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Percutaneous transorbital direct puncture to obliterate a cavernous sinus dural arteriovenous fistula
  1. Daniel D Cavalcanti1,
  2. Eytan Raz1,
  3. Maksim Shapiro1,2,
  4. Osman Mir1,
  5. Erez Nossek3,
  6. Peter Kim Nelson1,3
  1. 1 Radiology, New York University Langone Health, New York, New York, USA
  2. 2 Neurology, New York University Langone Health, New York, New York, USA
  3. 3 Neurosurgery, New York Univesity Langone Health, New York, New York, USA
  1. Correspondence to Dr Eytan Raz, Radiology, New York University, New York, New York, USA; eytan.raz{at}


Cavernous sinus dural arteriovenous fistulas (CS-DAVF) can have an indolent course, with insidious onset, but still showing a high likelihood of spontaneous resolution.1 Nevertheless, symptoms in a subset of patients evolve more rapidly, with malignant signs on imaging, warranting intervention.2 We report on a patient in his 40s presenting with redness and proptosis of the right eye, intermittent blurred vision and diplopia. Once ophthalmological examination revealed increased intraocular pressure and imaging showed cortical venous congestion, the decision was made to obliterate a CS-DAVF involving the posteromedial right cavernous sinus.

Multiple arteries including branches of the ascending pharyngeal artery, occipital artery and bilateral meningohypophyseal trunks supplied the fistula. Once transarterial embolization was deemed unsafe and both inferior petrosal sinuses did not grant access to the right cavernous sinus, a direct puncture to the cavernous sinus was performed to successfully coil the involved compartments.3–5 The aid of DynaCT imaging and needle guidance software is emphasized (video 1).

Video 1
  • arteriovenous malformation
  • coil
  • fistula
  • orbit
  • navigation

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  • Correction notice This article has been corrected since it appeareed Online First. Author Daniel Cavalcanti has been updated to Daniel D Cavalcanti.

  • Contributors DC, ER, MS, OM edited the video. DC, ER, EN, PKN critically reviewed the content. DC narrated the video. DC, ER data collection.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

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