PMC9256014_01
A: Preoperative sagittal T2-weighted magnetic resonance imagingrevealing swelling and an abnormal intensity of the upper cervical spinal cord. B: Lateral view of preoperative right internal carotid angiography showing the varix (asterisk). The feeding system was composed of the tentorial artery (arrowhead) and the feeder from the meningohypophyseal trunk (double arrowheads). C: Anterior-posterior view of preoperative right internal carotid angiography showing TPV (double arrows) as the main draining route into the AMPV. D: Preoperative gadolinium-enhanced CT revealing the varix (asterisk) and petrosal vein (drainer; arrow) around the right trigeminal nerve. Each arrow and arrowhead in A-E show the same vascular structures. E: A schematic illustration of the preoperative angiographic interpretation.
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MRI showed a swollen cord with high intensity on T2-weighted images at the C3/4 level (Fig. 1A). Right cerebral angiography showed a DAVF fed by the tentorial artery, a feeding artery from the meningohypophyseal trunk, and a petrosal branch of the middle meningeal artery (Fig. 1B, C). The shunt point was detected at the para sinus near the superior petrosal sinus (SPS) (Fig. 1D). The draining route involved a petrosal vein draining into the transverse pontine vein, medial medullary vein, and anterior spinal vein (Fig. 1E).
A: Intraoperative photograph showing the varix (asterisk) and petrosal vein (arrow) over the trigeminal nerve. B: Operative field illustration. C: Intraoperative indocyanine green video angiography showing the drainer running down from the varix to the petrosal vein. D: Final view of the operation showing the coagulated varix and disconnected petrosal vein.
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During the surgery, we found dilated petrosal veins covered with a tough arachnoid membrane (Fig. 2A). The varix was adjacent to the petrosal vein (Fig. 2B). Indocyanine green video angiography revealed shunt flow (Fig. 2C). To occlude the shunt, we simply coagulated and disconnected the petrosal veins and then coagulated the varix and tentorial dura (Fig. 2D).
A: Sagittal T2-weighted magnetic resonance imagingobtained 1 month after treatment showing the marked resolution of the upper cervical spinal cord swelling and edema. B, C: Follow-up right internal carotid angiography performed 1 month after treatment showing no residual shunt.
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Postoperative MRI revealed the resolution of the T2-hyperintense signal, swelling of the spinal cord, and abnormal dilated spinal vein disappearance (Fig. 3A). Follow-up angiography performed 1 month after the surgery confirmed DAVF disappearance (Fig. 3B, C).