Embolectomy by SOLUMBRA Technique for Nontarget Intracranial Glue Migration— Complication and Bailout after Percutaneous Embolization of Orbital Meningioma
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.333513
Source of Support: None, Conflict of Interest: None
Keywords: Glue, orbital meningioma, percutaneous embolization, SOLUMBRA
Preoperative embolization is commonly advocated in hypervascular tumors of the head and neck, including certain orbital tumors, to mitigate the blood loss during surgery. Tumor devascularization is usually accomplished via the endovascular trans-arterial route using particulate agents. More comprehensive devascularization can be accomplished by performing direct percutaneous embolization with liquid embolic agents. Among the few reports available on direct percutaneous glue embolization of the head and neck tumors, complications due to glue migration have been described. In this report, we discuss a case of percutaneous glue embolization of an orbital meningioma with distal migration of polymerized glue in the left middle cerebral artery, presenting as stroke, 7 h after the procedure.
A patient in her early 70s, presented with left upper and lower palpebral swelling associated with orbital pain of 1-year duration. The patient was a known hypertensive and diabetic and was on regular medication. About 15 years back, her left eye was enucleated due to phthisis bulbi.
Non-contrast computed tomography (NCCT) of the head demonstrated a left intraorbital hypodense mass, reaching up to the orbital apex [Figure 1]a. There was associated adjoining bone remodeling and hyperostosis [Figure 1]b involving the left orbital roof and lesser wing of the sphenoid. Magnetic resonance imaging (MRI) exhibited an intensely enhancing left intraconal-intraorbital mass, extending to the orbital apex. Associated dural thickening and enhancement were also evident in the left anterior temporal region [Figure 1]c and [Figure 1]d. The digital subtraction angiogram revealed a hypervascular tumor with multiple diminutive feeders from branches of the left ophthalmic artery (OA) supplying the superior and medial component of the tumor [Figure 1]e,[Figure 1]f,[Figure 1]g. External carotid artery (ECA) angiogram demonstrated feeders from the left middle meningeal artery rendering supply to the inferolateral aspect of the lesion [Figure 1]h and [Figure 1]i. In addition, a prominent left anterior deep temporal artery was also perfusing the lesion. Following a careful assessment of MRI and angiographic findings, the meningioma was classified as of moderate vascularity.
In view of her premorbid conditions and age, various management options were contemplated. The multi-compartmental extent of the tumor, vascularity, and large dimension were the primary concerns of the treating neurosurgeon. A decision of preoperative devascularization of the tumor was finally considered in favor of near-total excision of the orbital component of the tumor. A direct percutaneous glue (n-butyl-2-cyanoacrylate [NBCA]) embolization under general anesthesia was adopted because i) possibility of inadvertent embolization to the intra-orbital visual apparatus was deemed irrelevant due to enucleation, ii) liquid embolic agents provide more robust devascularization. The right common femoral artery was accessed, and 5 Fr vascular sheath (Avanti+, Cordis, Miami Lakes, FL) was placed. An 18G spinal needle was introduced percutaneously in the inferolateral quadrant of the orbit [Figure 2]a and [Figure 2]b. Tumorogram demonstrated a marked blush in the inferior and lateral component of the tumor [Figure 2]c and [Figure 2]d with venous drainage into the external jugular vein. No opacification of the intracranial vessels was evident, suggesting safe needle placement. Maintaining extreme vigilance, concentrated glue (50%) (Histocryl) was injected under fluoroscopic guidance; subsequent left common carotid artery (CCA) angiogram demonstrated diminution of the tumoral blush (inferolateral component) with normal opacification of the intracranial circulation. The second 18G spinal needle was then introduced percutaneously along the upper and inner quadrant of the orbit [Figure 2]e and [Figure 2]f. After confirming adequate intratumoral needle placement [Figure 2]g and [Figure 2]h, concentrated glue (50%) was cautiously injected under fluoroscopic guidance. Post-procedure fluoroscopy showed a glue cast in the tumor bed [Figure 2]i and [Figure 2]j. Left CCA angiogram revealed a near-total (>90%) disappearance of the tumor blush with non-opacification of the left OA just distal to its origin. Besides, normal opacification of the intracranial arteries was observed in the post-procedure angiogram [Figure 2]k and [Figure 2]l. The patient was extubated uneventfully with post-procedure GCS of 15/15.
