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Original research
Increase in fluoroscopic radiation dose in successive sessions of multistage Onyx embolization of brain arteriovenous malformations compared with the first session
  1. Jae Jon Sheen1,
  2. Yuan Yuan Jiang2,
  3. Young Eun Kim1,
  4. Jun Young Maeng1,
  5. Tae-Il Kim1,
  6. Deok Hee Lee1
  1. 1 Department of Radiology, Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea (the Republic of)
  2. 2 Department of Biotechnology, Dongguk University, Ilsan, Korea (the Republic of)
  1. Correspondence to Dr Deok Hee Lee, Department of Radiology, Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea (the Republic of); dhlee{at}


Background and purpose Onyx embolization is a treatment for brain arteriovenous malformations (AVMs). However, multistage embolization usually involves the presence of radiodense Onyx cast from the previous sessions, which may influence the fluoroscopic radiation dose. We compared the fluoroscopic dose between the initial and final embolization sessions.

Materials and method From January 2014 to September 2016, 18 patients underwent multistage Onyx embolization (more than twice) for brain AVMs. The total fluoroscopic duration (minutes), dose–area product (DAP, Gy×cm2), and cumulative air kerma (CAK, mGy) of both the frontal and lateral planes were obtained. We compared the frontal and lateral fluoroscopic dose rates (dose/time) of the final embolization session with those of the initial session. The relationship between the injected Onyx volume and radiation dose was tested.

Results The initial and final procedures on the frontal plane showed significantly different fluoroscopic dose rates (DAP: initial 0.668 Gy×cm2/min, final 0.848 Gy×cm2/min, P=0.02; CAK: initial 12.7 mGy/min, final 23.1 mGy/min, P=0.007). Those on the lateral plane also showed a similar pattern (DAP: initial 0.365 Gy×cm2/min, final 0.519 Gy×cm2/min, P=0.03; CAK: initial 6.2 mGy/min, final 12.9 mGy/min, P=0.01). The correlation between the cumulative Onyx volume (vials) and radiation dose ratio of both planes showed an increasing trend (rho 0.4325–0.7053; P=0.0011–0.0730).

Conclusion Owing to the automatic exposure control function during fluoroscopy, successive Onyx embolization procedures increase the fluoroscopic radiation dose in multistage brain AVM embolization because of the presence of radiodense Onyx mass.

  • angiography
  • arteriovenous malformation
  • liquid embolic material
  • embolic
  • intervention

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  • Contributors All authors made substantial contributions to the design of the study, and analysis and interpretation of the data for the work. All authors drafted and/or revised it critically, and provided final approval of the version to be published, and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • Funding This work was partly supported by a research grant (AMC 2015-9114) from Dongkuk Pharma Co Ltd Korea.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Ethics approval The study was approved by the Asan Medical Center’s institutional review board.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement The authors are ready to share spreadsheets from their data acquisition and experimental set-up details on request.