title: Transorbital Cavernous Sinus Direct Puncture : Alternative to treat dural arteriovenous fistula.
abstract: BACKGROUND
  The authors present a retrospective series of their clinical experience in the treatment of cavernous dural arteriovenous fistulas (DAVF) by direct transorbital puncture of the cavernous sinus as an alternative to the endovascular approach.
  
  
  METHODS
  Between October 2012 and September 2014, eight patients harboring cavernous DAVF underwent percutaneous treatment by direct transorbital puncture of the cavernous sinus at three institutions. All patients presented with ocular symptoms. Standard endovascular approaches, including transvenous and transarterial routes, were primarily attempted without success in all cases. Direct puncture was performed through two different approaches, namely inferolateral and superomedial. The entry point was the inferior and superior eyelid, respectively. Embolization was performed with coils or Onyx (Covidien, Irvine, CA). Immediate and late angiographies were used to evaluate the occlusion of the fistula.
  
  
  RESULTS
  Of the patients seven had complete occlusion of the cavernous DAVFs noted on the immediate and follow-up angiograms and one patient had residual filling but reduction of the shunt resulted in clinical improvement. None of the patients had worsening of neurological function. One case was complicated by inadvertent internal carotid puncture but without clinical manifestations. One patient experienced postoperative superior ophthalmic vein thrombosis.
  
  
  CONCLUSIONS
  In very specific cases, when endovascular access is not possible or fails to occlude cavernous DAVF, direct transorbital puncture of the cavernous sinus was shown to be feasible, safe and very effective.
authors: Instituto Neurovascular, Felício Rocho Hospital, Mater Dei Hospital, Belo Horizonte, Minas Gerais, Brazil. felipepadovani@yahoo.com.br.
authors: Felipe Padovani
authors: FP
authors: Trivelato
authors: Serviço de Neurologia e Neurocirurgia, Passo Fundo, Rio Grande do Sul, Brazil.
authors: Luciano Bambini
authors: LB
authors: Manzato
authors: Serviço de Neurologia e Neurocirurgia, Passo Fundo, Rio Grande do Sul, Brazil.
authors: Paulo Moacir Mesquita
authors: PMM
authors: Filho
authors: Instituto Neurovascular, Felício Rocho Hospital, Mater Dei Hospital, Belo Horizonte, Minas Gerais, Brazil.
authors: Alexandre Cordeiro
authors: AC
authors: Ulhôa
authors: Serviço de Neurologia e Neurocirurgia, Passo Fundo, Rio Grande do Sul, Brazil.
authors: José Ricardo
authors: JR
authors: Vanzin
authors: Faculdade de Medicina, Universidade de São Paulo, Ribeirão Preto, São Paulo, Brazil.
authors: Daniel Giansante
authors: DG
authors: Abud
authors: Instituto Neurovascular, Felício Rocho Hospital, Mater Dei Hospital, Belo Horizonte, Minas Gerais, Brazil.
authors: Marco Túlio Salles
authors: MTS
authors: Rezende
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D020216:Carotid-Cavernous Sinus Fistula / Q000628:therapy*; D002426:Cavernous Sinus; D020785:Central Nervous System Vascular Malformations / Q000628:therapy*; D002533:Cerebral Angiography; D004621:Embolization, Therapeutic; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011677:Punctures; D012189:Retrospective Studies
keywords: Cavernous sinus; Dural arteriovenous fistula; Embolization; Endovascular