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Table of Contents    
Year : 2012  |  Volume : 60  |  Issue : 1  |  Page : 94-95

Dural arteriovenous fistula of crianiocervical junction: Four case reports

Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China

Date of Submission18-Oct-2011
Date of Decision19-Oct-2011
Date of Acceptance02-Dec-2011
Date of Web Publication7-Mar-2012

Correspondence Address:
Zhongxue Wu
Beijing Neurosurgical Institute, No. 6, Tiantan Xili, Chongwen, Beijing, 100050
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.93612

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 » Abstract 

The clinical characteristics of aggressive craniocervical junction dural arteriovenous fistula (CCJDAVF) and effect treatment was studied in four patients and all four patients were treated endovascularly with liquid embolic agents. Post-embolization angiography documented complete obliteration in one patient and partial obliteration in the other three patients. All patients had good recovery without any procedure-related complications. Endovascular embolization can be used to reduce the rate of flow through CCJDAVFs or as a definitive treatment when the fistula is accessible endovascularly.

Keywords: Craniocervical junction, dural arteriovenous fistula, medulla, spinal cord vein

How to cite this article:
Jiang P, Lv X, Wu Z, Li Y. Dural arteriovenous fistula of crianiocervical junction: Four case reports. Neurol India 2012;60:94-5

How to cite this URL:
Jiang P, Lv X, Wu Z, Li Y. Dural arteriovenous fistula of crianiocervical junction: Four case reports. Neurol India [serial online] 2012 [cited 2023 Nov 30];60:94-5. Available from:

 » Introduction Top

Dural arteriovenous fistulas (DAVFs) are usually classified according to their location, drainage pattern, and the presence of leptomeningeal venous reflux. [1],[2],[3] The venous drainage pattern is the most important predictor of the clinical behavior and DAVFs with cortical venous reflux exhibit a much higher incidence of hemorrhage or venous infarction. Craniocervical junction DAVF (CCJDAVF) is an unusual condition and presents with myelopathy and subarachnoid hemorrhage (SAH). [4] We report on four patients with CCJDAVFs with drainage directly into the bridging vein in the vicinity of the medulla.

 » Case Reports Top

Between 2008 and 2009, of the 42 consecutive patients with DAVFs, four patients (mean age 57.5 years, range 40-73 years, three males) had CCJDAVF with drainage into the medulla bridging vein. The clinical data and angiographic findings were reviewed [Table 1]. We excluded DAVFs located in remote regions that drained into the medulla bridging vein. The clinical manifestation in these patients was SAH. An ascending pharyngeal arteriogram was found to be useful in determining the exact level of the fistula, with its relation to the hypoglossal branch indicating the position of the hypoglossal canal. Three patients showed ascending venous drainage into veins of the cerebellum or supratentorially through the lateral pontine and lateral mesencephalic veins [Figure 1]. Descending drainage through anterior and/or posterior spinal vein was shown in two patients. In all the four patients, small ectatic and varicose draining vein was identified, and in all the four patients who presented with SAH, varices were identified in the draining veins.
Figure 1: Case 2. a: In this angiogram, the DAVF is shown draining into the anterior spinal vein through the ectatic anterior medullary vein (black arrow). b: Angiogram showing that the fistula was drained by a leptomeningeal vein that proceeded upward via the anterior medullary (thin arrow)-anterior pontomesencephalic (thick arrow) veins and bridging veins connected to the left inferior petrosal sinus (white asterisk), and downward to the anterior spinal vein (crossed arrow) and via the bridging vein connected to the suboccipital vein (arrowhead). Transarterial embolization can be performed because the feeding artery can be cannulated using a microcatheter. c: Post-embolization angiogram demonstrating incomplete obliteration of the fistula

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Table 1: Clinical and angiographic characteristics in 4 cases with craniocervical junction DAVFs

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Transarterial embolization was initially attempted in all the patients with Marathon microcatheter (M.T.I.-ev3). In one patient, Onyx injected into the dilated hypoglossal branch of the ascending pharyngeal artery reached the venous side of the fistula, and complete occlusion of the fistula was obtained without neurological sequelae. In the other three patients, transarterial embolization via the dural branch of the vertebral artery (VA) resulted in partial obliteration of the fistula. The three partially embolized fistulas were referred to direct surgical treatment.

