The superior petrosal venous complex drains into the superior petrosal sinus; there are three different identified drainage pattern variants. Type I describes a superior petrosal venous complex that empties into the superior petrosal sinus above and lateral to the boundaries of the internal acoustic meatus. Type II describes drainage between the lateral trigeminal nerve and the medial facial nerve at the internal acoustic meatus. Type III describes drainage above or medial to the Meckel cave. Of the three types, Type II is the most common drainage pattern.[5]

Because the tentorium cerebelli is attached to the edges of the superior petrosal sinus, during surgical procedures, the superior petrosal sinus is useful as a landmark. The tentorium cerebelli is also used to classify the location of tumors. Herniation of the brain through the tentorium cerebelli may require surgical intervention.[6]

The drainage pattern of the superior petrosal venous complex into the superior petrosal sinus can determine the surgical approach in neurosurgical procedures. For example, surgeons use the retrosigmoid suprameatal neurosurgical approach in type II and III cases. To better outcomes, before surgery, CT angiogram and magnetic resonance venogram can be used to visualize the junction of the superior petrosal venous complex and the superior petrosal sinus to determine the drainage pattern. The correct classification of superior petrosal venous complex drainage pattern and imaging can guide both the surgical approach and division of the superior petrosal sinus and the tentorium cerebelli.[5][7]

The superior petrosal sinus is especially clinically relevant when involved in conditions such as carotid-cavernous fistulas and dural arteriovenous fistula malformations (AVFMs). AVFMs are abnormal connections between meningeal arteries and dural sinuses. Arteriovenous fistula malformations can classify into three categories: Type I, II, and III. To clarify, this classification system differs from the method used to classify the drainage pattern of the superior petrosal venous complex into the superior petrosal sinus. Type I AVFMs drain directly into meningeal veins or dural venous sinuses. Type II AVFMs are Type I AVFMs, but additionally, this type has retrograde drainage into subarachnoid veins due to high pressure. In contrast, Type III AVFMs do not have meningeal or dural venous sinus drainage and drain solely into subarachnoid granulations.[8] 

Arteriovenous fistula malformations involving the superior petrosal sinus are definitively treatable with either surgery or endovascular therapy.[9] Of the endovascular therapies, transvenous embolization is the nonsurgical treatment of choice for Type I, II, and III AVFMs; transarterial embolization can also be performed but may be more challenging to achieve definitive treatment.[8] If preservation of venous flow is necessary, transarterial embolization or surgery are both options. Furthermore, transvenous embolization can be used preoperatively to minimize bleeding and complications. Endovascular embolization allows for closure of the AVFM or effective preoperative treatment.[9] 

Another therapy for superior petrosal sinus AVFM is gamma knife radiosurgery. However, gamma knife-induced closure of the fistula requires up to three years. As a result, gamma knife radiosurgery is not a viable therapy in high-grade AVFMs but may be an option in low-grade AVFMs. Unfortunately, superior petrosal sinus AVFMs are typically high-grade.[9] Additionally, the proximity of the superior petrosal sinus to the brainstem can result in radiation-induced deleterious effects.[2][10]