title: Onyx HD-500 embolization of intracranial aneurysms: modified technique using continuous balloon inflation under conscious sedation.
abstract: The conventional technique of intracranial aneurysm embolization using Onyx HD-500 (ev3 Neurovascular, Irvine, CA, USA) involves repetitive balloon inflation-deflation cycles under general anesthesia. By limiting parent artery occlusion to 5 minutes, this cyclic technique is thought to minimize cerebral ischemia. However, intermittent balloon deflation may lengthen procedure time and allow balloon migration, resulting in intimal injury or Onyx leakage. We report our experience using a modified technique of uninterrupted Onyx injection with continuous balloon occlusion under conscious sedation. All Onyx embolization procedures for unruptured aneurysms performed by the senior author (A.J.R.) between September 2008 and April 2010 were retrospectively reviewed. Demographic, clinical, angiographic, and procedural data were recorded. Twenty-four embolization procedures were performed in 21 patients with 23 aneurysms, including four recurrences. Twenty aneurysms (87%) involved the paraclinoid or proximal supraclinoid internal carotid artery. Size ranged from 2.5 to 24mm and neck diameter from 2 to 8mm. The modified technique was employed in 19 cases. All but one patient (94.4%) tolerated continuous balloon inflation. Complete occlusion was achieved in 20 aneurysms (83.3%) and subtotal occlusion in three (12.5%). Stable angiographic results were seen in 85%, 94%, 94%, and 100% of patients at 6, 12, 24, and 36months, respectively. There were no deaths. Permanent non-disabling neurological morbidity occurred in one patient (4.2%). Minor, transient, and/or angiographic complications were seen in three patients (12.5%), none related to the technique itself. Onyx embolization of unruptured intracranial aneurysms can be safely and effectively performed using continuous balloon inflation under conscious sedation.
authors.affiliation: Department of Neurosurgery, University of Cincinnati (UC) College of Medicine and Comprehensive Stroke Center at UC Neuroscience Institute, 260 Stetson Street, ML 0515, Cincinnati, OH 45267-0515, USA; Department of Neurosurgery, University of Louisville, Louisville, KY, USA.
authors.forename: Ralph
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, 260 Stetson Street, ML 0515, Cincinnati, OH 45267-0515, USA; Department of Neurosurgery, University of Minnesota, Minneapolis, MN, 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, 260 Stetson Street, ML 0515, Cincinnati, OH 45267-0515, 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, 260 Stetson Street, ML 0515, Cincinnati, OH 45267-0515, USA; Mayfield Clinic, Cincinnati, OH, 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, 260 Stetson Street, ML 0515, Cincinnati, OH 45267-0515, USA; Mayfield Clinic, Cincinnati, OH, USA. Electronic address: mary.kemper@uc.edu.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Ringer
mesh_terms: D000328:Adult; D000368:Aged; D021721:Balloon Occlusion / Q000379:methods*; D002533:Cerebral Angiography; D016292:Procedural Sedation; D004121:Dimethyl Sulfoxide / Q000627:therapeutic use*; D005260:Female; D006401:Hematologic Agents / Q000627:therapeutic use*; D006801:Humans; D002532:Intracranial Aneurysm / Q000473:pathology / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D011145:Polyvinyls / Q000627:therapeutic use*; D012189:Retrospective Studies; D016896:Treatment Outcome
chemical_list: D006401:Hematologic Agents; C505752:Onyx HD 500; D011145:Polyvinyls; D004121:Dimethyl Sulfoxide
keywords: Balloon occlusion; Conscious sedation; Endovascular embolization; General anesthesia; Intracranial aneurysm; Onyx