Endovascular treatment of distal intracranial aneurysms with Onyx 18/34

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Abstract

Objective

Surgical clipping and coil embolization of distally located intracranial aneurysms can be challenging. The goal of this study was to assess the feasibility, safety and efficacy of treatment of distal aneurysms with the liquid embolic agent Onyx 18/34.

Methods

Sixteen patients were treated with Onyx 18/34 for distally located aneurysms in our institution between March 2009 and September 2012. The technique consists of occluding the aneurysm as well as the parent vessel at the level of aneurysm with Onyx 18 or 34. Candidates for this treatment were patients with distal aneurysms including mycotic aneurysms, dissecting aneurysms, and pseudoaneurysms in which coiling was considered impossible.

Results

Of the 16 patients, 12 presented with subarachnoid and/or intracerebral hemorrhage. Median aneurysm size was 4.6 mm. Aneurysm locations were as follows: Posterior inferior cerebellar artery (n = 5), distal anterior inferior cerebellar artery (n = 3), distal pericallosal (n = 3), distal anterior cerebral artery (n = 3), lenticulostriate artery (n = 1), and anterior ethmoidal artery (n = 1). There were 4 mycotic aneurysms. Complete aneurysm obliteration was achieved in all 6 patients with available angiographic follow-up. There was only 1 (6.3%) symptomatic complication in the series. There were no instances of reflux or accidental migration of embolic material. Favorable outcomes were noted in 82% of patients at discharge. Two patients with mycotic aneurysms died from cardiac complications of endocarditis. No aneurysm recanalization or rehemorrhage were seen.

Conclusion

Parent vessel trapping with Onyx 18/34 offers a simple, safe, and effective means of achieving obliteration of distal challenging aneurysms.

Introduction

Distally located aneurysms are rare accounting for only 7–9% of anterior cerebral artery aneurysms, 5% of posterior cerebral artery aneurysms, and 2–7% of middle cerebral artery aneurysms [1]. Distal aneurysms are often small, fusiform, thin-walled, and prone to hemorrhage, which makes endosaccular access and coiling technically difficult and hazardous, so that parent artery sparing is usually neither feasible nor safe. Surgical clipping is also challenging due to difficulty in aneurysm localization and may be associated with significant morbidity [2], [3]. The purpose of this study was to assess the feasibility, safety and efficacy of treating distal intracranial aneurysms with the liquid embolic agent Onyx 18/34 (EV3, Irvine, California, USA).

Section snippets

Methods

The study protocol was approved by the University Institutional Review Board. Between March 2009 and September 2012, a total of 16 patients were treated with Onyx 18/34 for distally located intracranial aneurysms in our institution.

The technique consists of occluding the aneurysm as well as the parent vessel at the level of aneurysm with Onyx 18 or 34. Candidates for this treatment were patients with distal aneurysms including mycotic aneurysms, dissecting aneurysms, and pseudoaneurysms in

Results

The median patient age in the series was 59.5 years, with a range of 25–78 years. Seven patients were women and 9 were men. Median aneurysm size was 4.6 mm, with a range of 1–12 mm. Of the 16 patients, 12 (75%) presented with subarachnoid and/or intracerebral hemorrhage. There were 4 (25%) mycotic aneurysms, 3 of which had caused a hemorrhage (the remaining aneurysm was discovered incidentally in a patient with a history of drug abuse and endocarditis). Aneurysms were associated with an

Case 1

A 60-year-old woman was transferred to our institution with a grade III subarachnoid hemorrhage. After placement of a ventriculostomy catheter, she was taken to the interventional neuroradiology suite where a cerebral angiography demonstrated a distal right AICA aneurysm consistent with a dissecting aneurysm (Fig. 1A). Given the location of the aneurysm, the small caliber of the AICA, and the dissected nature of the vessel, we decided to occlude the AICA and the aneurysm with Onyx. Although

Discussion

Endovascular techniques have been gaining ground in the management of intracranial aneurysms. At our institution, endovascular therapy has become a first-line option for most aneurysms [4], [5], [6], [7], [8], [9], [10]. In this study, we assessed our experience with Onyx embolization of distal aneurysms. Onyx is a non-adhesive liquid embolic agent comprised of ethylene vinyl alcohol copolymer dissolved in dimethyl sulfoxide and suspended micronized tantalum powder to provide contrast for

Conclusion

In this paper, we found parent vessel trapping at the level of the aneurysm using Onyx 18/34 to be a simple and fast technique for treating distal aneurysms. The morbidity and mortality rate was satisfactory and patient outcomes were favorable. We believe this technique offers a simple, safe, and effective means of achieving obliteration of distal aneurysms.

Acknowledgment

None.

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