Kee Tze Phei, Kiyosue Hiro, Krings Timo
Department of Neuroradiology, National Neuroscience Institute, Singapore.
Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan.
J Clin Neurosci. 2025 Aug 6;140:111544. doi: 10.1016/j.jocn.2025.111544.
Superior sagittal sinus (SSS) dural arteriovenous fistulas (DAVFs) are sinus-type fistulas with shunting point(s) centered on the sinus or parallel parasinus wall, while its counterpart parasagittal DAVFs are non-sinus-type fistulas with shunting point(s) centered on the junctional zone of the bridging vein and the SSS. SSS DAVFs can be challenging to treat due to the widespread shunting zone, eloquence of the involved venous structure and their rarity. We explore the clinical data, imaging characteristics, endovascular treatment modalities and treatment outcomes of SSS DAVF, with the aim of identifying the ideal treatment strategies.
Clinical and imaging data of 14 patients with SSS DAVFs treated in our institutions across the past 10 years were retrospectively analyzed. The angiographic findings, endovascular treatment strategies and angiographic outcomes were evaluated and recorded.
Among these 14 patients with SSS DAVF, two (14 %) presented with intracranial hemorrhages (ICH); both were of Borden type III. Arterial feeders included the middle meningeal artery (MMA), superficial temporal artery (STA) and occipital artery (OA) with induced pial-dural supply in 57 % of cases. Trans-arterial embolization, via the MMA as the primary route of access, was the primary treatment approach in 71 % of cases (10/14). Final complete angiographic occlusion was achieved in only 64 % (9/14) of the cases. Complications included non-occlusive reflux of embolization material into the SSS (1/14, 7 %), reflux of liquid embolic materials into pial arteries resulting in small ischemia (1/14, 7 %), and scalp necrosis (2/14, 14 %).
SSS DAVFs are often highly vascularized and thus present significant treatment challenges. Trans-arterial embolization via the MMA(s) can be used as the primary treatment strategy in most cases, although more complex, staged treatment strategies may often be required to achieve complete cure. Comprehensive understanding of the angioarchitecture and avoiding overzealous embolization are key to minimizing complications.
