Patient and DAVF baseline characteristics
The patients had an average age of 52.8 ± 11.8 years (range, 25–73), with 85.3% (29/34) being men. Upon admission to our hospital, the median disease duration was 2 months (IQR 0.48 to 6). 19 patients (55.9%, 19/34) presented with venous hypertensive myelopathy (VHM) (such as weakness and numbness in the limbs, as well as urinary and fecal incontinence). Eight patients (23.5%, 8/34) presented with intracranial hemorrhage or subarachnoid hemorrhage. Other symptoms included trigeminal neuralgia, hemiparesis, headache, hemifacial spasm, hiccups, slurred speech, difficulty breathing, aphasia. One patients (2.9%, 1/34) were diagnosed with DAVF by chance. Three patients (8.8%, 3/34) had a history of steroid administration, and all experienced worsening symptoms of VHM. Five patients (14.7%, 5/34) had previously undergone unsuccessful endovascular treatment at another hospital. At presentation, the median mRS score was 2 (IQR 1 to 4).
67.6% (23/34) of DAVFs were found to have multiple feeders. The meningohypophyseal trunk was the most common arterial feeder (85.3%, 29/34), followed by the MMA (64.7%, 22/34), the occipital artery (17.6%, 6/34), the pure pial or drual branches of the anterior inferior cerebellar artery (17.6%, 6/34) and the superior cerebellar artery (11.8%, 4/34), the ascending pharyngeal artery (8.8%, 3/34), the artery of foramen rotundum (5.9%, 2/34), the accessory meningeal artery (2.9%, 1/34) and the posterior meningeal artery (2.9%, 1/34). The detailed baseline characteristics of the 34 patients with SPS DAVFs are summarized in Table 1.
Table 1
Characteristics of 34 patients with superior petrosal sinus dural arteriovenous fistulas treated microsurgically.
Variables | N(%) |
Sex,n | 34 |
Male/Female | 29/5 |
Age,mean(SD,years) | 52.8 ± 11.8 |
Disease duration(months,median,IQR) | 2(0.48-6) |
Presentation | |
Venous hypertensive myelopathy | 19(55.9) |
Subarachnoid hemorrhage | 5(14.7) |
Intracerebral haemorrhage | 3(8.8) |
Trigeminal neuralgia | 2(5.9) |
Hemiparesis | 2(5.9) |
Headache | 1(2.9) |
Hemifacial spasm | 1(2.9) |
Incidental | 1(2.9) |
Steroid administration | 3(8.8) |
Previous treatment | 5(14.7) |
Treatment modalities | |
TAE + microsurgery | 7(20.6) |
Microsurgery alone | 27(79.4) |
DAVF side | |
Left side | 19(55.9) |
Right side | 15(44.1) |
Number of feeders | |
One | 11(32.4) |
Multiple | 23(67.6) |
Arterial feeders | |
Meningohypophyseal trunk | 29(85.3) |
Middle meningeal artery | 22(64.7) |
Occipital artery | 6(17.6) |
Anterior inferior cerebellar artery | 6(17.6) |
Superior cerebellar artery | 4(11.8) |
Ascending pharyngeal artery | 3(8.8) |
Artery of foramen rotundum | 2(5.9) |
Accessory meningeal artery | 1(2.9) |
Posterior meningeal artery | 1(2.9) |
Venous Drainage | |
Supratentorial | 8(23.5) |
Infratentorial | 24(70.6) |
Supra- and infratentorial | 2(5.9) |
Varix of drainage vein | 17(50) |
Cognard type | |
Ⅲ | 3(8.8) |
Ⅳ | 12(35.3) |
Ⅴ | 19(55.9) |
Complication | 6(17.6) |
Death | 4(11.8) |
Follow-up period(months,median,IQR) 1 | 40(26–55) |
DAVF, dural arteriovenous fistula. IQR, interquartile range. mRS, modified ranking scale. SD, standard deviation. TAE, trans-arterial embolization. |
1. Based on 25 (25/30,83.3%) patients who were either clinically or telephoned for follow-up. |
The most common arterialized tributaries were the vein of the cerebellopontine fissure (VCPF) (47.1%), followed by the pontotrigeminal vein (PTV) (29.4%), the transverse pontine vein (TPV) (26.5%), the anterior lateral marginal vein (ALMV) (5.9%) and the vein of the middle cerebellar peduncle (VMCP) (2.9%). During surgery, four patients were discovered to have occluded SPV tributaries, while 13 were found to have normal SPV tributaries. Among our 13 cases with normal SPV tributaries, six had three tributaries, four had two tributaries, two had four tributaries, and one had five tributaries, including two cases with occluded SPV tributaries. The coexisting normal and occluded tributaries are summarized in Table 2. 70.6% (24/34) of SPS DAVFs drained infratentorially, 23.5% (8/34) drained supratentorially, and 5.9% (2/34) did both. All cases drained into the SPV and its tributaries. 90% of SPS DAVFs drained supratentorially via the PTV. Finally, the most common drainage pattern was to drain into the basal vein of Rosenthal and the vein of Galen. 61.5% of SPS DAVFs drained infratentorially via the VCPF, 34.6% via the TPV, 7.7% via the ALMV, 3.8% via the VMCP. 90% of cases drained into the perimedullary venous system via the VCPF or TPV, and lateral anterior medullary veins (Fig. 1), while the remaining cases drained infratentorially into cerebellar cortical veins. Venous varix was observed in 50% of SPS DAVFs.
