Quest for the optimal venous access in a complex skull base dural fistula: Case illustrations and principles.

Treatment of dural arteriovenous fistulae (DAVFs) is dynamic and evolves between diagnostic and therapeutic angiography.A 79-year-old man with a left jugular foramen DAVF presented with new onset cranial nerve XII palsy. The DAVF progressed from Cognard grade I to IIa + b. A transvenous approach was chosen. Attempts to access the left inferior petrosal sinus (IPS) via the left internal jugular vein failed due to occlusion. An alternative route through the left superior ophthalmic vein and left cavernous sinus to the IPS was devised. Successful coil occlusion of the IPS was achieved. Postoperatively, symptoms resolved, and angiography showed no cortical venous reflux.