Balloon-assisted retrograde cerebral venography for enhanced visualization of the posterior and lateral dural venous sinuses: a feasibility study

Purpose: The venous phase of DSA offers inferior spatial resolution of cerebral venous anatomy due to contrast dilution. Likewise, retrograde cerebral venography (RCV) suffers from poor contrast retention due to contrast injection opposing the physiological direction of venous drainage. Therefore, this study aims to investigate the feasibility of balloon-assisted occlusion in improving visualization of cerebral venous anatomy during RCV. Methods: 17 consecutive patients who underwent balloon-assisted RCV between September 2023-June 2025 were included. A 9 F balloon guide catheter was positioned in the internal jugular vein or sigmoid sinus. Venography was performed before and after balloon inflation. Using standardized criteria, three neuroradiologists independently assessed visualization quality of venous structures, anatomical furthest extent of contrast enhancement, and pathology delineation. McNemar’s test was used for paired statistical comparisons between visualization with and without balloon occlusion. Results: Balloon inflation improved rates of “well visualized” pathology from 15.7% to 88.2% (p < 0.001, OR = 29.04). The most distant structure visualized shifted from the ipsilateral sigmoid sinus without balloon occlusion (visible in 45.1% of cases) to the contralateral sigmoid sinus with balloon occlusion (visible in 72.5% of cases, p < 0.001). With balloon occlusion, homogenous opacification and clear margin delineation of both transverse and sigmoid sinuses showed significant improvements (p < 0.001 for both). No procedure-related complications were observed in this limited cohort. Conclusion: In this feasibility experience, balloon-assisted occlusion during RCV improved visualization of the posterior and lateral dural venous sinuses and associated pathology. Future well-powered studies are needed to validate our findings and determine the definitive safety of this technique.