Dural arteriovenous fistulas draining into the petrosal vein or bridging vein of the medulla: possible homologs of spinal dural arteriovenous fistulas

Clinical article

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Dural arteriovenous fistulas (DAVFs) with leptomeningeal venous reflux generally pose a high risk of aggressive manifestations including hemorrhage. Among DAVFs, there is a peculiar type that demonstrates direct drainage into the bridging vein rather than the dural venous sinus. The purpose of this study was to investigate the characteristics of DAVFs that drain directly into the petrosal vein or the bridging vein of the medulla oblongata.


Eleven consecutive cases of DAVFs that drained directly into the petrosal vein and 6 that drained directly into the bridging vein of the medulla were retrospectively reviewed. These cases were evaluated and/or treated at Hospital de Bicêtre in Paris, France, over a 27-year period. A review of previously reported cases was also performed.


Both of these “extrasinusal”-type DAVFs demonstrated very similar characteristics. There was a significant male predominance (p < 0.001) for this lesion, and a significantly higher incidence of aggressive neurological manifestations including hemorrhage or venous hypertension than in DAVFs of the transverse-sigmoid or cavernous sinus (p < 0.001). This finding was considered to be attributable to leptomeningeal venous reflux. Regarding treatment, endovascular embolization (either transarterial or transvenous) is frequently difficult, and surgery may be an effective therapeutic choice in many instances.


Embryologically, both the petrosal vein and the bridging vein of the medulla are cranial homologs of the spinal cord emissary bridging veins that drain the pial venous network. The authors believe that DAVFs in these locations may be included in a single category with spinal DAVFs because of their similar clinical characteristics.

Abbreviations used in this paper: DAVF = dural arteriovenous fistula; ICA = internal carotid artery; MMA = middle meningeal artery; NBCA = N-butyl cyanoacrylate; SAH = subarachnoid hemorrhage; SRS = stereotactic radiosurgery; TAE = transarterial embolization; VA = vertebral artery.

Article Information

Address correspondence to: Yutaka Mitsuhashi, M.D., Ph.D., Department of Neurosurgery, Osaka City University, Graduate School of Medicine 1-4-3 Asahi-machi, Abeno-ku, Osaka, Japan 545-8585. email: y-mitsuhashi@mtf.biglobe.ne.jp.

Please include this information when citing this paper: published online May 8, 2009; DOI: 10.3171/2009.1.JNS08840.

© AANS, except where prohibited by US copyright law.



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    Case 6. A: Axial T2-weighted MR image demonstrating a large, partially thrombosed varix (arrow) at the right thalamus. Prominent perifocal edema is identified. B: Selective angiogram of the right ICA showing a DAVF supplied by cavernous internal carotid branches, draining directly into the petrosal vein (arrowhead). Note the ectasia and varix (crossed arrow) of the draining vein. C: Superselective angiogram of the petrosquamous branch from the right MMA. The convergence of the small feeding arteries into the petrosal vein is well demonstrated. D: Angiogram showing the injection of 40% diluted NBCA reaching the diseased petrosal vein (asterisk). E: Postembolization angiogram confirming complete obliteration of the fistula. F: Posttreatment CT scan shows decreased perifocal edema.

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    Case 8. Angiograms. A and B: Selective angiography of the right ICA, anteroposterior (A) and lateral (B) projections. A DAVF at the termination of the right petrosal vein (arrow) is shown supplied by the meningohypophysial trunk. Note the varix (arrowhead) in the draining cortical vein. C: Selective angiogram of the right external carotid artery (lateral projection) showing the blood supply to the fistula from the MMA and accessory meningeal artery. D: Superselective angiogram of the right accessory meningeal artery. E: Injection of 50% NBCA is shown penetrating to the affected petrosal vein (crossed arrow). F: Follow-up image obtained 3 months after TAE injection confirms complete obliteration of the fistula.

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    Case 14. A: Admission CT scan demonstrating SAH around the medulla oblongata. B: Selective angiogram of the right VA reveals a DAVF at the craniocervical junction, which drains into the lateral spinal vein with varix formation (arrow). C: Selective angiogram of the external carotid artery showing additional blood supply from the neuromeningeal branch of the ascending pharyngeal artery (arrowhead). D: Follow-up angiogram obtained after surgery demonstrating complete cure of the fistula.

