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Neurology India
Medknow Publications on behalf of the Neurological Society of India
ISSN: 0028-3886 EISSN: 1998-4022
Vol. 59, Num. 3, 2011, pp. 420-423

Neurology India, Vol. 59, No. 3, May-June, 2011, pp. 420-423

Brief Report

Endovascular treatment for dural arteriovenous fistulas at the jugular foramen

Guobiao Liang, Zhiqing Li, Xu Gao, Haifeng Zhang, Jun Lin, Shize Feng, Xuezhong Wei

Department of Neurosurgery, General Hospital of Shenyang Military Region, Shenyang, China

Correspondence Address: Guobiao Liang Department of Neurosurgery, General Hospital of Shenyang Military Region, Shenyang, 11016 China

Date of Submission: 14-Jun-2010
Date of Decision: 11-Aug-2010
Date of Acceptance: 19-Aug-2010

Code Number: ni11121

PMID: 21743174

DOI: 10.4103/0028-3886.82761


We report the technique and results of the endovascular treatment of jugular foramen dural arteriovenous fistulas (DAVFs) in 4 (3 men and 1 women, mean age 50.75 years) symptomatic patients. The jugular foramen DAVFs accounted for 5.9% of intracranial DAVFs. Three patients presented with pulsatile tinnitus and 1 patient presented with intracranial hemorrhage. Angiography demonstrated an AV fistula at the jugular foramen, mostly arising from the middle meningeal, ascending pharyngeal and vertebral arteries with direct drainage to the internal jugular vein. All patients underwent transarterial embolization using Onyx-18. Complete shunt obliteration was achieved in 3 patients; and shunt reduction, in 1 patient, who was cured with additional surgery. Our study suggests that in jugular foramen DAVF transarterial embolization with Onyx should be considered when access is available.

Keywords: Dural arteriovenous fistula, embolization, jugular foramen


Intracranial dural arteriovenous fistula (DAVF) is an abnormal communication between meningeal arteries and dural venous sinuses or veins and usually involves the transverse or sigmoid sinus. [1] The jugular foramen is thought to be an unusual location for DAVFs. [2] Jugular foramen DAVFs are mostly fed by the neuromeningeal branches of the bilateral ascending pharyngeal artery (APA) and the occipital artery (OA) and the meningeal branches of the vertebral artery via the foramen magnum. The internal jugular vein within the jugular foramen, which is the fistulous point, drains directly into the jugular vein. We present our experience of treating jugular foramen DAVFs using transarterial embolization.

Patients and Methods

Between 2006 and 2009, the neurovascular unit at Beijing Tiantan Hospital treated 68 consecutive patients with intracranial DAVFs endovascularly. Four (5.9%) patients had jugular foramen angiography demonstrated that 2 fistulas were type I, 1 was type IIa and 1 was type IIb according to the Cognard classification. [3] Cortical veins were evident in 1 patient. All endovascular procedures were performed under general anesthesia. If the arterial approach was accessible and could be catheterized, we chose the transarterial route.

Transarterial approach

A 6-French guiding catheter was then placed at the origin of the external carotid artery supplying the meningeal artery chosen for DAVF catheterization. A Marathon microcatheter (MTI-ev3, Irvine, California, USA ) was used to catheterize the dilated supplier using a steerable guide wire. Under biplane road-mapping, the microcatheter was slowly flushed with 0.25 mL of dimethyl sulfoxide (DMSO) over 40 seconds. Onyx-18 injection was followed by biplanar simultaneous subtracted fluoroscopy. To obtain a trace of the microcatheter trajectory and to precisely control the Onyx-18 reflux within the feeder, a nonsubtracted single image of the microcatheter with the guide wire was obtained when catheterizing the feeding pedicle. Selective catheterization of the feeding vessels was done to provide complete vascular mapping of these lesions. When the embolic material could not be filled antegradely, the injection was ended.


Radiological follow-up was done with repeat cerebral angiography at 3 to 8 months (mean, 5.5 months). Clinical follow-up was performed at 11 to 38 months (mean, 23 months) and clinical outcome was graded. using the Glasgow outcome scale (GOS) score.


Details of the patients and their symptoms are given in [Table - 1]. Three patients presented with pulsatile tinnitus as the initial symptom, and 1 patient with intracranial hemorrhage. None of the patients had a past history of head injury. The interval between symptom onset and diagnosis ranged from 9 months to 2 years; 3 patients were diagnosed after 1 year of symptom onset. All patients underwent digital subtraction angiography (DSA). Suppliers were from the middle meningeal artery (MMA) in 3 patients; posterior meningeal artery (PsMA), in 3 patients; APA, in 3; OA, in 1; and posterior auricular artery (PAA), in 1 patient with drainage to the internal jugular vein. Three patients underwent transarterial embolization, resulting in obliteration of the fistula. Surgery was performed in 1 patient after failure of a transarterial embolization. A microcatheter was advanced into MMA in 2 patients, PAA in 1 patient and APA in 1 patient. We achieved complete anatomical cure in all patients by the end of the procedure. Neither intraprocedural vessel rupture or other technical complications nor any transient or permanent neurological deficits occurred during or after the treatment.

