Dural arteriovenous fistulas of the hypoglossal canal: systematic review on imaging anatomy, clinical findings, and endovascular management

Dural arteriovenous fistulas (DAVFs) of the hypoglossal canal (HCDAVFs) are rare and display a complex angiographic anatomy. Hitherto, they have been referred to as various entities (for example, “marginal sinus DAVFs”) solely described in case reports or small series. In this in-depth review of HCDAVF, the authors describe clinical and imaging findings, as well as treatment strategies and subsequent outcomes, based on a systematic literature review supplemented by their own cases (120 cases total). Further, the involved craniocervical venous anatomy with variable venous anastomoses is summarized. Hypoglossal canal DAVFs consist of a fistulous pouch involving the anterior condylar confluence and/or anterior condylar vein with a variable intraosseous component. Three major types of venous drainage are associated with distinct clinical patterns: Type 1, with anterograde drainage (62.5%), mostly presents with pulsatile tinnitus; Type 2, with retrograde drainage to the cavernous sinus and/or orbital veins (23.3%), is associated with ocular symptoms and may mimic cavernous sinus DAVF; and Type 3, with cortical and/or perimedullary drainage (14.2%), presents with either hemorrhage or cervical myelopathy. For Types 1 and 2 HCDAVF, transvenous embolization demonstrates high safety and efficacy (2.9% morbidity, 92.7% total occlusion). Understanding the complex venous anatomy is crucial for planning alternative approaches if standard transjugular access is impossible. Transarterial embolization or surgical disconnection (morbidity 13.3%–16.7%) should be reserved for Type 3 HCDAVFs or lesions with poor venous access. A conservative strategy could be appropriate in Type 1 HCDAVF for which spontaneous regression (5.8%) may be observed.

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Gamma Knife surgery for low-flow cavernous sinus dural arteriovenous fistulas

Journal of Neurosurgery ◽

10.3171/2010.8.gks10977 ◽

2010 ◽

Vol 113 (Special_Supplement) ◽

pp. 21-27 ◽

Cited By ~ 5

Author(s):

Hyun Ho Jung ◽

Jong Hee Chang ◽

Kum Whang ◽

Jin Soo Pyen ◽

Jin Woo Chang ◽

...

Keyword(s):

Gamma Knife ◽

Cavernous Sinus ◽

Transarterial Embolization ◽

Gamma Knife Surgery ◽

Low Flow ◽

Close Monitoring ◽

Arteriovenous Fistulas ◽

Ocular Symptoms ◽

Dural Arteriovenous Fistulas

Object The purpose of this study was to assess the efficacy of Gamma Knife surgery (GKS) for treating cavernous sinus dural arteriovenous fistulas (CSDAVFs). Methods Of the 4123 GKSs performed between May 1992 and March 2009, 890 procedures were undertaken to treat vascular lesions. In 24 cases, the vascular lesion that was treated was a dural arteriovenous fistula, and in 6 of these cases, the lesion involved the cavernous sinus. One of these 6 cases was lost to follow-up, leaving the other 5 cases (4 women and 1 man) to comprise the subjects of this study. All 5 patients had more than 1 ocular symptom, such as ptosis, chemosis, proptosis, and extraocular movement palsy. In all patients, CSDAVF was confirmed by conventional angiography. Three patients were treated by GKS alone and 2 patients were treated by GKS combined with transarterial embolization. The median follow-up period after GKS in these 5 cases was 30 months (range 9–59 months). Results All patients experienced clinical improvement, and their improvement in ocular symptoms was noticed at a mean of 17.6 weeks after GKS (range 4–24 weeks). Two patients received embolization prior to GKS but did not display improvement in ocular symptoms. An average of 20 weeks (range 12–24 weeks) was needed for complete improvement in clinical symptoms. There were no treatment-related complications during the follow-up period. Conclusions Gamma Knife surgery should be considered as a primary, combined, or additional treatment option for CSDAVF in selected cases, such as when the lesion is a low-flow shunt without cortical venous drainage. For those selected cases, GKS alone may suffice as the primary treatment method when combined with close monitoring of ocular symptoms and intraocular pressure.

