title: Predicting parent vessel patency and treatment durability: a proposed grading scheme for the immediate angiographic results following Onyx HD-500 embolization of intracranial aneurysms.
abstract: BACKGROUND
  Onyx HD-500 embolization of intracranial aneurysms leads to high rates of complete and durable occlusion. However, little information exists as to what constitutes an optimal immediate angiographic result. We devised a simple grading scheme based on the pattern of parent artery and aneurysm neck reconstruction, and correlated it with long term outcome.
  
  
  METHODS
  All cases of Onyx embolization for unruptured aneurysms performed between September 2008 and April 2010 were retrospectively reviewed. Immediate angiographic results were categorized according to the pattern of extra-aneurysmal Onyx leakage: grade A, none; grade B, 'hat brim' lamination; and grade C, 'ectopic' Onyx (C1, non-flow limiting; C2, flow limiting). Results of follow-up vascular imaging were reviewed and correlated with the angiographic grade.
  
  
  RESULTS
  24 embolization procedures were performed in 21 patients with 23 aneurysms. Aneurysm size ranged from 2.5 to 24 mm and neck width from 2 to 8 mm. Complete occlusion was achieved in 20 cases (83.3%) and subtotal occlusion in three (12.5%). Immediate angiographic results were: grade A in ten (41.7%), grade B in eight (33.3%), and grade C in six (25%). Stable angiographic results were seen in 85%, 94%, 94%, and 100% at 6, 12, 24, and 36 months, respectively. Angiographic recurrence was observed in four cases (16.7%), all grade A (p=0.006). Delayed parent vessel occlusion occurred in two cases (8.3%), both grade C2 (p=0.014).
  
  
  CONCLUSIONS
  This simple grading system may help predict long term angiographic results. Hat brim Onyx lamination seems to provide an optimal balance between treatment durability and parent vessel patency. Prospective validation is warranted.
authors.affiliation: Department of Neurosurgery, University of Cincinnati (UC) College of Medicine and Comprehensive Stroke Center at UC Neuroscience Institute, Cincinnati, Ohio, USA Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA.
authors.forename: Ralph
authors.identifier: http://orcid.org/0000-0003-1796-7296
authors.initials: R
authors.lastname: Rahme
authors.affiliation: Department of Neurosurgery, University of Cincinnati (UC) College of Medicine and Comprehensive Stroke Center at UC Neuroscience Institute, Cincinnati, Ohio, USA Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA.
authors.forename: Andrew
authors.initials: A
authors.lastname: Grande
authors.affiliation: Department of Neurosurgery, University of Cincinnati (UC) College of Medicine and Comprehensive Stroke Center at UC Neuroscience Institute, Cincinnati, Ohio, USA.
authors.forename: Lincoln
authors.initials: L
authors.lastname: Jimenez
authors.affiliation: Department of Neurosurgery, University of Cincinnati (UC) College of Medicine and Comprehensive Stroke Center at UC Neuroscience Institute, Cincinnati, Ohio, USA Mayfield Clinic, Cincinnati, Ohio, USA.
authors.forename: Todd A
authors.initials: TA
authors.lastname: Abruzzo
authors.affiliation: Department of Neurosurgery, University of Cincinnati (UC) College of Medicine and Comprehensive Stroke Center at UC Neuroscience Institute, Cincinnati, Ohio, USA Mayfield Clinic, Cincinnati, Ohio, USA.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Ringer
mesh_terms: D000328:Adult; D000368:Aged; D002533:Cerebral Angiography; D004621:Embolization, Therapeutic / Q000295:instrumentation / Q000379:methods*; D005260:Female; D006801:Humans; D002532:Intracranial Aneurysm / Q000000981:diagnostic imaging / Q000473:pathology / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D015641:Radiography, Interventional; D012189:Retrospective Studies; D016896:Treatment Outcome
keywords: Aneurysm; Liquid Embolic Material; Stenosis