrosal vein, causing regurgitation into the anterior spinal vein and edematous changes in the brainstem. Transarterial embolization of the tentorial artery and gamma knife radiosurgery were not curative. Therefore, we performed direct surgery to block the superior petrosal vein, resulting in the disappearance of the dAVF.
Case 2: A 70-year-old woman presented with a subcortical cerebral hemorrhage. We performed transarterial embolization during the acute phase and transvenous sinus occlusion during the chronic phase. Inadequate embolization of the superior petrosal sinus resulted in residual regurgitation of the cerebellar cortical veins via the superior petrosal vein. As additional transarterial embolization was not curative, direct surgical interruption of the superior petrosal vein was performed, and the dAVF disappeared.
Conclusion: We report two cases of dAVF that were successfully treated by direct interruption of the superior petrosal vein without complications following unsuccessful endovascular embolization. Further case series are needed to determine the safety of this approach in dAVF.
