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Table of Contents    
BRIEF REPORT
Year : 2021  |  Volume : 69  |  Issue : 6  |  Page : 1767-1771

Embolectomy by SOLUMBRA Technique for Nontarget Intracranial Glue Migration— Complication and Bailout after Percutaneous Embolization of Orbital Meningioma


1 Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India
2 Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India

Date of Submission25-May-2020
Date of Decision10-Jul-2020
Date of Acceptance17-Jul-2020
Date of Web Publication23-Dec-2021

Correspondence Address:
Dr. Chandrajit Prasad
Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore - 560 029, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.333513

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 » Abstract 


Presurgical devascularization of neoplasms of the head and neck can be achieved by endovascular as well as direct percutaneous embolization techniques. We report a case of percutaneous glue embolization of an orbital meningioma, complicated by delayed acute stroke due to the distal migration of polymerized glue in the left middle cerebral artery. To the best of our knowledge, this is the first report to discuss the percutaneous embolization of orbital meningioma complicated by stroke due to intracranial glue migration.


Keywords: Glue, orbital meningioma, percutaneous embolization, SOLUMBRA
Key Message: Direct intratumoral injection of liquid embolics for embolization offers advantages over the endovascular route and should be adopted whenever feasible. Caution ought to be exercised while performing the procedure in terms of the rate and concentration of the injected glue, site of needle placement, control angiograms, and the use of a nondetachable occlusal intra-arterial balloon to obviate intracranial glue migration.


How to cite this article:
Chauhan RS, Prasad C, Siddiqui SM, Srinivas D. Embolectomy by SOLUMBRA Technique for Nontarget Intracranial Glue Migration— Complication and Bailout after Percutaneous Embolization of Orbital Meningioma. Neurol India 2021;69:1767-71

How to cite this URL:
Chauhan RS, Prasad C, Siddiqui SM, Srinivas D. Embolectomy by SOLUMBRA Technique for Nontarget Intracranial Glue Migration— Complication and Bailout after Percutaneous Embolization of Orbital Meningioma. Neurol India [serial online] 2021 [cited 2022 Jan 26];69:1767-71. Available from: https://www.neurologyindia.com/text.asp?2021/69/6/1767/333513




Preoperative embolization is commonly advocated in hypervascular tumors of the head and neck, including certain orbital tumors, to mitigate the blood loss during surgery.[1] 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.[2] Among the few reports available on direct percutaneous glue embolization of the head and neck tumors, complications due to glue migration have been described.[3] 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.


 » Case Presentation Top


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.

Investigations

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.[4]
Figure 1: (a and b) Axial and coronal NCCT images show a hypodense lesion in the left orbit with adjoining hyperostosis, (c) axial T2-weighted image shows an isointense orbital tumor and enucleated left eye, (d) axial post-contrast T1-weighted image shows intense tumoral enhancement with thickening and enhancement of dura, (e) left ICA angiogram (lateral-early arterial) shows the left ophthalmic artery supplying the superomedial tumor aspect, (f and g) left ICA angiogram (AP, lateral-capillary phase), (h and i) selective left IMA injection (AP, lateral) shows the tumor blush with MMA branches supplying the inferolateral component. NCCT: non contrast computed tomography; AP: anteroposterior; ICA: internal carotid artery; IMA: internal maxillary artery; MMA: middle meningeal artery

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Treatment

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.
Figure 2: (a and b) fluoroscopy images show first needle placement in the lower and outer quadrant of the left orbit, (c and d) tumorogram (AP, lateral) shows inferolateral tumor opacification with its venous drainage, (e and f) fluoroscopy images show second needle placement in the upper and inner quadrant, (g and h) tumorogram shows superomedial tumor opacification and glue cast from the first injection, (i and j) post-embolization fluoroscopy images show the final glue cast, (k and l) left CCA angiogram (AP, lateral) shows near-total (>90%) disappearance of tumor blush. Non-opacified left OA (L). AP: anteroposterior; CCA: common carotid artery; OA: ophthalmic artery

