P039 Planning the endovascular treatment of a complex galenic dural arterio-venous fistula using intra-arterial cone beam computed tomography

<h3>Introduction</h3> We describe the use of the intra-arterial cone-beam computed tomography (iaCBCT) for the planning of the endovascular treatment of a complex falco-tentorial galenic dural arterio-venous fistula (dAVF). <h3>Case Description</h3> The patient is a 58-year-old male who underwent brain MRI for evidence of dilated pulsating vessels under the scalp. The MRI demonstrated a falco-tentorial galenic dAVF with aneurysmal dilatation of the vein of Galen (VoG). It showed both pial and dural feeders originating from enlarged vessels of the external carotid arteries on the scalp and congestion of the deep cerebral venous system. He underwent transarterial embolization with cyanoacrylate glue of the pial feeders originating from right posterior cerebral and posterior communicating arteries. After one-month, intraoperative iaCBCT well depicted the pouch of the VoG into which the dural feeders drain. In the same session we performed the transvenous coil embolization of this pouch, with a significant reduction of the arterious-venous shunt, and the subsequent transarterial embolization with ONYX-18 by the middle meningeal artery resulted in the complete occlusion of dAVF and preservation of the VoG patency. <h3>Results</h3> Our case demonstrated that the iaCBCT may play a role in better understating the anatomy of complex falco-tentorial galenic dAVFs and planning the endovascular treatment aimed to cure the dAVF with the preservation of the VoG patency.