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Three Cases of Dural Arteriovenous Fistula of the Anterior Condylar Vein Within the Hypoglossal Canal

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Three Cases of Dural Arteriovenous Fistula of the Anterior Condylar Vein Within the Hypoglossal Canal AJNR Am J Neuroradiol 20:2016±2020, November/December 1999 Case Report Three Cases of Dural Arteriovenous Fistula of the Anterior Condylar Vein within the Hypoglossal Canal Robert Ernst, Robert Bulas, Thomas Tomsick, Harry van Loveren, and Khaled Abdel Aziz Summary: Dural arteriovenous ®stulas (DAVFs) of the an- perior ophthalmic vein, as well as extensive pial drainage. terior condylar vein are an uncommon but important sub- The exact location of the ®stula on angiography was re- set of ®stulas occurring at the skull base that can be con- vealed most accurately by contralateral common carotid an- giography (Fig 1B). MR angiography source images showed fused with DAVFs of the marginal sinus on angiography. abnormal ¯ow medial to the jugular bulb in the region of MR angiography source images can document the intraos- the hypoglossal canal, with a signi®cant intraosseous com- seous extent and the relationship to the hypoglossal canal ponent (Fig 1C-D). Complete transvenous occlusion of the of this type of ®stula, which can have signi®cant clinical ®stula was performed using a coaxial system of a 7F Ber- implications. We present the imaging features of angio- enstein catheter and a 3F infusion catheter with pushable, graphy, CT, and MR angiography of three cases of DAVFs ®bered, and Guglielmi detachable coils (Fig1E). Postem- bolization CT showed coils extending from the hypoglossal localized to the anterior condylar vein and within the hy- canal into the bone along the medial aspect of the jugular poglossal canal, which were con®rmed by source images bulb (Fig 1F-G). from MR angiography. Transvenous coil embolization was curative in two of three cases and would seem to be the Case 2 treatment of choice when venous access is available. A 74-year-old woman presented with headache and severe pulse-synchronous bruit. Diagnostic angiography revealed a Intracranial dural arteriovenous ®stulas (DAVFs) DAVF medial to the right jugular bulb (Fig 2A). Similar to are abnormal communications between meningeal case 1, the exact site of the ®stula was demonstrated best on arteries and dural venous sinuses, or veins, or both. the contralateral carotid artery angiogram (Fig 2B). Venous drainage ¯owed antegrade into the jugular vein and retrograde Fifty percent of DAVFs occur in the posterior fossa into the sigmoid and transverse sinuses. External carotid intra- and usually involve the transverse or sigmoid sinus. arterial embolization was performed initially with polyvinyl Previous articles have described less common ®s- alcohol, and the right vertebral artery was occluded. This was tulas occurring at the skull base in the region of followed by stereotactic radiation that resulted in only partial the foramen magnum (1, 2). This report focuses on relief of symptoms. MR angiography source images revealed a previously unreported subset of DAVFs occurring abnormal ¯ow medial to the jugular bulb adjacent to the hy- poglossal canal. A signi®cant amount of abnormal ¯ow signal at the skull base involving the anterior condylar appeared intraosseously (Fig 2C-D). After 1 year with persis- vein. tent symptoms, the patient underwent transvenous emboliza- tion that was performed with pushable, ®bered, and Guglielmi detachable coils, resulting in complete occlusion of the ®stula. Case Reports A triaxial catheter system used an 8F outer-guide catheter, a Case 1 4F inner-guide catheter, and a 3F infusion catheter. The patient has remained asymptomatic 2 years postembolization. A 74-year-old woman presented with an audible pulse- synchronous bruit. Diagnostic angiography showed a DAVF medial to the jugular bulb with unrestricted venous drainage Case 3 via antegrade ¯ow in the adjacent jugular vein (Fig 1A). A 57-year-old man presented with headache and mild pulse- Using polyvinyl alcohol, the patient was treated with intra- synchronous bruit. MR angiography revealed a large DAVF arterial embolization that partially relieved symptoms. Two medial to the right jugular bulb. MR angiography source im- years after initial embolization, the patient's bruit suddenly ages showed that ¯ow signal was partially intraosseous and disappeared, followed by concurrent development of ipsi- within the hypoglossal canal, similar in location to cases 1 and lateral chemosis and proptosis. Angiography revealed a dra- 2. On angiography, the ®stula was supplied primarily by the matic change in venous drainage, with retrograde ®lling of ipsilateral ascending pharyngeal and occipital arteries. Venous the inferior petrosal sinus and cavernous sinus to the su- drainage was antegrade to the jugular bulb and internal jugular vein. The exact ®stula site