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Pitfalls in Endovascular Treatment of Dural Arteriovenous Fistulas Involving the Cavernous Sinus

Interventional Neuroradiology ◽

10.1177/15910199970030s217 ◽

1997 ◽

Vol 3 (2_suppl) ◽

pp. 88-92

Author(s):

N. Kuwayama ◽

S. Endo ◽

M. Kubo ◽

T. Akai ◽

A. Takaku

Keyword(s):

Endovascular Treatment ◽

Cavernous Sinus ◽

Nerve Palsy ◽

Transarterial Embolization ◽

Abducens Nerve ◽

Abducens Nerve Palsy ◽

Arteriovenous Fistulas ◽

Type D ◽

Dural Arteriovenous Fistulas ◽

The Right

Angiographic changes of the sylvian veins, superior ophthalmic vein (SOV), and superior petrosal sinus (SPS) before and after endovascular treatment were determined for 18 patients with dural arteriovenous fistulas (AVFs) involving the cavernous sinus, and pitfalls of endovascular treatment, especially regarding venous drainage routes, for 3 of the patients were reported. Case 1: 57-year-old woman who presented with right abducens nerve palsy had a Barrow type D fistula in the right cavernous sinus draining into the bilateral inferior petrosal sinuses (IPS). One of the ipsilateral sylvian veins that had drained antegradely before treatment was occluded, and a small lacunar infarction in the corona radiata developed after transvenous embolization (TVE) of the right cavernous sinus. Case 2: 72-year-old woman who presented with symptoms of right ocular hypertension had a type D fistula in the right cavernous sinus draining into only the ipsilateral SOV. Conjunctival hyperemia persisted and was aggravated after angioanatomical obliteration of the fistula by transarterial embolization. Case 3: 55-year-old man who presented with left abducens nerve palsy had a type D fistula in the left cavernous sinus draining into the ipsilateral IPS and sylvian vein. The dural AVF was obliterated once with TVE, but recurred 1 week later with retrograde drainage into the ipsilateral SPS and mesencephalic veins. A second TVE resulted in complete obliteration of the fistula. In conclusion, detailed analysis of drainage routes is necessary for planning of treatment of patients with dural AVF, and prompt treatment is needed when redistribution of drainage routes develops during or after TVE.

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Selective Transvenous Embolization of Dural Arteriovenous Fistulas Involving the Hypoglossal Canal

Interventional Neuroradiology ◽

10.1177/159101990701300108 ◽

2007 ◽

Vol 13 (1) ◽

pp. 59-66 ◽

Cited By ~ 22

Author(s):

M. Okahara ◽

H. Kiyosue ◽

S. Tanoue ◽

Y. Sagara ◽

Y. Hori ◽

...

Keyword(s):

Jugular Vein ◽

Critical Evaluation ◽

Venous Drainage ◽

Transvenous Embolization ◽

Venous Plexus ◽

Venous Anatomy ◽

Hypoglossal Canal ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas ◽

Posterior Condylar

The hypoglossal canal contains a venous plexus that connects the inferior petrous sinus, condylar vein, jugular vein and paravertebral plexus. The venous plexus is one of the venous drainage routes of the posterior skull base. Only a few cases of dural arteriovenous fistulas (AVFs) involving the hypoglossal canal have been reported. We describe three cases (a 62-year-old female, a 52-year-old male, and an 83-year-old male) of dural AVFs involving the hypoglossal canal. Symptoms were pulse-synchronous bruit in two cases and proptosis/chemosis in one. All dural AVFs were mainly fed by the ipsilateral ascending pharyngeal artery. Two of three dural AVFs involving the hypoglossal canal mainly drained through the anterior condylar confluence into the inferior petrosal sinus retrogradely with antegrade drainage through the lateral condylar vein. The other one drained through the lateral and posterior condylar veins into the suboccipital cavernous sinus. All dural AVFs were completely occluded by selective transvenous embolization without any complications, and the symptoms disappeared within one week in all cases. Dural AVFs involving the hypoglossal canal can be successfully treated by selective transvenous embolization with critical evaluation of venous anatomy in each case.

