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Spinal arteriovenous fistulas (AVFs) account for approximately 70% of all vascular spinal malformations and commonly develop in the lateral epidural space at the epidural /radicular venous junction. The fistula is located close to the spinal nerve root where a radiculomeningeal artery shunts to a radicular vein. Increased venous pressure leads to decreased spinal venous drainage and venous congestion causing progressive myelopathy, bowel/bladder incontinence and erectile dysfunction. Treatment consists of surgical occlusion of the intradural vein, or endovascular embolization, which has a reported success rate of 25%-75%. 1 Endovascular failure can occur with inadequate embolic penetration of the nidus and the proximal segment of the draining vein, or premature reflux of the liquid embolic agent.The use of a dual-lumen balloon microcatheter offers advantage in these cases given the ability to push liquid embolysate more distally during balloon inflation. The Scepter Mini is a new dimethyl-sulfoxide (DMSO)-compatible dual-lumen balloon microcatheter with a distal-tip outer diameter of 1.6 Fr and a nominal balloon diameter of 2.2 mm, facilitating atraumatic navigation and safer balloon inflation. Limited neurointerventional experience using the Scepter Mini in predominantly cerebrovascular cases has reported favorable navigability and flow arrest 2, 3 Although Onyx is rarely used for spinal AVF embolization, success has been reported considering the well-known favorable experience in cerebral cases. 1, 4, 5 We present one of the first cases of Onyx embolization of a spinal dural AVF through a Scepter Mini in a patient with progressively worsening lower extremity sensorimotor dysfunction. Operators should be aware of radiculomedullary arteries arising at the same level or at adjacent levels to avoid unintentional Onyx migration during balloon inflation., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Epistaxis is common, impacting more than half the population, and can require procedural intervention in approximately 10% of cases. With an aging population and increasing use of antiplatelets and anticoagulants, severe epistaxis is likely to increase in frequency significantly over the next two decades. Sphenopalatine artery embolization is rapidly becoming the most common type of procedural intervention. The efficacy of endovascular embolization is dependent on a refined understanding of the anatomy and collateral physiology of this circulation as well as the impact of temporizing measures such as nasal packing and inflation of a nasal balloon. Likewise, safety is dependent on a detailed appreciation of collateralization with the internal carotid artery and ophthalmic artery. Cone beam CT imaging has the resolution to enable a clear visualization of the anatomy and collateral circulation associated with the arterial supply to the nasal cavity, in addition to assisting with hemorrhage localization. We present a review of epistaxis treatment, a detailed description of anatomic and physiologic considerations informed by cone beam CT imaging, and a proposed protocol for sphenopalatine embolization for which there is currently no standard., Competing Interests: Competing interests: DHS: grant from Microvention, consulting fees from Medtronic, Microvention and Phonex, support for attending meetings from Medtronic and Microvention, payment or honoraria for lectures from Medtronic and Microvention, equity from Scientia and Vasorum. AD: payment or honoraria from Cerenovus, payment for expert testimony. KA: consulting fees from Medtronic. TP: royalties from Stryker, payment for expert testimony. ER: consulting fees from Balt, Imperative Care and Medtronic, payment or honoraria for lectures from Penumbra, Medtronic, Stryker, Rapid Medical, Micrvention and Phenox, stock with Siemens, equity from Siemens, proctor for Microvention, site PI for PROST, Inspire and NECC. DG: consulting fees from iSchemaView, participation in RAPID AI Advisory Board, Chair of Stroke Performance Measures Oversight Committee (Stroke Council/American Heart Association)., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)