RT Journal Article SR Electronic T1 Unique percutaneous direct puncture technique for occlusion of a hypoglossal canal dural arteriovenous fistula JF Journal of NeuroInterventional Surgery JO J NeuroIntervent Surg FD BMJ Publishing Group Ltd. SP 1179 OP 1182 DO 10.1136/neurintsurg-2018-013845 VO 10 IS 12 A1 Orlando M Diaz A1 Maria M Toledo A1 John O F Roehm A1 Richard P Klucznik A1 Ponraj Chinnadurai A1 Gloria Viviana Lopez A1 Gavin W Britz YR 2018 UL http://jnis.bmj.com/content/10/12/1179.abstract AB 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.