Intraoperative cone-beam computed tomography contributes to avoiding hypoglossal nerve palsy during transvenous embolization for dural arteriovenous fistula of the anterior condylar confluence

Abstract

<jats:sec><jats:title>Background</jats:title><jats:p> Dural arteriovenous fistula of the anterior condylar confluence (ACC-DAVF) is a rare subtype of DAVFs that occurs around the hypoglossal canal. Transvenous embolization (TVE) with coils has been performed for most ACC-DAVFs with a high clinical cure rate. However, some reports call attention to hypoglossal nerve palsy associated with TVE due to coil mass compression of the hypoglossal nerve caused by coil deviation from the ACC to the anterior condylar vein (ACV). Herein, we report a case of ACC-DAVF in which an intraoperative cone-beam computed tomography (CT) contributed to avoiding hypoglossal nerve palsy. </jats:p></jats:sec><jats:sec><jats:title>Case presentation</jats:title><jats:p> A 74-year-old man presented with left pulse-synchronous tinnitus. An angiography detected left ACC-DAVF mainly supplied by the left ascending pharyngeal artery and mainly drained through the ACV. The two fistulous points were medial side of the ACC and the venous pouch just cranial of the ACC. We performed TVE detecting the fistulous points by contralateral external carotid angiography (ECAG). The diseased venous pouch and ACC were packed with seven coils but a slight remnant of the DAVF was recognized. Because a cone-beam CT revealed that the coil mass was localized in the lateral lower clivus osseous without deviation to the hypoglossal canal, we finished TVE to avoid hypoglossal nerve palsy. Postoperatively, no complication was observed. No recurrence of symptoms or imaging findings were detected during a five-month follow-up period. </jats:p></jats:sec><jats:sec><jats:title>Conclusion</jats:title><jats:p> An intraoperative cone-beam CT contributed to avoiding hypoglossal nerve palsy by estimating the relationship between the coil mass and the hypoglossal canal during TVE of ACC-DAVF. </jats:p></jats:sec>

Dural arteriovenous fistula of the lateral foramen magnum region: A review

“…The ACC is located at the extracranial aperture of the hypoglossal canal (HC) and has a rich venous network. 1,39 ACV is an emissary venous plexus that is located in the HC, and ACV DAVFs are therefore also called HC DAVFs. [40][41][42][43] HC DAVFs are rare and accounted for an incidence of only 3.6% of all DAVFs in a 2008 study by Manabe et al, 44 and only 4.2% in a 2013 study by Choi et al 41 ACC DAVFs are even rarer than HC DAVFs.…”

“…In addition, the AMA, PMA, and OA can also feed ACC and ACV DAVFs to varying degrees. 39 Rarely, the internal maxillary artery, the transosseous branch of the posterior auricular artery and the petrous branch of the middle meningeal artery of the ECA can be involved in ACC and ACV DAVFs. 6,39,40,53 Draining vein.…”

The Anterior Condylar Arteriovenous Fistula from the Viewpoint of the Osseous Venous Anatomy

“…that is affected by DAVFs is fundamentally important. Although the association of osseous venous structures with AC-AVFs has been reported frequently, 3,8,9,11,[13][14][15][16][17]19) the osseous venous structures adjacent to the hypoglossal canal were studied rarely [20][21][22][23] before we recently investigated them using CT digital subtraction venography. 18) The bone surrounding the hypoglossal canal contains many venous structures ( Figs.…”

“…Based on our investigation, the AC-AVF seemed to be considered as a group of fistulas adjacent to the lateral parts (exoccipital) of the occipital bone, which includes the hypoglossal canal, jugular tubercle, occipital condyle, and the jugular process. Although the involvement of the osseous structures has been frequently reported previously, 3,8,9,11,[13][14][15][16][17]19) the anterior condylar vein has been traditionally considered as a location of a fistulous pouch in AC-AVF. Without modern CT digital subtraction venography or cone beam CT, it is difficult to recognize these intraosseous venous structures and to distinguish between the two fistulous locations: the anterior condylar vein and JTVC.…”

Progress in research on intracranial multiple�dural�arteriovenous fistulas (Review)

“…It may also be used to identify venous hypertension and sinus thrombosis ( 49 ). Flat panel CT analysis and three-dimensional angiographic reconstructions are particularly useful for increasing understanding of the complex anatomy and relationships of intracranial MDAVFs ( 50 ). In Fig.…”