Table 2
Analysis of tributaries of the superior petrosal vein in 34 cases.
| Arterialized | Normal | Occluded |
VCPF | 16(47.1%) | 7(20.6%) | 1(2.9%) |
TPV | 9(26.5%) | 3(8.8%) | 1(2.9%) |
PTV | 10(29.4%) | 6(17.6%) | 0 |
ALMV | 2(5.9%) | 4(11.8%) | 4(11.8%) |
VMCP | 1(2.9%) | 0 | 0 |
VCPF, vein of the cerebellopontine fissure; TPV, transverse pontine vein; PTV, pontotrigeminal vein; ALMV, anterior lateral marginal vein; VMCP, vein of the middle cerebellar peduncle. |
A higher frequency of subarachnoid hemorrhage or intracerebral haemorrhage and venous varix was observed in supratentorial venous drainage pattern (50% versus 12.5%, p = 0.047; 87.5% versus 37.5%, p = 0.037; Table 3). VHM-related symptoms are more common in infratentorial venous drainage patterns than supratentorial venous drainage (p<0.001). The most common arterialized tributaries in infratentorial venous drainage pattern were the VCPF, while in supratentorial venous drainage pattern, the most common arterialized tributaries were the PTV (Table 3).
Table 3
Clinical presentation and fistula angioarchitecture stratified by supratentorial or infratentorial venous drainage in 32 patients.
| Supratentorial | Infratentorial | P value∗ |
No. of patients | 8 | 24 | |
Males(%) | 8(100) | 20(83.3) | 0.55 |
Venous hypertensive myelopathy(%) | 0 | 19(79.2) | <0.001 |
Subarachnoid hemorrhage or intracerebral haemorrhage(%) | 4(50) | 3(12.5) | 0.047 |
Trigeminal neuralgia(%) | 0 | 2(8.3) | 1 |
Arterialized tributaries(%) | | | |
VCPF | 0 | 14(58.3) | 0.004 |
TPV | 0 | 9(37.5) | 0.07 |
PTV | 8(100) | 1(4.2) | <0.001 |
ALMV | 0 | 1(4.2) | 1 |
VMCP | 0 | 1(4.2) | 1 |
Venous varix | 7(87.5) | 9(37.5) | 0.037 |
Poor outcome(last mRS score > 2) ∗∗ | 4/7(57.1) | 6/21(28.6) | 0.207 |
ALMV, anterior lateral marginal vein; PTV, pontotrigeminal vein; TPV, transverse pontine vein; VCPF, vein of the cerebellopontine fissure; VMCP, vein of the middle cerebellar peduncle. |
∗P value derived from Fisher’s exact text.、 |
∗∗ Data available for 28/32 |
Follow-up
Four patients died in the hospital: one due to hemorrhage upon presentation (mRS = 4), although the treatment was successful, and three due to major complications. Among 30 patients, 25 (83.3%) were followed-up either as inpatient, outpatient, or by telephone. No patients reported worsening symptoms after complete occlusion of the fistulas. Six patients (20%, 6/30) reported symptoms remained unchanged before and after surgery (all related to VHM). Additionally, five patients underwent DSA and clinical follow-up for durations ranging from 6 to 24 months, while 14 patients had MRI/MRA and clinical follow-up for periods ranging from 6 to 109 months. There was no recurrence of the fistula after the initial complete occlusion. The median mRS score during follow-up was 1 (IQR 0 to 2.5).