7 h post-procedure, the patient developed aphasia and right hemiparesis (power: 3/5). NCCT exhibited glue cast in the left orbit and a speck of glue in the left Sylvian region [Figure 3]a and [Figure 3]b. Diffusion-weighted MRI demonstrated acute infarct involving left posterior putamen, insula, and frontal operculum (diffusion ASPECTS of 7/10) [Figure 3]c and [Figure 3]d. Susceptibility-weighted imaging showed a blooming focus in the M1 segment of the left MCA. The patient was immediately taken for mechanical embolectomy. Left internal carotid artery (ICA) angiogram revealed partially occlusive polymerized glue in the M1 segment and proximal M2 segments (superior division) and non-visualization of the inferior division of the left MCA [Figure 3]e and [Figure 3]f. The first pass was performed with contact aspiration (ADAPT— A direct aspiration first pass technique) technique, which led to partial recanalization of the inferior division with a Y-shaped filling defect in the MCA bifurcation [Figure 3]g. The second pass was executed using the SOLUMBRA technique using a stentreiver (Solitaire, Medtronic Inc, Mansfield, Massachusetts, USA) and Penumbra aspiration catheter, which led to glue retrieval and complete recanalization of the MCA and its branches [Figure 3]h,[Figure 3]i,[Figure 3]j. Post-procedure NCCT was conspicuous by the absence of the left sylvian glue speck [Figure 4]a, though an established infarct was evident in the left MCA territory [Figure 4]b. The patient was kept intubated and was shifted to ICU. In view of increasing mass effect and hemorrhagic transformation of the infarct [Figure 4]c, a decompressive craniectomy [Figure 4]d was performed on the first post-procedure day.
The patient had a stable clinical course post decompression but developed right hemiplegia (power: 0/5) and aphasia. After a referral to the Department of Physiotherapy and Neurorehabilitation, the patient was discharged in stable condition with persistent aphasia and right hemiplegia. In view of ensuing clinical condition, it was deemed prudent to defer surgical excision along with calvarial flap replacement for a few months.
Treatment of hypervascular neoplasms of the head and neck, being complex, often demands a multidisciplinary approach. Preoperative tumor devascularization reduces blood loss as well as the surgical time and is commonly offered for the management of the head and neck tumors. The embolization route usually adopted is endovascular. However, direct percutaneous tumor access and embolization have also been described for juvenile nasopharyngeal angiofibroma (JNA), carotid body tumors,, paragangliomas as well as orbital hemangiopericytoma using a permanent liquid polymerizing agent (glue or Onyx). In our case, concentrated glue (50%) was used for the same, and satisfactory tumor devascularization was achieved. The percutaneous technique allows direct access to the tumor bed, avoiding the tortuous vascular anatomy, atherosclerotic disease, or catheter-induced vasospasm that could mar the endovascular approach.
Yang et al. have described successful percutaneous glue (20– 30%) embolization in two patients with carotid body tumors, under the safety of balloon inflation in the ICA to avoid inadvertent distal glue migration. Intracranial glue migration may ensue via ECA-ICA anastomoses or retrogradely through OA to the ICA or through the other named and unnamed regional branches arising from the ICA.
Casasco et al. have reported complications of distal glue migration in OA and MCA in two JNA cases during intra-tumoral Histoacryl embolization. They stressed on scrutinizing the site of the needle placement in two orthogonal planes on pre-embolization angiogram and tumorogram. The authors emphasized on the use of high concentration glue for rapid polymerization, and have underscored the role of non-detachable balloon inflation in ICA during glue injection to avoid non-targeted embolization. However, OA feeders require surgical intervention as percutaneous embolization can lead to ocular complications.
Krishnamoorthy et al. have reported a case of stroke consequent to delayed intracranial glue migration following the percutaneous injection of a carotid body tumor. They used 50% glue and additionally inflated balloon in the ICA to prevent intraprocedural glue migration. Post-procedure, the patient remained neurologically intact for several hours. They hypothesized that apart from intraprocedural, non-targeted, non-polymerized glue embolization, infrequently, fragments of polymerized glue can also embolize distally during the early post-procedural period.
In our case, concentrated glue was used without an adjunctive balloon. Glue migration possibly occurred during the early post-procedure period, retrogradely via the OA to ICA, and finally into the left MCA. To reiterate, though the post-procedure angiogram demonstrated non-visualization of the left OA, but for the small stump at its origin, the rest of the intracranial vasculature was unremarkable. In retrospect, the risk of embolic induced devascularization should be carefully weighed against the safer alternatives such as partial excision in a pertinent case. Notwithstanding the devastating complication (as in our case), we do feel such untoward incidents are infrequent, individualized, and tailored approach toward appropriate case selection is advocated. The importance of due diligence and extreme caution cannot be overemphasized during embolic infiltration, irrespective of the route employed.
Liquid embolic agents have an adjunctive role in managing several hypervascular tumors of the head and neck. The use of concentrated glue with balloon protection should be used to avoid non-targeted glue embolization.
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