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Angiographic Changes in Venous Drainage of Cavernous Sinus Dural Arteriovenous Fistulae after Palliative Transarterial Embolization or Observational Management: A Proposed Stage Classification

Neurosurgery ◽

10.1227/01.neu.0000153750.95524.62 ◽

2005 ◽

Vol 56 (3) ◽

pp. 494-502 ◽

Cited By ~ 69

Author(s):

Junichiro Satomi ◽

Koichi Satoh ◽

Shunji Matsubara ◽

Norio Nakajima ◽

Shinji Nagahiro

Keyword(s):

Cavernous Sinus ◽

Transarterial Embolization ◽

Venous Drainage ◽

Arteriovenous Fistulae ◽

Complete Cure ◽

Drainage Patterns ◽

Type 3

Abstract OBJECTIVE: We assessed whether angiographic changes in venous drainage patterns occur over time in cavernous sinus dural arteriovenous fistulae (dAVFs) without a complete cure. METHODS: We classified 65 cavernous sinus dAVFs into three types on the basis of initial angiographic findings. In Type 1, both anterior and posterior drainage routes were open; in Type 2, the posterior drainage route was closed, whereas the anterior drainage route was open; and in Type 3, both the posterior and anterior drainage routes were closed. RESULTS: Of the 65 dAVFs, 40 were of Type 1, 21 of Type 2, and 4 of Type 3. During the follow-up period, 17 of the dAVFs that were treated palliatively with transarterial embolization (n = 11) or monitored without therapy (n = 6) demonstrated angiographic changes. In these 11 patients, there was a change in the venous drainage pattern from Type 1 to Type 2 (n = 5), from Type 2 to Type 3 (n = 3), and from Type 1 to Type 3 (n = 3). One of 11 had a conversion into a lesion with cortical venous drainage. The remaining 6 dAVFs (4 with observational management, 2 with transarterial embolization) demonstrated closure of the fistula; in 5 of these, the affected cavernous sinus was not depicted on follow-up angiograms. CONCLUSION: In some cavernous sinus dAVFs with palliative transarterial embolization or observational management, there was a change in the venous drainage patterns, consisting of a decrease in the number of venous drainage routes. There was a trend for the posterior route to close before the anterior drainage or cortical drainage route. This suggests the occurrence of a staged progression in a regular direction in cavernous sinus dAVFs. Without treatment aiming at a complete cure, most cavernous sinus dAVFs can behave benignly, with a low possibility of development of cortical venous reflux during follow-up.

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Transarterial Embolization of Cavernous Sinus Dural Arteriovenous Fistulas with Ipsilateral Inferior Petrosal Sinus Occlusion via the Ascending Pharyngeal Artery

World Neurosurgery ◽

10.1016/j.wneu.2018.06.098 ◽

2018 ◽

Vol 117 ◽

pp. e603-e611 ◽

Cited By ~ 4

Author(s):

Bing Fang ◽

Cong Qian ◽

Jun Yu ◽

Liang Xu ◽

Dingyao Jiang ◽

...

Keyword(s):

Cavernous Sinus ◽

Transarterial Embolization ◽

Inferior Petrosal Sinus ◽

Ascending Pharyngeal Artery ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas

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Endovascular Approaches to the Cavernous Sinus in the Setting of Dural Arteriovenous Fistula

Brain Sciences ◽

10.3390/brainsci10080554 ◽

2020 ◽

Vol 10 (8) ◽

pp. 554

Author(s):

Justin Dye ◽

Gary Duckwiler ◽

Nestor Gonzalez ◽

Naoki Kaneko ◽

Robert Goldberg ◽

...

Keyword(s):

Cavernous Sinus ◽

Vision Loss ◽

Sinus Thrombosis ◽

Venous Anatomy ◽

Arteriovenous Fistulas ◽

Orbital Pain ◽

Dural Arteriovenous Fistulas ◽

Cortical Venous Reflux ◽

Current Report

Dural arteriovenous fistulas involving the cavernous sinus can lead to orbital pain, vision loss and, in the setting of associated cortical venous reflux, intracranial hemorrhage. The treatment of dural arteriovenous fistulas has primarily become the role of the endovascular surgeon. The venous anatomy surrounding the cavernous sinus and venous sinus thrombosis that is often associated with these fistulas contributes to the complexity of these interventions. The current report gives a detailed description of the alternate endovascular routes to the cavernous sinus based on a single center’s experience as well as a literature review supporting each approach. A comprehensive understanding of the anatomy and approaches to the cavernous sinus available to the endovascular surgeon is vital to the successful treatment of this condition.

