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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Object

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.

Methods

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.

Results

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.

Conclusions

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.

Headings

Figures

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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.

  • View in gallery

    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.

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