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Many treatments for posttraumatic, skull base aneurysms have been described. Eight months after an all-terrain-vehicle accident, this 12-year-old girl presented with right-side Horner syndrome caused by a 33 × 19–mm internal carotid artery aneurysm at the C-1 level. We chose to treat the aneurysm with a new liquid embolic agent for wide-necked, side-wall aneurysms (Onyx HD 500). We felt this treatment would result in less morbidity than surgery and was less likely to occlude the parent artery than placement of a covered stent, especially in a smaller artery in a pediatric patient. Liquid embolic agents also appear to be associated with a lower chance of recanalization and lower cost compared with stent-assisted coil embolization. After the patient was treated with loading doses of aspirin, clopidogrel bisulfate, and heparin, 99% of the aneurysm was embolized with 9 cc of the liquid embolic agent. There were no complications, and the patient remained neurologically stable. Follow-up angiography revealed durable aneurysm occlusion after 1 year. The cost of Onyx was less than the cost of coils required for coil embolization of similarly sized intracranial aneurysms at our institution. Liquid embolic agents can provide a safe, efficacious, and cost-effective approach to treatment of select giant, posttraumatic, skull base aneurysms in pediatric patients.

The authors describe a novel approach to the management of high-output heart failure secondary to an intracranial high-flow dural arteriovenous fistula (DAVF) by using extracorporeal membrane oxygenation (ECMO). To the best of the authors' knowledge, this represents the first report of an embolization performed in conjunction with the use of an ECMO circuit and the first report in which an ECMO cannula was used for intraarterial access for cerebral angiography. A 2-day-old girl presented with severe, high-output heart failure secondary to a high-flow intracranial DAVF. The patient was neurologically intact and no brain parenchymal abnormalities were revealed on computerized tomography scanning of the head, but she suffered severe heart failure, pulmonary hypertension, and liver and renal dysfunction. The patient underwent three endovascular embolization procedures involving coils and liquid embolic agents. Despite a decrease in the DAVF flow, the patient had only transient improvement in her pulmonary hypertension, and venoarterial ECMO therapy was instituted. Another embolization was performed while the patient was receiving ECMO therapy. Her cardiovascular status improved, she was weaned from ECMO, and she was eventually discharged home to her family. Extracorporeal membrane oxygenation can be used to sustain severely ill neonates with high-output heart failure secondary to intracranial AVFs. Embolization can be performed while the patient is receiving ECMO therapy.