American Journal of Neuroradiology 28:1599-1601, September 2007
DOI 10.3174/ajnr.A0606
© 2007 American Society of Neuroradiology
Case Report
INTERVENTIONAL
Dural Arteriovenous Fistula Involving the Posterior Condylar Canal
H. Kiyosuea,
M. Okaharab,
Y. Sagaraa,
S. Tanouea,
S. Uedab,
C. Mimatac and
H. Moria
a Department of Radiology, Oita University Faculty of Medicine, Yufu City, Oita, Japan
b Department of Radiology, Shinbeppu Hospital, Oita, Japan
c Department of Neurosurgery, Shinbeppu Hospital, Oita, Japan
Please address correspondence to Hiro Kiyosue, Department of Radiology, Oita University Faculty of Medicine, 1-one Idaigaoka Hasama, Yufu City, Oita, Japan; e-mail: hkiyosue{at}med.oita-u.ac.jp
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Abstract
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SUMMARY: Although dural arteriovenous fistulas (DAVFs) occur
in any structure that is covered by the dura mater, DAVFs at
the posterior condylar canal have not been reported. We present
a DAVF that involves the posterior condylar canal and drains
into the posterior condylar vein and the occipital sinus, which
was treated by selective transvenous embolization. Knowledge
of venous anatomy of the craniocervical junction and careful
assessment of the location of the arteriovenous fistula can
contribute to successful treatment.
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Introduction
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The posterior condylar canal is one of the important canals
that communicate between the intracranial and extracranial space.
Intracranial dural arteriovenous fistulas (DAVFs) can involve
any structure that is covered by dural or meningeal matter.
However, to the best of our knowledge, no case of DAVF involving
the posterior condylar canal has been reported. We present the
case of a patient with a DAVF that involves the posterior condylar
canal. We also discuss the venous structures related to the
posterior condylar canal.
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Case Report
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A 54-year-old man presented with a pulse-synchronous bruit for
3 months. He had no history of head trauma or cerebrovascular
disease. Neurologic examinations showed no abnormal findings
except for the bruit around the left ear. MR angiography showed
an abnormal signal intensity, which suggested a DAVF locating
inferiorly to the sigmoid sinus and draining into the posterior
cervical vein and the occipital sinus. An angiogram of the left
external carotid artery showed that the arteriovenous fistula
(AVF) was fed by the left ascending pharyngeal artery and the
left occipital artery, and it drained through the posterior
condylar vein into the sigmoid sinus and the paravertebral vein
and into the occipital sinus (
Fig 1A,
B). The AVF was also supplied
by the dorsal clival artery of the left internal carotid artery
and the anterior meningeal arteries of both vertebral arteries
(
Fig 1C-F). Axial reconstructed images of rotational angiography
of the left external carotid artery clearly demonstrated the
relationship between the fistulous pouch and the draining veins
of the posterior condylar vein and the occipital sinus (
Fig 2).
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Fig 1. Frontal (A) and lateral (B) views of an angiogram of the left external carotid artery show the AVF (white arrow) being fed by the left ascending pharyngeal artery and the left occipital artery, draining through the posterior condylar vein (black arrows) into the posterior cervical vein and sigmoid sinus and into the occipital sinus (arrowheads). Frontal (C) and lateral (D) views of an angiogram of the left vertebral artery show the AVF (white arrow) being fed by the left anterior meningeal artery. Black arrows indicate the posterior condylar vein, and arrowheads indicate the occipital sinus. Angiogram of the right vertebral artery (E) demonstrates the shunted venous pouch (white arrow) being fed by the right anterior meningeal artery. Angiogram of the left internal carotid artery (F) shows the AVF being fed by the dorsal clival artery.
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Fig 2. Axial reconstructed images of rotational angiogram of the left external carotid artery show the fistulous pouch (white arrows) draining through the posterior condylar vein (PCV) into the posterior cervical vein inferiorly and the occipital sinus (OS) posterosuperiorly. The occipital sinus and the posterior condylar vein form a common trunk (arrowheads) that joins into the sigmoid sinus (SS).
