Exploring the 'Visible Versus Invisible' Paradigm in Cavernous Sinus Dural Arteriovenous Fistula

BackgroundCavernous sinus dural arteriovenous fistulas (CS-DAVFs) present significant treatment challenges when the inferior petrosal sinus (IPS) is not opacified during cerebral angiography. However, the widely accepted transvenous IPS recanalization approach is associated with a high failure rate. The consistently visible superior ophthalmic vein (SOV) offers a promising alternative, though it has yet to be fully evaluated in large-scale studies. MethodsThis retrospective, case-control study was conducted between May 2017 and October 2024. Data collection for this multicenter, population-based study took place across eight tertiary referral centers. Eligible patients were diagnosed with CS- DAVF with occluded IPS. Endovascular treatment via the transvenous SOV approach versus the IPS recanalization approach in patients with occluded IPS. ResultsOf 178 eligible cases, 70 cases (39.3%) were treated using the transvenous SOV approach, while 108 cases (60.7%) underwent the transvenous IPS approach. The initial treatment success rate was significantly higher in the SOV group compared to the IPS group (91.4% vs. 75.9%; odds ratio [OR], 3.38; 95% CI, 1.30-8.35; P = 0.0092). The overall complication rate was 1.4% in the SOV group and 2.8% in the IPS group (OR, 0.51; 95% CI, 0.04-3.47; P > 0.9999). After classifying the SOV approach into simple and complex types, the SOV-simple type further demonstrated significant advantages, including shorter average operation times (126.20 {+/-} 46.99 minutes, P = 0.0197) and a higher initial treatment success rate (95.7%, P = 0.0027) compared to the IPS group. ConclusionThe SOV approach should be considered a first-line treatment for CS- DAVF patients with invisible IPS. These findings establish a new treatment standard, underscoring the importance of precise preoperative classification and individualized surgical planning.