Neuroradiology/Head and Neck Imaging · Clinical Perspective 1626 | www.ajronline.org AJR:216, June 2021 Dural arteriovenous fistulas (DAVFs) are high-flow acquired shunts that can carry high risk of intracranial hemorrhage. Because DAVFs can often be managed by endo- vascular means, early and accurate diagnosis can markedly improve patient morbidi- ty. Time-of-flight and arterial spin-labeling MRA have increased the diagnostic utility of MRI for DAVF by showing hemodynamic rather than anatomic evidence of shunt- ing. The purpose of this article is to describe the cases of seven patients who had co- localization of arterial spin-labeling signal intensity and time-of-flight flow-related enhancement in the left skull base, resulting in a misdiagnosis of DAVF and a recom- mendation for catheter angiography by the interpreting radiologist. Benign jugular venous reflux is identified as a common mechanism in each case, and the physiology behind this imaging pitfall is described. An algorithmic diagnostic approach to differ- entiating physiologic venous reflux from true posterior skull base DAVFs is presented. M. Travis Caton, MD 1,2 , Andrew L. Callen, MD 2 , Alexander Z. Copelan, MD 1 , Kazim H. Narsinh, MD 1 , Eric R. Smith, MD 2,3 , Matthew R. Amans, MD, MSc 1 Jugular Venous Reflux Can Mimic Posterior Fossa Dural Arteriovenous Fistulas on MRI-MRA Dural arteriovenous fistulas (DAVFs) are an acquired cerebral vascular disorder charac- terized by abnormal connections between high-pressure arteries and low-pressure veins without an intervening nidus or normal tissue capillaries [1]. DAVFs have varying presen- tations, ranging from clinically silent to catastrophic cerebral hemorrhage, and are no- toriously challenging to diagnose with conventional noninvasive imaging. Digital sub- traction angiography remains the reference standard for diagnosis. However, newer MRI techniques of assessing brain perfusion and vasculature have improved noninvasive as- sessment of patients with suspected DAVF. Specifically, the use of time-of-flight (TOF) and arterial spin-labeling (ASL) perfusion imaging techniques facilitates detection of small DAVFs that would otherwise be occult on MR images obtained with conventional se- quences [2, 3]. TOF technique saturates stationary spins with repetitive radiofrequency pulses, allowing inflowing unsaturated spins to generate flow-related signal. ASL relies on magnetic labeling of inflowing arterial blood in the neck [4]. Both of these techniques rely on identification of what appears to be arterial signal intensity in venous structures to sug- gest the presence of a DAVF. Despite improved sensitivity, areas of high signal intensity on both ASL and TOF MRA may be indistinguishable from DAVFs, even for experienced neuroradiologists [5] (Fig. 1). Misinterpretation of the findings creates risk that the interpreting radiologist will refer the patient for catheter angiography. This is one of several imaging pitfalls that have been uncovered in retrospect owing to the increased use of these MRI techniques in combina- tion with subsequent digital subtraction angiography [6]. To explore this pitfall further, we reviewed MRI reports from a single tertiary academic center between October 2014 through October 2019 and identified seven cases in which the impression statement rec- ommended neurointerventional consultation based on artifactual MRI findings sugges- tive of a posterior skull base DAVF on both ASL and TOF MRA. We present these cases, discuss the likely physiologic mechanism responsible for the artifact, and provide an algo- rithmic approach for radiologists to use in differentiating artifact from true posterior skull base DAVFs. We suggest an approach to interpretation that can limit misdiagnosis and avert unneeded angiography. 1 Department of Radiology and Biomedical Imaging, Neurointerventional Section, University of California San Francisco, 505 Parnassus Ave, Rm L349, San Francisco, CA 94143. Address correspondence to M. T. Caton ([email protected]). 2 Department of Radiology and Biomedical Imaging, Neuroradiology Section, University of California San Francisco, San Francisco, CA. 3 Department of Radiology, Medical College of Wisconsin, Milwaukee, WI. doi.org/10.2214/AJR.20.24012 AJR 2021; 216:1626–1633 ISSN-L 0361–803X/21/2166–1626 © American Roentgen Ray Society Caton et al. MRI-MRA Angiography of Jugular Venous Reflux Caton MT, Callen AL, Copelan AZ, Narsinh KH, Smith ER, Amans MR Neuroradiology/Head and Neck Imaging Clinical Perspective Keywords arterial spin labeling, arteriovenous fistula, cerebral angiography, jugular vein, reflux, MRA Submitted: Jun 1, 2020 Revision requested: Jun 16, 2020 Revision received: Jul 16, 2020 Accepted: Jul 27, 2020 First published online: Sep 2, 2020 The authors declare that they have no disclosures relevant to the subject matter of this article. Based on a presentation from the American Society of Neuroradiology 2020 virtual annual meeting. Supported by National Institute on Deafness and Other Communication Disorders of the National Institutes of Health (no. R21DC016087-01A1) (M. R. Amans) and National Heart, Lung, and Blood Institute of the National Institutes of Health (no. R56HL149124-01) (M. R. Amans). An electronic supplement is available online at doi.org/10.2214/AJR.20.24012. 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