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Introduction Dural arterio-venous malformations of the cavernous sinus can present with various signs and symptoms of which acute optic neuropathy is particularly serious. Treatment of choice is transvenous embolization of the fistulous cavernous compartment which can be achieved via several routes. In rare instances of transvenous microcatheterization failure direct puncture techniques can be applied.Abstract C96 Figure 1Case Description A 64 year-old female patient presented with acute right-sided reduction of visual acuity. MRI showed a dural arterio-venous malformation of the right cavernous sinus. On angiography it was fed by dural branches of both internal and external carotid arteries and drained through the superior ophthalmic vein (SOV) into the orbit where the SOV ramified into tiny veins causing orbital congestion. No other venous drainage was present. Subsequent microcatheter access to the lesion via conventional venous routes failed. Given rapid visual deterioration direct puncture of the SOV in the orbital fissure was pursued by puncturing the lateral aspect of the inferior eyelid and advancing a 20G spinal needle under roadmap guidance along the orbital floor. Once the SOV was punctured within the fissure, a microcatheter was advanced over the needle into the pouch which was completely occluded with coils. The following day the patient had largely improved orbital and visual symptoms.Abstract C96 Figure 2Conclusions Direct puncture of the superior ophthalmic vein in the superior orbital fissure represents a valuable tool for the endovascular therapy of cavernous aerterio-venous malformations, especially in case of failure of transvenous microcatheter access.Technical and clinical aspects of this technique are illustrated in this case report.Abstract C96 Figure 3Conflict of Interest No