• Anchalee Churojana, Ittichai Sakarunchai, Thaweesak Aurboonyawat, Ekawut Chankaew, Pattarawit Withayasuk, and Boonrerk Sangpetngam.
• Division of Diagnostic Radiology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand. Electronic address: achurojana@gmail.com.
• World Neurosurg. 2021 Feb 1; 146: e53-e66.

BackgroundThe principles of endovascular treatment of bilateral cavernous sinus dural arteriovenous fistula (CS-dAVF) are not well established because of the complexity in the number of fistula tracts and their behavior, which seems to be more aggressive. We aimed to determine an efficient technique for endovascular treatment of bilateral CS-dAVF and the associated factors to achieve good clinical and angiographic outcomes.MethodsThe data were analyzed from 165 consecutive patients diagnosed with CS-dAVF from January 2005 to September 2018. The demographic data included approaching route, embolization times, embolization material, sequence of embolization, number of embolization sessions, and angiographic and clinical outcomes. Interrater agreement of bilateral CS-dAVF diagnosis was performed using the κ coefficient. The factors associated with treatment outcome were analyzed using a Pearson χ2 test.ResultsBilateral CS-dAVF was detected in 43 patients (26%). Angiographic presentations that showed evidence of sinus thrombosis, dangerous venous drainage, and higher Satomi classification were more commonly found in bilateral CS-dAVF than in unilateral CS-dAVF. Good clinical outcome and cure from angiography were obtained in 90% and 74%, respectively. Ipsilateral inferior petrosal sinus-intercavernous sinus-contralateral cavernous sinus catheterization was the major approach route of treatment. The factors associated with improved clinical outcome were transvenous approach, shunt closure, coil embolization, and sequencing the embolization (P < 0.001).ConclusionsDangerous venous drainage tends to increase in bilateral CS-dAVF. Retrograde ipsilateral inferior petrosal sinus catheterization using coil embolization and sequencing the embolization are the major concerns for treatment.Copyright © 2020 Elsevier Inc. All rights reserved.

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