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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.
Figure 3: (a and b) axial CT shows orbital glue cast. Note the glue speck in the left Sylvian region, (c and d) DWI and ADC map shows acute infarct involving left putamen, insula, frontal operculum, (e and f) Left ICA angiogram shows partially occlusive polymerized glue in left M1 MCA, occluded inferior division, and non-filling parieto-occipital branch (*), (g) Angiogram after the first aspiration shows Y-shaped glue fragment at MCA bifurcation with the re-opened inferior division, (h and i) Angiogram after the second pass shows no MCA filling defect with the normal antegrade flow, (j) Retrieved glue and clot. DWI: diffusion weighted imaging; ADC: apparent diffusion coefficient; ICA: internal carotid artery; MCA: middle meningeal artery

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Figure 4: Post mechanical thrombectomy axial NCCT images (a and b) show no glue speck in the left Sylvian region and established left MCA territory infarct. Axial NCCT image on post-procedure day 1 (c) shows the hemorrhagic transformation of the infarct with contralateral subfalcine herniation. Axial NCCT image post-decompressive craniectomy (d) shows the resolution of the midline shift. NCCT: non contrast computed tomography; MCA: middle meningeal artery

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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.


 » Discussion Top


Treatment of hypervascular neoplasms of the head and neck, being complex, often demands a multidisciplinary approach.[5] 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),[3] carotid body tumors,[6],[7] paragangliomas[8] as well as orbital hemangiopericytoma[1] 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.[7] 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.[3]

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.[6]

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.

Learning points

  • Direct intratumoral injection of liquid embolic for tumor devascularization is more comprehensive and scores over the particulate endovascular technique.
  • Caution ought to be exercised while performing the procedure, particularly concerning (i) glue concentration, (ii) adequate needle placement, (iii) control angiograms, (iv) rate of liquid embolic injection, (v) use of nondetachable occlusal balloon intra-arterially to obviate intracranial migration of the embolic agent.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Pihlblad MS, Schaefer DP. Percutaneous embolization of an orbital hemangiopericytoma with Onyx facilitate its surgical excision. Ophthal Plast Reconstr Surg 2012;28:e147-9.  Back to cited text no. 1
    
2.
Liang Y, Wang D, Huang W, Ling F, Liu Y, Lu F. Direct intratumoral embolization of hypervascular tumors of the head and neck. Chin Med J 2003;116:616-9.  Back to cited text no. 2
    
3.
Casasco A, Houdart E, Biondi A, Jhaveri HS, Herbreteau D, Aymard A, et al. Major complications of percutaneous embolization of skull-base tumors. AJNR Am J Neuroradiol 1999;20:179-81.  Back to cited text no. 3
    
4.
Toh CH, Wei KC, Chang CN, Peng YW, Ng SH, Wong HF, et al. Assessment of angiographic vascularity of meningiomas with dynamic susceptibility contrast-enhanced perfusion-weighted imaging and diffusion tensor imaging. Am J Neuroradiol 2014;35:263-9.  Back to cited text no. 4
    
5.
Duffis EJ, Gandhi CD, Prestigiacomo CJ, Abruzzo T, Albuquerque F, Bulsara KR, et al. Head, neck, and brain tumor embolization guidelines. J NeuroIntervent Surg 2012;4:251-5.  Back to cited text no. 5
    
6.
Krishnamoorthy T, Gupta AK, Rajan JE, Thomas B. Stroke from delayed embolization of polymerized glue following percutaneous direct injection of a carotid body tumor. Korean J Radiol 2007;8:249-53.  Back to cited text no. 6
    
7.
Yang TH, Ou CH, Yang MS, Lee YC, Yeh LR. Pre-operative embolization of carotid body tumor by direct percutaneous intratumoral injection of N-butyl cyanoacrylate glue assisted with balloon protection technique. J Chinese Med Assoc 2011;74:91-4.  Back to cited text no. 7
    
8.
Abud DG, Mounayer C, Benndorf G, Piotin M, Spelle L, Moret J. Intratumoral injection of cyanoacrylate glue in head and neck paragangliomas. AJNR Am J Neuroradiol 2004;25:1457-62.  Back to cited text no. 8
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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