Dural arteriovenous fistula draining into the superior petrosal vein: a comparative analysis of two case reports for enhanced anatomical understanding and optimal treatment strategy

Background: Cerebral dural arteriovenous fistulas (dAVFs) draining into the superior petrosal vein (SPV) are rare and complex vascular lesions with a high bleeding risk, necessitating multidisciplinary treatment strategies aiming at occluding the draining vein near the dural wall. Our study showcases two seemingly similar cases with distinct hemorrhage sites, treatment approaches, and outcomes, illustrating the critical importance of personalized intervention strategies. Case Description: In case 1, we present a 63-year-old woman, with unremarkable past medical history, who was admitted to our emergency room (ER) after a loss of consciousness and a subsequent right hemi-syndrome associated to fluent aphasia. Imaging showed a left thalamic hemorrhage from a dural arterio-venous fistula draining in the left SPV that was treated surgically. In case 2, we present a 61-year-old woman, with unremarkable past medical history, who was admitted to our ER after the onset of headache with subsequent drop of the state of consciousness (Glasgow Coma Scale 10) and a right hemiparesis. Imaging showed a left pontine hemorrhage due to arteriovenous shunt with a nidus-like architecture with drainage in the SPV toward the superior petrosal sinus. An endovascular approach was considered feasible due to the vascular architecture of the lesion. Conclusions: The insights from our case studies, encompassing both microsurgical and endovascular interventions, significantly enhance the understanding and treatment strategies for dAVFs, emphasizing the critical role of comprehending their pathophysiology. These cases contribute uniquely to the existing body of knowledge, demonstrating the importance of a thorough understanding of anatomy, flow dynamics, and lesion architecture. This comprehensive approach is essential for the tailored management of such complex cases, highlighting the advancements and practical implications in the evolving field of dAVF treatment.