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Transvenous embolization was performed with the right femoral venous approach. A 5F/7F coaxial guiding catheter was advanced into the left jugular vein, and a microcatheter (Excelsior; Boston Scientific, Tokyo, Japan) was advanced through the guiding catheter. The microcatheter was introduced via the sigmoid sinus and the posterior condylar vein into the fistulous pouch, and then 3 detachable coils were placed in the pouch. Immediately after the procedure, angiography showed complete occlusion of the AVF. CT after embolization showed coils at the left posterior condylar canal (Fig 3). The symptoms resolved, and no complications were observed during and after the procedure. A follow-up MR angiogram 3 months after embolization showed no recurrent AVF, and no symptoms recurred 14 months after the procedure.
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Discussion
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The posterior condylar canal contains the posterior condylar
vein and meningeal branches of the occipital artery. The posterior
condylar vein originates from the anterior condylar confluence,
the jugular bulb, or the sigmoid sinus at the most medial portion.
1,2 It drains through the posterior condylar canal into the suboccipital
cavernous sinus or the paravertebral vein.
1,2 The occipital
sinus is developed at the fetal period, which originates from
the sinus confluence and drains mainly into the marginal sinus
or the sigmoid sinus.
3 The occipital sinus diminishes after
birth in most cases, but residual small, sinuslike structures
are usually recognized on MR venography. A developed occipital
sinus is occasionally found on cerebral angiography. However,
the anatomic details of the occipital sinus in adults have not
been investigated. In our investigation of MR venography of
23 cases without lesions affecting the venous structures at
the base of the skull and craniocervical junctions, all cases
showed the bilateral occipital sinuses. Among the 46 occipital
sinuses, 40 continued into the marginal sinus, 3 were bifurcated
into 2 venous structures and continued into the marginal sinus
and the posterior condylar vein, and the remaining 3 continued
into the posterior condylar vein at the origin (data not published).
Knowledge of venous anatomy is important for understanding the
drainage pattern of DAVFs at the craniocervical junction.
Although a few authors reported DAVFs that involve the anterior condylar canal,4–7 DAVFs of the posterior condylar vein have not been reported. All published cases of DAVFs of the anterior condylar canal could be treated successfully with transvenous embolization of the fistulous venous pouch. Treatment strategy for DAVFs of both the posterior condylar and anterior condylar veins could be similar. Ernst et al4 mentioned that source images of MR angiography were useful for description of the fistulous pouch. In the presented case, source images of MR angiography were useful, but axial reconstructed images of rotational angiography could demonstrate more clearly the relationship between the fistulous pouch and the drainage veins and was useful for determination of the easiest route of transvenous access into the fistulous pouch. Knowledge of venous anatomy of the craniocervical junction and probing evaluation of the location and drainage veins of the DAVF can contribute to successful endovascular treatment of this AVF at the craniocervical junction.
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References
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- San Millan Ruiz D, Gailloud P, Rufenacht DA, et al. The craniocervical venous system in relation to cerebral venous drainage. AJNR Am J Neuroradiol 2002;23:1500–08[Abstract/Free Full Text]
- Takahashi S, Sakuma I, Omachi K, et al. Craniocervical junction venous anatomy around the suboccipital cavernous sinus: evaluation by MR imaging. Eur Radiol 2005;15:1694–700[Medline]
- Okudera T, Huang YP, Ohta T, et al. Development of posterior fossa dural sinuses, emissary veins, and jugular bulb: morphological and radiologic study. AJNR Am J Neuroradiol 1994;15:1871–83[Abstract]
- Ernst R, Bulas R, Tomsick T, et al. Three cases of dural arteriovenous fistula of the anterior condylar vein within the hypoglossal canal. AJNR Am J Neuroradiol 1999;20:2016–20[Abstract/Free Full Text]
- Kiyosue H, Tanoue S, Okahara M, et al. Ocular symptoms associated with a dural arteriovenous fistula involving the hypoglossal canal: selective transvenous coil embolization. Case report. J Neurosurg 2001;94:630–32[Medline]
- Komiyama M, Ishiguro T, Matsuzaka Y, et al. [Intense pulse-synchronous tinnitus caused by dural arteriovenous fistula at the hypoglossal canal.] No To Shinkei 2002;54:830–31[Medline]
- Tanoue S, Goto K, Oota S. Endovascular treatment for dural arteriovenous fistula of the anterior condylar vein with unusual venous drainage: report of two cases. AJNR Am J Neuroradiol 2005;26:1955–59[Abstract/Free Full Text]
Received December 7, 2006;
accepted after revision January 23, 2007.
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Abstract
Introduction