Transvenous embolization via the inferior petroclival vein for cavernous sinus dural arteriovenous fistula using preoperative and intraoperative image guidance: illustrative case.

BACKGROUND

The standard approach for transvenous embolization (TVE) of a cavernous sinus (CS) dural arteriovenous fistula (DAVF) involves the inferior petrosal sinus (IPS). However, the IPS is often obstructed in many cases. In some cases, the IPS is not connected to the internal jugular vein, making access to the CS via the IPS difficult. The inferior petroclival vein (IPCV) runs through the extracranial petroclival fissures. Although only one case series has reported on the treatment of a CS DAVF via the IPCV, no detailed technical tips have been provided.

OBSERVATIONS

A 76-year-old female presented with right abducens nerve palsy and left ptosis. Angiography revealed a right CS DAVF with bilateral IPS obstructions. Preoperative contrast-enhanced MRI confirmed the IPCV, connecting caudally to the anterior condylar confluence (ACC) and cranially to the internal carotid artery venous plexus of Rektorzik. Intraoperative venography of the ACC revealed the IPCV, allowing easy access to the CS. The patient's symptoms resolved after TVE.

LESSONS

The IPCV is rarely used due to its low anatomical recognition and narrow, tortuous structure compared to the IPS. However, understanding the course of the IPCV through preoperative contrast-enhanced MRI and visualizing the IPCV using intraoperative ACC venography can facilitate the IPCV approach. https://thejns.org/doi/10.3171/CASE24574.