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Background Dural sinus malformation (DSM) is a rare congenital cerebrovascular anomaly characterized by dysplastic dilation of the dural sinuses, often associated with arteriovenous shunting and significant morbidity in neonates and infants. Due to its rarity, management strategies are primarily based on small series and institutional experience. We present a multi-center, two-decade experience evaluating clinical presentation, angioarchitecture, treatment strategies, and outcomes following endovascular embolization.Method We performed a retrospective multi-center case series of pediatric patients with DSM treated with endovascular embolization between 2004 and 2024 at two tertiary care centers. Clinical, imaging, procedural, and outcome data were collected. DSMs were categorized by location and angioarchitecture. Treatment strategies, embolic agents, and procedural approaches were evaluated. The primary outcome was a favorable functional outcome (modified Rankin Scale [mRS] 0-2).Results Fourteen pediatric patients (8 males, 6 females) with DSM were included, with a mean age at presentation of approximately 6 months (range: premature to 13 months). Lesions were predominantly midline (11/14), most commonly involving the torcular Herophili, followed by the superior sagittal sinus, transverse sinus, and sigmoid sinus. Arterial supply most frequently arose from branches of the middle meningeal, occipital, vertebral, and external carotid arteries. Thrombosis within the dilated dural venous system was identified in 8 cases. Venous outflow patterns were variable, including anterograde (n=5), retrograde (n=5), and mixed (n=4). All patients underwent endovascular embolization, with the number of treatment sessions ranging from 1 to 7. Embolic materials included ethylene vinyl alcohol copolymer (Onyx), N-butyl cyanoacrylate (NBCA), and coils. At the last follow-up, 10 patients achieved favorable clinical outcomes (modified Rankin Scale [mRS] 0-2), including 8 patients with mRS 0, 1 patient with mRS 1, and 1 patient with mRS 2. One patient had a poor outcome (mRS 4), attributed to pre-existing disease-related brain injury. Three patients died due to a severe disease course and irreversible complications. Among the 11 surviving patients, good functional outcomes were observed in 7 of 8 midline DSM cases. Favorable outcomes were also seen in 5 of 6 patients with retrograde venous drainage, 3 of 4 patients with associated venopathies, and 2 of 3 patients with associated thrombosis.Conclusion Pediatric DSMs remain high-risk lesions with heterogeneous presentations and complex angioarchitecture. In this multi-center series, staged endovascular embolization resulted in favorable outcomes in the majority of survivors, even in the presence of traditionally unfavorable features such as midline location, retrograde venous drainage, thrombosis, and associated venopathies. These findings reinforce that prognosis is not solely dictated by angioarchitectural risk factors, but can be significantly modified by timely, individualized intervention. Treatment strategies should prioritize preservation of venous outflow and be tailored to lesion-specific hemodynamics, with a multidisciplinary approach essential to optimizing outcomes.Disclosures A. Shahidi: None. F. Requejo: None. M. Gonzalez: None. A.S. Al-Smadi: None. D. Cantrell: None. R. Abdalla: None. S.A. Ansari: None. A. Shaibani: None.