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Original research
Unique percutaneous direct puncture technique for occlusion of a hypoglossal canal dural arteriovenous fistula
  1. Orlando M Diaz1,
  2. Maria M Toledo2,
  3. John O F Roehm3,4,
  4. Richard P Klucznik1,
  5. Ponraj Chinnadurai4,
  6. Gloria Viviana Lopez1,
  7. Gavin W Britz1,5
  1. 1 Division of Interventional Neuroradiology, Houston Methodist Research Institute, Houston, Texas, USA
  2. 2 Department of Endovascular/Cerebrovascular Surgery, Sacred Heart Health System, Pensacola, Florida, USA
  3. 3 Division of Interventional Radiology, Houston Methodist Hospital, Houston, Texas, USA
  4. 4 Advanced Therapies, Siemens Medical Solutions, Hoffman Estates, Illinois, USA
  5. 5 Department of Neurosurgery, Houston Methodist Hospital, Houston, Texas, USA
  1. Correspondence to Dr Orlando M Diaz, Cerebrovascular Center, Houston Methodist Research Institute, Houston, TX 77030, USA; ODiaz{at}


Purpose To report percutaneous transcranial puncture, embolization and occlusion of a very symptomatic hypoglossal canal/anterior condylar vein dural arteriovenous fistula (DAVF) using syngo iGuide navigational software in a patient in whom transarterial and transvenous embolization and surgery had failed.

Methods After unsuccessful arterial and venous embolization and surgical treatment of a symptomatic hypoglossal canal DAVF, a 47-year-old man was transferred for further management. With exquisite anatomic detail provided by C-arm cone-beam computed tomography (CBCT) equipment (Artis zee Biplane, Dyna CT VC21H, Siemens Healthcare GmbH, Germany) and syngo iGuide needle guidance navigational software (Siemens Healthcare GmbHy) for planning a safe direct approach, the hypoglossal/anterior condylar vein, the dominant outflow vein of the fistula, was needle punctured percutaneously at the hypoglossal foramen and occluded with ethylene vinyl alcohol copolymer liquid embolic agent (Onyx, Medtronic, Minneapolis, Minnesota, USA) after placing two anchoring platinum coils (Target detachable coils, Stryker Neurovascular, Fremont, California, USA).

Results After a year of progressively severe left eye proptosis, chemosis and increased intraocular pressure, the symptoms quickly subsided after this embolization and the patient was symptom free at his 3-month and later checkups.

Conclusion With guidance and imaging provided by CBCT and syngo iGuide navigational software, an otherwise untreatable DAVF was successfully embolized and obliterated by an aggressive unique percutaneous trans-cranial needle puncture of the dominant outflow vein in the hypoglossal canal.

  • arteriovenous malformation
  • posterior fossa
  • CT angiography
  • angiography
  • fistula

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  • Contributors All authors have made a substantial direct and intellectual contribution to the work. OD was involved in procedural planning and performance, contributed to manuscript conception, design, creation, editing, and revision. MT was involved in the neurointerventional procedure and contributed to manuscript conception and design. JR was involved in manuscript creation, design, editing, and revision. GB and RK were involved in the neurointerventional procedure, study design and manuscript preparation. GL was involved in manuscript preparation and revision. PC was involved in pre-procedural 3D planning and intra-procedural guidance with cone beam CT imaging and software.

  • Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests PC: full-time paid research scientist, Siemens Medical Solutions USA Inc., Hoffman Estates, Illinois, USA. All other authors: none declared.

  • Patient consent Obtained.

  • Ethics approval The study was approved by the Institutional Review Board of the Houston Methodist Hospital.

  • Provenance and peer review Not commissioned; externally peer reviewed.