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    Case 16. A: Sagittal T2-weighted MR image showing intramedullary high signal intensity (white arrow) in the cervical spinal cord. B: Selective angiogram of the right VA demonstrating a DAVF at the craniocervical junction fed by a dural branch of the right VA (black arrow). C: In this angiogram, the DAVF is shown draining into the spinal vein through the ectatic medullary vein (crossed arrow). D: Angiogram showing that the dilated neuromeningeal branch of the right ascending pharyngeal artery also supplies the DAVF (arrowhead). E: Follow-up angiogram demonstrating complete cure of the fistula after the direct surgery. F: A concomitant anterior cranial fossa DAVF (asterisk) is also identified on preoperative angiography.

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    The development of the petrosal vein and bridging veins in the vicinity of the medulla is presented schematically. Posteroanterior view of the posterior fossa and part of the spinal region is shown. A: In the early embryonic phase the primary pia-arachnoidal veins (metencephalic, ventral myelencephalic, and hypoglossal veins) and cervical intersegmental veins drain the corresponding primitive brain (metencephalon and myelencephalon) and primitive cervical spinal cord. B: The petrosal vein is derived from the metencephalic vein. The bridging vein draining the vicinity of the medulla is developed through annexation of the ventral myelencephalic vein, hypoglossal vein, and first cervical intersegmental vein. These veins are the cranial homologs of spinal emissary bridging veins. Dural arteriovenous fistulas that develop in the dural zone around the termination of these bridging veins have the same embryological topology. To make the figure easier to understand, the cerebral hemispheres and cerebellum are not shown.



Asakawa HYanaka KFujita KMarushima AAnno INose T: Intracranial dural arteriovenous fistula showing diffuse MR enhancement of the spinal cord: case report and review of the literature. Surg Neurol 58:2512572002


Awad IALittle JRAkarawi WPAhl J: Intracranial dural arteriovenous malformations: factors predisposing to an aggressive neurological course. J Neurosurg 72:8398501990


Borden JAWu JKShucart WA: A proposed classification for spinal and cranial dural arteriovenous fistulous malformations and implications for treatment. J Neurosurg 82:1661791995


Branco GTakahashi AEzura MYoshida MYoshimoto T: Dural arteriovenous shunt involving the superior petrosal sinus: presentation and treatment by transvenous embolisation via the occipital and transverse sinuses. Neuroradiology 39:67701997


Bret PSalzmann MBascoulergue YGuyotat J: Dural arteriovenous fistula of the posterior fossa draining into the spinal medullary veins—an unusual cause of myelopathy: case report. Neurosurgery 35:9659691994


Cognard CGobin YPPierot LBailly ALHoudart ECasasco A: Cerebral dural arteriovenous fistulas: clinical and angiographic correlation with a revised classification of venous drainage. Radiology 194:6716801995


De Jesus ORosado JE: Tentorial dural arteriovenous fistula obliterated using the petrosal approach. Surg Neurol 51:1641671999


Deasy NPGholkar ARCox TCJeffree MA: Tentorial dural arteriovenous fistulae: endovascular treatment with transvenous coil embolisation. Neuroradiology 41:3083121999


Deshmukh VRMaughan PHSpetzler RF: Resolution of hemifacial spasm after surgical obliteration of a tentorial arteriovenous fistula: case report. Neurosurgery 58:E2022006


Djindjian RMerland JJThéron J: Super-Selective Arteriography of the External Carotid Artery New YorkSpringer-Verlag1978


Do HMJensen MECloft HJKallmes DFDion JE: Dural arteriovenous fistula of the cervical spine presenting with subarachnoid hemorrhage. AJNR Am J Neuroradiol 20:3483501999


Duvernoy HM: Human Brain Stem Vessels: Including the Pineal Gland and Information on Brain Stem Infarction ed 2BerlinSpringer1999. 8293


Fujita ATamaki NNakamura MYasuo KMorikawa M: A tentorial dural arteriovenous fistula successfully treated with interruption of leptomeningeal venous drainage using microvascular Doppler sonography: case report. Surg Neurol 56:56612001


Gaensler EHJackson DE JrHalbach VV: Arteriovenous fistulas of the cervicomedullary junction as a cause of myelopathy: radiographic findings in two cases. AJNR Am J Neuroradiol 11:5185211990


Geibprasert SPereira VKrings TJiarakongmun PToulgoat FPongpech S: Dural arteriovenous shunts: a new classification of craniospinal epidural venous anatomical bases and clinical correlations. Stroke 39:278327942008


Grisoli FVincentelli FFuchs SBaldini MRaybaud CLeclercq TA: Surgical treatment of tentorial arteriovenous malformations draining into the subarachnoid space. Report of four cases. J Neurosurg 60:105910661984


