• Zheng-Yi Fu, Yu Feng, Chao Ma, Jin-Cao Chen, Timo Krings, and Wen-Yuan Zhao.
• Department of Neurosurgery, University of Wuhan, Zhongnan Hospital, Hubei, China.
• World Neurosurg. 2019 Oct 1; 130: 306-312.

BackgroundCertain cavernous sinus (CS) dural arteriovenous fistulas (DAVFs) are difficult to access through transarterial or transvenous routes and may necessitate access through direct transorbital puncture of the superior ophthalmic vein (SOV) or the CS. However, to be successful, the accurate design of the puncture route and guidance are crucial. This study aimed to report our preliminary clinical experience using cone-beam computed tomography (CT) with real-time fluoroscopic overlays for image guidance during transorbital needle puncture.MethodsBetween December 2017 and July 2018, 3 patients with CS DAVFs were treated via a transorbital puncture to establish access to the CS under the guidance of XperGuide planning software either via direct CS puncture or through the SOV. The guidance trajectory was superimposed onto the real-time fluoroscopic image during needle puncture. Once access was established, the CS DAVFs were treated with a combination of liquid embolic materials and coils.ResultsImage guidance aided to avoid at-risk structures and treatment resulted in all cases in complete obliteration of the CS DAVFs as verified by control angiography without peri- or postprocedural complications.ConclusionsEndovascular embolization of CS DAVFs via direct transorbital puncture aided by image guidance provided an alternative option when more conventional approaches are deemed not possible.Copyright © 2019 Elsevier Inc. All rights reserved.

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