RT Journal Article SR Electronic T1 Percutaneous transorbital direct puncture to obliterate a cavernous sinus dural arteriovenous fistula JF Journal of NeuroInterventional Surgery JO J NeuroIntervent Surg FD BMJ Publishing Group Ltd. SP neurintsurg-2020-017118 DO 10.1136/neurintsurg-2020-017118 A1 Daniel D Cavalcanti A1 Eytan Raz A1 Maksim Shapiro A1 Osman Mir A1 Erez Nossek A1 Peter Kim Nelson YR 2021 UL http://jnis.bmj.com/content/early/2021/03/17/neurintsurg-2020-017118.abstract AB 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