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Dural arteriovenous fistula of the anterior condylar confluence and hypoglossal canal mimicking a jugular foramen tumor

Journal of Neurosurgery ◽

10.3171/jns/2008/109/8/0335 ◽

2008 ◽

Vol 109 (2) ◽

pp. 335-340 ◽

Cited By ~ 15

Author(s):

James K. Liu ◽

Kelly Mahaney ◽

Stanley L. Barnwell ◽

Sean O. McMenomey ◽

Johnny B. Delashaw

Keyword(s):

Nerve Palsy ◽

Hypoglossal Nerve ◽

Transarterial Embolization ◽

Jugular Foramen ◽

Jugular Bulb ◽

Venous Plexus ◽

Hypoglossal Nerve Palsy ◽

Hypoglossal Canal ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas

The anterior condylar confluence (ACC) is located on the external orifice of the canal of the hypoglossal nerve and provides multiple connections with the dural venous sinuses of the posterior fossa, internal jugular vein, and the vertebral venous plexus. Dural arteriovenous fistulas (DAVFs) of the ACC and hypoglossal canal (anterior condylar vein) are extremely rare. The authors present a case involving an ACC DAVF and hypoglossal canal that mimicked a hypervascular jugular bulb tumor. This 53-year-old man presented with right hypoglossal nerve palsy. A right pulsatile tinnitus had resolved several months previously. Magnetic resonance imaging demonstrated an enhancing right-sided jugular foramen lesion involving the hypoglossal canal. Cerebral angiography revealed a hypervascular lesion at the jugular bulb, with early venous drainage into the extracranial vertebral venous plexus. This was thought to represent either a glomus jugulare tumor or a DAVF. The patient underwent preoperative transarterial embolization followed by surgical exploration via a far-lateral transcondylar approach. At surgery, a DAVF was identified draining into the ACC and hypoglossal canal. The fistula was surgically obliterated, and this was confirmed on postoperative angiography. The patient's hypoglossal nerve palsy resolved. Dural arteriovenous fistulas of the ACC and hypoglossal canal are rare lesions that can present with isolated hypoglossal nerve palsies. They should be included in the differential diagnosis of hypervascular jugular bulb lesions. The authors review the anatomy of the ACC and discuss the literature on DAVFs involving the hypoglossal canal.

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Results of 1940 embolizations for dural arteriovenous fistulas: Japanese Registry of Neuroendovascular Therapy (JR-NET3)

Journal of Neurosurgery ◽

10.3171/2019.4.jns183458 ◽

2020 ◽

Vol 133 (1) ◽

pp. 166-173 ◽

Cited By ~ 4

Author(s):

Masafumi Hiramatsu ◽

Kenji Sugiu ◽

Tomohito Hishikawa ◽

Shingo Nishihiro ◽

Naoya Kidani ◽

...

Keyword(s):

Risk Factors ◽

Data Extraction ◽

Transarterial Embolization ◽

Complication Rates ◽

Multicenter Observational Study ◽

Arteriovenous Fistulas ◽

Emergency Procedures ◽

Dural Arteriovenous Fistulas ◽

Nature Frequency ◽

Independent Risk Factors

OBJECTIVEEmbolization is the most common treatment for dural arteriovenous fistulas (dAVFs). A retrospective, multicenter observational study was conducted in Japan to clarify the nature, frequency, and risk factors for complications of dAVF embolization.METHODSPatient data were derived from the Japanese Registry of Neuroendovascular Therapy 3 (JR-NET3). A total of 40,169 procedures were registered in JR-NET3, including 2121 procedures (5.28%) in which dAVFs were treated with embolization. After data extraction, the authors analyzed complication details and risk factors in 1940 procedures performed in 1458 patients with cranial dAVFs treated with successful or attempted embolization.RESULTSTransarterial embolization (TAE) alone was performed in 858 cases (44%), and transvenous embolization (TVE) alone was performed in 910 cases (47%). Both TAE and TVE were performed in one session in 172 cases (9%). Complications occurred in 149 cases (7.7%). Thirty-day morbidity and mortality occurred in 55 cases (2.8%) and 16 cases (0.8%), respectively. Non–sinus-type locations, radical embolization as the strategy, procedure done at a hospital that performed dAVF embolization in fewer than 10 cases during the study period, and emergency procedures were independent risk factors for overall complications.CONCLUSIONSComplication rates of dAVF embolization in Japan were acceptable. For better results, the risk factors identified in this study should be considered in treatment decisions.

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