Hanabusa KMorikawa ATashiro HYamanaka M: [Craniocervical junction dural arteriovenous malformation presenting with subarachnoid hemorrhage: report of two cases.]. No Shinkei Geka 27:2372411999. (Jpn)


Hashiguchi AMimata CIchimura HKuratsu J: Occipital neuralgia as a presenting symptom of cervicomedullary dural arteriovenous fistula. Headache 47:109510972007


Hashimoto HIida JShin YHironaka YSakaki T: Spinal dural arteriovenous fistula with perimesencephalic subarachnoid haemorrhage. J Clin Neurosci 7:64662000


Hurst RWBagley LJScanlon MFlamm ES: Dural arteriovenous fistulas of the craniocervical junction. Skull Base Surg 9:171999


Iwamuro YNakahara IHigashi TIwaasa MWatanabe YHirata E: Tentorial dural arteriovenous fistula presenting symptoms due to mass effect on the dilated draining vein: case report. Surg Neurol 65:5115152006


Kai YHamada JMorioka MYano SMizuno TKuratsu J: Arteriovenous fistulas at the cervicomedullary junction presenting with subarachnoid hemorrhage: six case reports with special reference to the angiographic pattern of venous drainage. AJNR Am J Neuroradiol 26:194919542005


Kattner KARoth TCGiannotta SL: Cranial base approaches for the surgical treatment of aggressive posterior fossa dural arteriovenous fistulae with leptomeningeal drainage: report of four technical cases. Neurosurgery 50:115611612002


Kim MSHan DHHan MHOh CW: Posterior fossa hemorrhage caused by dural arteriovenous fistula: case reports. Surg Neurol 59:5125172003


Kinouchi HMizoi KTakahashi ANagamine YKoshu KYoshimoto T: Dural arteriovenous shunts at the craniocervical junction. J Neurosurg 89:7557611998


Koch CGottschalk SGiese A: Dural arteriovenous fistula of the lumbar spine presenting with subarachnoid hemorrhage. Case report and review of the literature. J Neurosurg 100:3853912004


Kwon BJHan MHKang HSChang KH: MR imaging findings of intracranial dural arteriovenous fistulas: relations with venous drainage patterns. AJNR Am J Neuroradiol 26:250025072005


Lasjaunias PChiu Mter Brugge KTolia AHurth MBernstein M: Neurological manifestations of intracranial dural arteriovenous malformations. J Neurosurg 64:7247301986


Lasjaunias PGeibprasert SPereira VKrings TJiarakongmun PAurboonyawat T: Classification of dural arteriovenous shunts (DAVS) based on the craniospinal epidural venous drainage of the central nervous system and adjacent bony structures. Jpn J Neurosurg (Tokyo) 17:3563612008


Lewis AITomsick TATew JM Jr: Management of tentorial dural arteriovenous malformations: transarterial embolization combined with stereotactic radiation or surgery. J Neurosurg 81:8518591994


Mascalchi MScazzeri FProsetti DFerrito GSalvi FQuilici N: Dural arteriovenous fistula at the craniocervical junction with perimedullary venous drainage. AJNR Am J Neuroradiol 17:113711411996


Masuo OOzaki FOkita RYamaga HMaeshima SMoriwaki H: [Dural arteriovenous fistula at the cranio-cervical junction presenting transient ischemic attack: a case report.]. No Shinkei Geka 27:104310461999. (Jpn)


Matsushige TNakaoka MOhta KYahara KOkamoto HKurisu K: Tentorial dural arteriovenous malformation manifesting as trigeminal neuralgia treated by stereotactic radiosurgery: a case report. Surg Neurol 66:5195232006


Matsushima TRhoton AL Jrde Oliveira EPeace D: Microsurgical anatomy of the veins of the posterior fossa. J Neurosurg 59:631051983


McDougall CGHalbach VVDowd CFHigashida RTLarsen DWHieshima GB: Dural arteriovenous fistulas of the marginal sinus. AJNR Am J Neuroradiol 18:156515721997


Nakahara IPile-Spellman JHacein-Bey LCrowell RMGress D: [Posterior fossa dural arteriovenous fistula with isolated sinus segment.]. No To Shinkei 45:7037091993. (Jpn)


Ng PPHalbach VVQuinn RBalousek PCaragine LPDowd CF: Endovascular treatment for dural arteriovenous fistulae of the superior petrosal sinus. Neurosurgery 53:25332003


