LAUSR

BACKGROUND Certain cavernous sinus (CS) dural arteriovenous fistulae (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, in order 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 CT with real-time fluoroscopic overlays for image guidance during transorbital needle puncture. METHODS Between 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 DAVF were treated with a combination of liquid embolic materials and coils. RESULTS Image guidance aided to avoid at-risk structures and treatment resulted in all cases in complete obliteration of the CS DAVF as verified by control angiography without peri- or post-procedural complications. CONCLUSION Endovascular embolization of CS DAVFs via direct transorbital puncture aided by image guidance provided an alternative option when more conventional approaches are deemed not possible.