• Kazuki Sakakura, Yasunobu Nakai, Go Ikeda, Masanari Shiigai, Noriyuki Watanabe, Kazuya Uemura, Alexander Zaboronok, Eiichi Ishikawa, and Akira Matsumura.
• Department of Neurosurgery, Tsukuba Medical Center Hospital, Tsukuba, Ibaraki, Japan; Department of Neurosurgery, University of Tsukuba, Tsukuba, Ibaraki, Japan.
• World Neurosurg. 2019 Jun 1; 126: 151-155.

BackgroundDural arteriovenous fistulae (dAVFs) of the anatomically complex anterior condylar confluence (ACC) are often examined by computed tomography (CT) angiography and conventional angiography before treatment. Contrasted vessels often overlap with skull bones in enhanced CT scan and make it difficult to detect the shunt point of the dAVF. Bone subtraction CT angiography (BSCTA) can overcome this limitation and allow for superior imaging of dAVFs that may help to find an alternative access for catheterization.Case DescriptionAn 80-year-old woman suffered from right ear tinnitus, headache, and an audible bruit. Preoperative imaging showed a dAVF of the ACC. It was fed by the bilateral ascending pharyngeal artery, drained to the internal jugular vein (IJV) via the inferior petrosal sinus, and had an intraosseous shunt pouch. We therefore performed transvenous embolization (TVE) via the intercavernous sinus because the angle between the anterior condylar vein and the IJV was too sharp to catheterize vessels through the ipsilateral IJV.ConclusionsUnderstanding the inherently complex and individually unique venous anatomy of the ACC is crucial for treatment of dAVFs. BSCTA is an effective visualization technique for dAVFs of the ACC and allows for precise preoperative vascular structure evaluation. We suggest that in the case of the angle between the ACV and the IJV being too sharp to catheterize vessels through the ipsilateral IJV, TVE via the intercavernous sinus can be efficiently used.Copyright © 2019 Elsevier Inc. All rights reserved.

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