Direct superior ophthalmic vein puncture for cavernous sinus dural arteriovenous fistula with dual orbital venous outflow: illustrative case.

BACKGROUND

Direct superior ophthalmic vein (SOV) puncture is a viable alternative for transvenous embolization (TVE) of cavernous sinus dural arteriovenous fistulas (CSdAVFs), especially when standard routes are inaccessible. Tailored planning is crucial to preserve venous drainage and avoid orbital complications.

OBSERVATIONS: A 78-year-old man presented with progressive left exophthalmos, conjunctival injection, and diplopia. Digital subtraction angiography revealed a CSdAVF limited to the anterior cavernous sinus with dual venous outflows via the angular and retromandibular veins. The posterior compartment drained physiologically through the inferior petrosal sinus. To preserve venous return and avoid orbital hypertension, direct SOV puncture was selected. Coil embolization achieved complete occlusion of the fistula, maintaining retromandibular drainage. Symptoms resolved immediately without recurrence at 1 year.

LESSONS: Direct SOV puncture is a safe and effective TVE route when standard access is challenging, particularly in cases with dual orbital outflows and preserved posterior drainage. Selecting a single SOV for access minimizes hemodynamic disruption. Preoperative venous mapping is essential to confirm safe drainage pathways and guide approach selection. https://thejns.org/doi/10.3171/CASE2673.