Nishino ASakurai YTakahashi ASatoh HNiizuma HKayama T: [Superior petrosal sinus dural arteriovenous malformation with varix indenting brain stem—report of a case and review of the literature.]. No To Shinkei 43:62691991. (Jpn)


Oda YKonishi TSuzui HFujimoto NNakamura KMatsumoto M: [Partially thrombosed radiculomeningeal arterio-venous fistula in spinomedullary junction.]. No Shinkei Geka 17:63681989. (Jpn)


Oishi HOkuda OArai HMaehara TIizuka Y: Successful surgical treatment of a dural arteriovenous fistula at the craniocervical junction with reference to pre- and postoperative MRI. Neuroradiology 41:4634671999


Ott DBien SKrasznai L: Embolization of a tentorial dural arterio-venous fistula presenting as atypical trigeminal neuralgia. Headache 33:5035081993


Padget DH: The development of the cranial venous system in man, from the viewpoint of comparative anatomy. Contrib Embryol 36:811401957


Partington MDRufenacht DAMarsh WRPiepgras DG: Cranial and sacral dural arteriovenous fistulas as a cause of myelopathy. J Neurosurg 76:6156221992


Piske RLLasjaunias P: Extrasinusal dural arteriovenous malformations. Report of three cases. Neuroradiology 30:4264321988


Rahme RAli YSlaba SSamaha E: Dural arteriovenous malformation: an unusual cause of trigeminal neuralgia. Acta Neurochir (Wien) 149:9379412007


Reinges MHThron AMull MHuffmann BCGilsbach JM: Dural arteriovenous fistulae at the foramen magnum. J Neurol 248:1972032001


Rhoton AL Jr: The cerebellopontine angle and posterior fossa cranial nerves by the retrosigmoid approach. Neurosurgery 47:S93S1292000


Ricolfi FManelfe CMeder JFArrue PDecq PBrugieres P: Intracranial dural arteriovenous fistulae with perimedullary venous drainage. Anatomical, clinical and therapeutic considerations. Neuroradiology 41:8038121999


Rodesch GComoy JHurth MLasjaunias P: Jugular foramen arteriovenous shunt with subarachnoid hemorrhage. Skull Base Surg 1:1321361991


Symon LKuyama HKendall B: Dural arteriovenous malformations of the spine. Clinical features and surgical results in 55 cases. J Neurosurg 60:2382471984


Tanoue SGoto KOota S: Endovascular treatment for dural arteriovenous fistula of the anterior condylar vein with unusual venous drainage: report of two cases. AJNR Am J Neuroradiol 26:195519592005


Thompson BGDoppman JLOldfield EH: Treatment of cranial dural arteriovenous fistulae by interruption of leptomeningeal venous drainage. J Neurosurg 80:6176231994


Trop IRoy DRaymond JRoux ABourgouin PLesage J: Craniocervical dural fistula associated with cervical myelopathy: angiographic demonstration of normal venous drainage of the thoracolumbar cord does not rule out diagnosis. AJNR Am J Neuroradiol 19:5835861998


van Dijk JMterBrugge KGWillinsky RAWallace MC: Clinical course of cranial dural arteriovenous fistulas with long-term persistent cortical venous reflux. Stroke 33:123312362002


van Rooij WJSluzewski MBeute GN: Tentorial artery embolization in tentorial dural arteriovenous fistulas. Neuroradiology 48:7377432006


Versari PPD'Aliberti GTalamonti GBranca VBoccardi ECollice M: Progressive myelopathy caused by intracranial dural arteriovenous fistula: report of two cases and review of the literature. Neurosurgery 33:9149191993


Wackenheim ABraun JP: The Veins of the Posterior Fossa: Normal and Pathologic Findings BerlinSpringer-Verlag1978. 723


Willinsky RTerBrugge KLasjaunias PMontanera W: The variable presentations of craniocervical and cervical dural arteriovenous malformations. Surg Neurol 34:1181231990


Wrobel CJOldfield EHDi Chiro GTarlov ECBaker RADoppman JL: Myelopathy due to intracranial dural arteriovenous fistulas draining intrathecally into spinal medullary veins. Report of three cases. J Neurosurg 69:9349391988


Yamaguchi SOki SMikami TKawamoto YKuwamoto KSaito T: [Myelopathy caused by tentorial dural arteriovenous fistula: a rare case report.]. No Shinkei Geka 28:73782000. (Jpn)


Yoshida SOda YKawakami YSato S: Progressive myelopathy caused by dural arteriovenous fistula at the craniocervical junction—case report. Neurol Med Chir (Tokyo) 39:3763791999




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