• Jong Kook Rhim, Young Dae Cho, Jeong Jin Park, Jin Pyeong Jeon, Hyun-Seung Kang, Jeong Eun Kim, Won-Sang Cho, and Moon Hee Han.
• Departments of *Radiology and ‡Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.
• Neurosurgery. 2015 Aug 1;77(2):192-9; discussion 199.

BackgroundAlthough a transvenous route via the ipsilateral inferior petrosal sinus (IPS) is preferred in treating cavernous sinus dural arteriovenous fistula (CSdAVF), this option may be limited if an occluded ipsilateral IPS undermines microcatheter delivery to the cavernous sinus.ObjectiveTo describe our experience with endovascular treatment of CSdAVF complicated by ipsilateral IPS occlusion.MethodsFrom January 2003 through September 2014, a total of 49 CSdAVFs with ipsilateral IPS occlusion were identified in 49 patients, who then underwent endovascular treatment. Clinical and radiologic data were retrospectively reviewed.ResultsEither transvenous (n = 38) or transarterial (n = 11) access was initially elected, the latter reserved for single-hole or dominant arterial feeder fistulas. Access via occluded ipsilateral IPS was usually attempted (n = 34) by transvenous approach, with a 54.3% success rate. Anterior (n = 3) or posterior (n = 1) facial vein was alternatively used. Direct surgical exposure of ophthalmic vein (n = 3) or radiosurgery (n = 4) was performed for access failure or unsuccessful occlusion by other means. In 46 fistulas (93.9%), complete occlusion was achieved, with no procedure-related morbidity or mortality. Postprocedural symptom improvement was noted in all but 2 patients, who separately experienced paradoxical worsening of cranial nerve palsy and access failure.ConclusionIn patients with CSdAVF and ipsilateral IPS occlusion, various treatment strategies may be applied (given angioanatomic suitability), resulting in excellent procedural and short-term follow-up results. Reopening of an occluded IPS is reasonable as an initial access attempt.

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