Introduction Aggressive dural arteriovenous fistula (DAVF) can result in venous ectasia forming variceal pouch. Treatment is inevitable because of high risk for hemorrhage. If hypoglossal artery are feeders, special care must be taken during embolization, because of lower cranial nerve(CN) deficit.

Aim of Study We report a case of DAVF with multiple venous varices, fed by middle meningeal artery(MMA) and hypoglossal artery.

Methods A 78-year-old man manifested by only headache. MRI showed abnormal flow voids in temporal lobe, with multiple large venous varices and dilated veins. Cerebral angiogram revealed DAVF at the left transverse sinus(TS). It was supplied by ipsilateral MMA and hypoglossal branch of ascending pharyngeal artery. Cortical venous reflux was evident from the isolated transverse sinus, forming multiple venous varices.

Results Transarterial embolization for ipsilateral MMA was performed with Onyx. There no more filling of the fistula from MMA, but residual filling and pial venous reflux from ascending pharyngeal artery (APA) hypoglossal branch. Before embolization of hypoglossal branch, position of the microcatheter tip was confirmed to be in the hypoglossal canal through 3D reconstruction images, to avoid lower CN deficit. Final angiogram showed complete occlusion of DAVF with no venous ectasia.

Conclusion DAVF with venous varix is defined as high risk for venous hypertension or hemorrhage. There is a possibility of lower CN injury during embolization for hypoglossal artery, so accurate knowledge of anatomical structures is essential. Transarterial embolization for DAVF with large venous varix is a safe and considerable treatment option, even when fed by hypoglossal artery.

Disclosure of Interest Nothing to disclose