PMC1705527_01
DAVFs with transosseous arterial feeders. Right external carotid angiogram, antero-posterior (AP) (a) and lateral (b) views, demonstrate arteriovenous fistulas (arrows) adjacent to the right internal jugular bulb. The fistulas are mainly fed by the right-sided ascending pharyngeal and occipital arteries. Symptoms were improved following transarterial embolization with coils (c), but the fistulas persisted. Intraoperative photograph with the patient in the sitting position showing the electrodes for lower cranial nerve monitoring (d). Postoperative angiograms (e and f) demonstrate cure of the DAVFs. The same patient's axial CT scan reveals the preoperative intraosseous lesion near the jugular process (g). Postoperative CT scan shows minimal bony removal (h)
10143_2006_56_Fig1_HTML.jpg
PMC1705527_01_10143_2006_56_Fig1_HTML.jpg
Fig1
Although the endovascular intervention resulted in coil occlusion of the occipital artery, the DAVFs still persisted (Fig. 1). Only minimal bony involvement around the jugular foramen was detectable on the CT scan (Fig. 1). 
Lateral (a) and AP (b) preoperative angiograms of the right common carotid artery (CCA), demonstrating the right intraosseous DAVFs (arrows). Postoperative right CCA angiogram revealing the remaining fistula (c). On the CT scan (d) bony erosion of the medial portion of the right jugular tubercle becomes evident (white arrows). Selective injection of preoperative right occipital artery reveals intraosseous fistula (e). The patient is positioned in the left lateral park bench position (f)
10143_2006_56_Fig2_HTML.jpg
PMC1705527_01_10143_2006_56_Fig2_HTML.jpg
Fig2
A recent angiography disclosed the typical early filling of the right jugular bulb, and right sigmoid and transverse sinuses through intraosseous DAVFs mainly supplied by both ascending pharyngeal arteries and both occipital arteries (Fig. 2). The patient subsequently underwent surgical intervention in the left park bench position (Fig. 2). 
Bilateral intraosseous DAVFs causing bilateral pulsatile tinnitus. Right lateral (a) and AP (b) external carotid angiograms, as well as right AP (c) common carotid angiogram demonstrate multiple arteriovenous shunts fed by the right internal maxillary and occipital arteries. MRI (d) and CT (e) studies show the abnormal vessels posterior to the right jugular tubercle and the enlarged jugular foramen with its surrounding bony erosion, respectively (arrows). The photograph shows the skin incision for the right transcondylar approach (f). Intraoperative screenshot of navigation, applied for localizing the exent of the arteriovenous fistulas (g)
10143_2006_56_Fig3_HTML.jpg
PMC1705527_01_10143_2006_56_Fig3_HTML.jpg
Fig3
Neurological examination was irrelevant, and superselective angiography revealed numerous bilateral DAVFs in the foramen magnum region affecting both occipital condyles and jugular processes (Fig. 3). Additionally, the patient developed a movement-related neck pain which proved to be caused by a fracture of the right occipital condyle, with dislocation of a bony fragment and craniocervical instability (Fig. 3).
Postoperative CT scan of the same patient shown in Fig. 3 reveals a fracture of the right occipital condyle with dislocation of a bony fragment (a). Postoperative angiograms of the right external carotid artery (ECA), lateral (b) and AP (c) views showing no arteriovenous fistula after the surgical resection of right intraosseous DAVFs. Preoperative angiogram of the left ECA revealing arterial filling of the jugular vein and left-side DAVFs (d). The patient is placed in the prone position for the surgery of the left intraosseous DAVFs and the occipito-cervical fusion (e). Postoperative lateral plain radiogram (f) and a schematic drawing (g) demonstrating the instrumentation used for the occipitocervical fusion (g)
10143_2006_56_Fig4_HTML.jpg
PMC1705527_01_10143_2006_56_Fig4_HTML.jpg
Fig4
She underwent a second surgical procedure via a left transcondylar approach to treat the left DAVFs, followed by an occipitocervical fusion performed in the same surgical setting (Fig. 4). 