Illustrative cases

Case 2

A 69-year-old man presented with intracranial hemorrhage associated with dementia [Figure - 1]. Magnetic resonance imaging (MRI) revealed diffuse white matter hyperintensity in the left occipital lobe on the FLAIR. In some regions, the cortical gray matter was also affected; however, this was subtle. An angiogram revealed a type IIb DAVF of the jugular foramen with a single feeder from the left external arteries. Venous drainage was through the left transverse-sigmoid sinus, vein of Labbe, and vein of Trolard with a venous aneurysm. A 5-French catheter was introduced into the left external carotid artery. A Marathon microcatheter was coaxially brought to the fistula point of the DAVF. Onyx-18 was injected, and there was immediate disappearance of the fistula. The patient is now completely asymptomatic, with a follow-up of 3 months.

Case 3

A 47-year-old woman presented with a 1-year history of left pulse-synchronous bruit [Figure - 2]. Diagnostic angiography showed DAVF located at the jugular foramen. The patient underwent transarterial embolization using Onyx-18 via the left MMA. She had complete relief of the symptoms. Control angiograms demonstrated complete occlusion of the fistula by the end of the procedure. She was asymptomatic at 28-month follow-up.


Initially, DAVFs were described only in association with venous sinuses. Subsequently, they have been reported at other locations, such as the tentorium, the skull base and the intraorbital area. [4] The dural arteriovenous fistulas located within the jugular foramen region are fed by dural branches of external carotid arteries and vertebral arteries. DAVFs involving the transverse and sigmoid sinuses often present with pulsatile tinnitus. [1] It seems that this symptom is related to venous turbulence in contact with the petrous bone, or to the high shunt flow into the petrosal sinus. This might explain why most of our patients presented with bruit as the predominant symptom. Cerebral angiography remains the most important modality in evaluating DAVFs.

According to current opinion, transarterial embolization is ideal for the obliteration of Cognard types III to V DAVFs, and management of Cognard types I and II requires an interdisciplinary-team approach, which must be individualized for each patient. [5] Being less invasive, endovascular technique is given preference as the primary mode of treatment. [2],[6],[7],[8] Surgical therapy is warranted if the endovascular technique eventually fails, as it happened one patient in this study. The reason for failure of the endovascular intervention was probably due to the great number of arterial feeders. A transvenous embolization was not carried out in our patients, to avoid the risk of major venous occlusion. The risks in transarterial embolization of sinus-type DAVFs are migration of Onyx from the sinus to the arterialized draining veins, which may cause distal venous occlusion and consequent venous infarction or hemorrhage [9] and embolization of the ascending pharyngeal artery.


1.Lv X, Jiang C, Li Y, Yang X, Wu Z. Intraarterial and intravenous treatment of transverse/sigmoid sinus dural arteriovenous fistulas. Interv Neuroradiol 2009;15:291-300.  Back to cited text no. 1  [PUBMED]  
2.Byun JS, Hwang SN, Park SW, Nam TK. Dural arteriovenous fistula of jugular foramen with subarachnoid hemorrhage: Selective transarterial embolization. J Korean Neurosurg Soc 2009;45:199-202.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.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. 3  [PUBMED]  [FULLTEXT]
4.Tirakotai W, Benes L, Kappus C, Sure U, Farhoud A, Bien S, et al. Surgical management of dural arteriovenous fistulas with transosseous arterial feeders involving the jugular bulb. Neurosurg Rev 2007;30:40-9.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Lv X, Jiang C, Li Y, Wu Z. Embolization of intracranial dural arteriovenous fistulas with Onyx-18. Eur J Radiol 2010;73:664-71.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Liu JK, Mahaney K, Barnwell SL, McMenomey SO, Delashaw JB Jr. Dural arteriovenous fistula of the anterior condylar confluence and hypoglossal canal mimicking a jugular foramen tumor. J Neurosurg 2008;109:335-40.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7.Saraf R, Shrivastava M, Siddhartha W, Limaye U. Evolution of endovascular management of intracranial dural arteriovenous fistulas: Single center experience. Neurol India 2010;58:62-8.  Back to cited text no. 7  [PUBMED]  
8.Gao B. Evolution of endovascular treatment of intracranial dural arteriovenous fistulas. Neurol India 2010;58:1-2.  Back to cited text no. 8  [PUBMED]  
9.H, Lv X, Jiang C, Li Y, Wu Z, Xu K. Onyx migration in endovascular management of intracranial dural arteriovenous fistulas. Interv Neuroradiol 2009;15:301-8.  Back to cited text no. 9  [PUBMED]  

Copyright 2011 - Neurology India

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