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●Abstract● Purpose: We report a case of cavernous dural arteriovenous fistulas (dAVFs) completely occluded by transarterial embolization with n-butyl cyanoacrylate (NBCA) as the embolic agent and using balloon assisted technique. Case: A 37-year-old woman presented with right conjunctival injection, proptosis and diplopia. She was initially treated with right carotid compression without improvement of symptoms. Two weeks prior to admission to our institution, she experienced acute worsening of the symptoms. Her right intraocular pressure was 31mmHg on admission. MRI showed right cavernous dAVFs. Angiographic study showed dAVFs to the right anterior inferior cavernous sinus supplied by the branches of the right internal and external carotid arteries. Endovascular treatment was performed by a bi-femoral approach. A microballoon catheter was placed in the right internal carotid artery across the cavernous segment. A microcatheter was wedged into the carotid branch of the ascending pharyngeal artery. Under balloon inflation to close the origin of the C4 feeder to the fistulas, 0.7cc of 25% NBCA mixed with ethiodol was injected from the wedged microcatheter, resulting in complete occlusion of the fistulas. The patient showed immediate improvement of the symptoms and her right intraocular pressure was normal one week after treatment. Conclusion: Trans-arterial embolization may be the best treatment option for selected cases of cavernous dAVFs. Balloon protection of the internal carotid artery may be necessary for aggressive trans-arterial embolization to prevent NBCA migration into the cerebral circulation through the anastomosis between the external and internal carotid arteries.

Cavernous sinus dural arteriovenous fistula completely occluded by transarterial NBCA embolization with balloon assisted technique