 » Discussion Top

CCJDAVFs have been described using a variety of terms, such as foramen magnum, medulla bridging vein-draining DAVFs or spinomedullary junction DAVFs. The reported incidence of CCJDAVFs with aggressive manifestations was significantly higher (P<0.001) than that of cavernous sinus DAVFs or transverse-sigmoid sinus DAVFs. [5] Aggressive manifestations of CCJDAVFs may be attributed to the presence of significant cortical venous reflux. The feeding arteries are usually small and tortuous, and arise directly from the VA or neuromeningeal trunk of the ascending pharyngeal artery, presenting a high risk of embolic complications due to the anatomic situation and many high-risk collaterals. Although there is a lack of information in the literature, from the author's point of view the use of ONYX in such situations should be avoided and N-butyl cyanoacrylate (NBCA) should be preferred. Transarterial embolization can, however, be useful in reducing the rate of flow through a fistula before attempting definitive treatment. Generally, surgical interruption of the draining vein is the most effective treatment for CCJDAVFs. However, we do not consider that radiosurgery is an adequate modality to treat the majority of these DAVFs. The exact level of the draining vein of these DAVFs varied individually. Kinouchi et al., [6] discussed the variability in the location of the draining veins in these DAVFs based on intraoperative findings. Regarding the draining veins situated near the foramen magnum and connecting the pial venous network in the vicinity of the medulla oblongata to the surrounding epidural venous system, in their examination of cadavers, Matsushima et al., [7] described these vessels as connecting the vein of the pontomedullary sulcus or the lateral medullary vein to the sigmoid or inferior petrosal sinus near the jugular foramen, or to the marginal sinus near the hypoglossal canal. Although they did not provide detailed descriptions, the existence of these bridging veins has also been noted by other authors. [8],[9],[10]

 » References Top

1.Borden JA, Wu JK, Shucart WA. A proposed classification for spinal and cranial dural arteriovenous fistulous malformations and implications for treatment. J Neurosurg 1995;82:166-79.  Back to cited text no. 1
2.Cognard C, Gobin YP, Pierot L, Bailly AL, Houdart E, Casasco A, et al. Cerebral dural arteriovenous fistulas: Clinical and angiographic correlation with a revised classification of venous drainage. Radiology 1995;194:671-80.  Back to cited text no. 2
3.Djindjian R, Merland JJ, Théron J. Super-Selective Arteriography of the External Carotid Artery. New York: Springer-Verlag, 1978.  Back to cited text no. 3
4.Hurst RW, Bagley LJ, Scanlon M, Flamm ES. Dural arteriovenous fistulas of the craniocervical junction. Skull Base Surg 1999;9:1-7.  Back to cited text no. 4
5.Awad IA, Little JR, Akarawi WP, Ahl J. Intracranial dural arteriovenous malformations: Factors predisposing to an aggressive neurological course. J Neurosurg 1990;72:839-50.  Back to cited text no. 5
6.Kinouchi H, Mizoi K, Takahashi A, Nagamine Y, Koshu K, Yoshimoto T. Dural arteriovenous shunts at the craniocervical junction. J Neurosurg 1998;89:755-61.  Back to cited text no. 6
7.Kiyosue H, Tanoue S, Sagara Y, Hori Y, Okahara M, Kashiwagi J, et al. The anterior medullary-anterior pontomesencephalic venous system and its bridging veins communicating to the dural sinuses: Normal anatomy and drainage routes from dural arteriovenous fistulas. Neuroradiology 2008;50:1013-23.  Back to cited text no. 7
8.Duvernoy HM. Human Brain Stem Vessels. Including the Pineal Gland and Information on Brain Stem Infarction. 2 nd ed. Berlin: Springer; 1999. p. 82-93.  Back to cited text no. 8
9.Rhoton AL Jr. The cerebellopontine angle and posterior fossa cranial nerves by the retrosigmoid approach. Neurosurgery 2000;47: S93-129.  Back to cited text no. 9
10.Wackenheim A, Braun JP. The Veins of the Posterior Fossa: Normal and Pathologic Findings. Berlin: Springer-Verlag; 1978. p. 7-23.  Back to cited text no. 10


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