OBJECTIVE: Dural arteriovenous fistula (DAVF) at the petrous apex with pial arterial supplies possesses complicated angioarchitecture, associates with aggressive neurologic behaviors, and associates with high risk of complications. This study aimed to summarize our experience with this type of DAVF in the last 15 years. METHODS: This retrospective study reviewed 26 consecutive patients diagnosed with DAVFs of the petrous apex with pial arterial supplies from February 2002 to June 2017. Clinical information was extracted from medical records, radiographic data, intraoperative images, and complications and follow-up records. RESULTS: The 26 patients included 24 men and 2 women, with a mean age of 46.54 +/- 12.49 years (range, 28-73 years). Manifestations included nonhemorrhagic neurologic defects (19/26, 73.1%), subarachnoid hemorrhage (SAH) (5/26, 19.2%), and no symptoms (2/26, 7.7%). Supratentorial draining direction was detected in 89.47% of the lesions, and 80% of the patients with venous ectasia had SAH. Complete occlusion was achieved in 21 patients (80.77%) through transarterial embolization and 5 patients (19.2%) through preoperative embolization combined with microsurgery. Complications included transient cranial nerve palsy in 1 patient (3.8%) and rebleeding in 2 patients (7.7%). The Barthel Index scores ranged from 10 to 100 (average, 66.73) and improved significantly (average, 96.62) in the follow-up period (10-175 months; median, 85.6 months). CONCLUSIONS: Supratentorial draining direction may be a risk factor for venous ectasia and SAH in petrous apex DAVFs with pial arterial supplies. The feeding pial arteries appeared to be at risk of embolization-related hemorrhagic complication and are therefore suggested to be embolized first.