Jugular reflux mimicking dural arteriovenous fistula

Case contributed by Frank Gaillard


Posterior circulation TIA symptoms.

Patient Data

Age: 70 years
Gender: Female

High signal, suggestive of arterialized flow, is seen in the cavernous sinus and down the inferior petrosal sinus, into the jugular foramen with additional high signal suggesting retrograde flow up the sigmoid and transverse sinus.

These findings could be (and were) interpreted as being from a dural arteriovenous fistula from the inferolateral trunk arising from the internal carotid artery.

In fact, these findings are due to retrograde flow up the left internal jugular vein (reflux) 1

A few clues indicate that this is the case, in addition to it being increasingly recognized as a normal finding. Firstly the left internal jugular is the most likely location due to the presence of venous valves in the neck and the non-dominant size of the vein. Secondly, if this was forward (downward) arterialized flow it would be expected to be saturated out in the lower slabs, whereas instead, the brightest signal is in the lowest parts of the visualized internal jugular vein. 

Otherwise, MR angiography is unremarkable other than a calcified atherosclerotic change, particularly prominent in the dominant left vertebral artery, better seen on CT (not shown)

Common carotid injections only obtained, as well as left vertebral artery injection from the left subclavian. No vascular anomaly was shown to correlate with findings on MRI. In particular, there is no early venous filling or other evidence of a dural arteriovenous fistula in the region of the left sigmoid/transverse sinus or elsewhere. Of note, the abnormality is also not shown on CT angiography (not shown).

Case Discussion

This is a good example of retrograde venous flow mimicking arteriovenous shunting. 

To confirm this a time-resolved MR angiogram or CTA (provided contrast was injected on the right) or catheter angiogram could be performed. 

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