Transvenous coil embolization with intra-operative cone beam CT assistance in the treatment of hypoglossal canal dural arteriovenous fistulae

BACKGROUND: Hypoglossal canal dural arteriovenous fistulae (HC-dAVF) are a rare subtype of skull base fistulae involving the anterior condylar confluence or anterior condular vein within the hypoglossal canal. Transvenous coil embolization is a preferred treatment strategy, however delineation of fistula angio-architecture during workup and localization of microcatheter tip during embolization remain challenging on planar DSA. For this reason, our group have utilized intra-operative cone beam CT (CBCT) and selective cone beam CT angiography (sCBCTA) as adjuncts to planar DSA during workup and treatment. The purpose of this article is to present our experience in the treatment of HC-dAVF using transvenous coil embolization (TVCE) with cone beam CT assistance, describing our technique as well as presenting our angiographic and clinical outcomes.

METHODS: Ten patients with symptomatic HC-dAVF were treated using TVCE with intra-operative cone beam CT assistance. Prospectively collected data regarding clinical and angiographic results and complication rates was recorded and reviewed.

RESULTS: Complication-free fistula occlusion was achieved in our entire patient cohort. The dominant symptom of pulsatile tinnitus resolved in all 10 patients.

CONCLUSIONS: This study demonstrates that TVCE with CBCT assistance is a highly effective treatment option for HC-dAVF, achieving complication-free fistula occlusion in our entire patient cohort. We have found low-dose sCBCTA and CBCT to be an extremely useful adjunct to planar DSA imaging during both workup and treatment of these rare fistulae.