Micro-balloon-assisted embolization of anterior cranial fossa dural arteriovenous fistula via a trans-ophthalmic approach — a technical report and case series

PURPOSE: Dural arteriovenous fistulas (dAVF) account for approximately 10–15% of all intracranial arteriovenous abnormalities. dAVFs carry a significant risk of mortality, particularly in cases of acute hemorrhage, of up to 10%. A small proportion of these dAVFs are found in the anterior cranial fossa (ACF), of which the rate of hemorrhage can be as high as up to 91%. The Scepter Mini (SM) is the smallest dual-lumen micro-balloon (MB) available for neurointerventional practice. It consists of a 2.8 French outer diameter, with a 2.2 mm × 9 mm semi-compliant balloon providing a working length of 165 cm. The SM is navigated with a 0.008-inch wire making it a particularly attractive tool accessible to the pedicles normally reached with liquid embolization micro-catheters. METHODS: Five consecutive patients over a 1-year period between 2020 and 2021 were evaluated and treated for ACF dAVF using a liquid embolization approach using the SM balloon. All patients were treated using ethylene–vinyl alcohol copolymer (EVOH), of which Squid 18 and/or Squid 12 were the chosen viscosities. Control angiograms were performed for all patients post-embolization. RESULTS: All patients demonstrated complete occlusion of the ACF dAVF on immediate post-treatment angiography. No immediate complications were encountered; particularly, there were no reports of visual field deficit in any of the patients. CONCLUSION: The MB is a valuable adjunctive tool that can enhance the safety and efficacy of trans-ophthalmic embolization of ACF dAVFs, providing additional protection to the retinal and posterior ciliary arteries against unwanted reflux of liquid embolic agent.