was shown most accurately by con- Received February 9, 1999; accepted after revision July 8. tralateral external carotid artery injection. Treatment consisted From the Neuroscience Institute, Departments of Radiology of transvenous coil embolization and transarterial polyvinyl al- (R.E., T.T.) and Neurosurgery (H.V.L., K.A.A.), University of cohol embolization of the ascending pharyngeal artery. Ap- Cincinnati Medical Center, Cincinnati, OH; Department of Ra- proximately 90% of the ®stula was occluded. The patient's diology (R.B.) The Christ Hospital, Cincinnati, OH; and The tinnitus and bruit resolved with embolization. May®eld Clinic (H.V.L.), Cincinnati, OH. Address reprint requests to Robert Ernst, MD, 0 Editorial Of®ce, University of Cincinnati Department of Neurosurgery, Discussion 231 Bethesda Avenue, Cincinnati, OH 45267-0515. The venous plexus within the hypoglossal canal q American Society of Neuroradiology is referred to as the anterior condylar vein. This 2016 MS AJNR: 20, November/December 1999 DURAL ARTERIOVENOUS FISTULAS 2017 venous plexus originates at the junction of the jug- external carotid angiogram was most useful in iden- ular bulb and inferior petrosal sinus and extends tifying the location of the ®stula on angiography. In into the hypoglossal canal. The anterior condylar case 1, venous drainage was via the jugular vein ini- vein traverses the hypoglossal canal (anterior con- tially. After development of chemosis and proptosis, dylar canal) joining the inferomedial aspect of the there was a dramatic change in venous drainage with inferior petrosal sinus to the suboccipital venous retrograde ¯ow in the inferior petrosal sinus and cav- plexus, vertebral or paravertebral veins, marginal ernous sinus to the superior ophthalmic vein as well sinus, or the internal vertebral venous plexus. The as extensive pial drainage. Case 2 showed retrograde hypoglossal canal contains the hypoglossal nerve, ¯ow in the sigmoid and transverse sinuses. Case 3 the neuromeningeal branch of the ascending pha- demonstrated antegrade ¯ow in the jugular bulb and ryngeal artery, and the surrounding venous plexus posterior condylar vein. All cases showed antegrade (Fig 3). An emissary vein, the anterior condylar ¯ow in the jugular bulb and jugular vein. There was vein extends through the calvarium to join the in- no direct venous ¯ow to the extracranial suboccipital tradural sinuses and the extracranial veins (3±6). venous plexus or paravertebral venous system. We The majority of DAVFs that occur in the poste- have identi®ed two additional such ®stulas by angi- rior fossa involve the transverse or sigmoid sinuses. ography and MR angiography that have yet to be Several recent articles, however, have described treated and we suspect a number of other similar less common ®stulas occurring at the skull base in cases exist after review of prior arteriograms that the region of the foramen magnum. Pierot et al (1) were not documented by MR angiography. These un- reported six cases of DAVFs involving the skull proved cases suggest the ®stula of the anterior con- base located along the margin of the foramen mag- dylar vein may not be as rare as previously thought. num, four of which had venous drainage into a pial Because ®stulas of the anterior condylar vein vein with retrograde ¯ow. Four of these cases in- may be confused with marginal sinus DAVFs on volved intracranial hemorrhage. Three of the pa- angiography, source images from MR angiography tients in these cases were treated with surgery, and are essential in localizing the ®stula to the hypo- all were cured. One patient was treated partially glossal canal. MR angiography source images in with embolization; however, the patient had a sub- case 1 demonstrated abnormal intraosseous ¯ow arachnoid hemorrhage 3 months later and died. signal medial to the jugular bulb and within the McDougall et al (2) described 14 DAVFs in- hypoglossal canal, in the location of the anterior volving the marginal sinus (the sinus located be- condylar vein. The location of coil placement as tween the layers of dura at the rim of the foramen documented by CT in case 1 con®rms the signi®- magnum). The marginal sinus encircles the fora- cant intraosseous component and its relationship to men magnum, linking the basal venous plexus of the hypoglossal canal. MR angiography source im- the clivus and the occipital sinus posteriorly. The ages of cases 2 and 3 also showed similar abnormal marginal sinus drains to the sigmoid sinus or jug- ular bulb. These DAVFs were separate from the ¯ow signal localized to the hypoglossal canal and jugular bulb and sigmoid sinus, medial to these medial to the jugular bulb with a signi®cant in- structures. Six of their 14 cases had unrestricted traosseous component. venous drainage. Three cases had restricted venous Intraosseous DAVFs have been described previ- drainage. Three cases had retrograde
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