Charles

A. Jungreis,

MD

Skull-Base Tumors: Ethanol Embolizatlon ofthe Cavernous Carotid Artery’ Tumors of the skull base frequenfly have some blood supply from cavernous branches of the internal carotid artery (ICA). tion of such

Preoperative

completed

after

emboli-

zation. The other five patients had much drier surgical fields than expected. Index terms: Alcohol #{149} Arteries, therapeutic blockade, 172.1299 #{149} Carotid arteries, therapeutic blockade, 172.1299

Radiology

1991; 181:741-743

From the Departments of Radiology and Neurological Surgery, University of Pittsburgh School of Medicine, Presbyterian University Hospital, DeSoto at OHara Sts, Pittsburgh, PA 15213. Received June 10, 1991; revision requested July 3; revision received July 12; accepted July 22. Address reprint requests to the author. C RSNA, 1991 I

Data

Age/Sex

emboliza-

pedicles can expedite the subsequently performed surgery. Sometimes, however, the tumor yessels are multiple and very small so selective catheterizations are not possible, particularly when the tumor invades the cavernous sinus. In eight procedures in seven patients of this type, the tumor was embolized with 100% ethyl alcohol by temporarily occluding the ICA above the feeders while infusing ethanol with a microcatheter as close to the feeders as possible. At fluoroscopy, tumor blush was seen to have decreased markedly in all cases. In one patient,. no obvious benefit was gained at surgery. In another patient, a first surgery that was aborted due to blood loss was successfully

Patient

.

Diagnosis

28/M

Meningioma

31/F

Meningioma

32/M 37/F

Meningioma Meningioma

Neurobogic Increased nerve

weakness Vi already

S

in cranial paralyzed);

nerves HI and IV (cranial transient mild upper

extremity weakness on balloon deflation Transient right cranial nerve VI palsy (first procedure on right ICA); delayed onset of transient paralysis of cranial nerves ifi-VI (second procedure on left ICA) No change Transient

decreased

of ipsilaterab 42/F 45/F 60/F

Change

Meningioma Meningioma Meningioma

sensation

trigeminab

in face

nerve

(maxillary

division

) on balloon

deflation

No change No change No change

tumors sometimes receive a portion of their blood supply from cavernous branches of the internal carotid artery (ICA). For example, the meningohypophyseal trunk frequently feeds tumors of the cavernous sinus and/or the tentonium cenebelli. If catheters can be sebectively placed into a particular feeding vessel, then preoperative embobization can be performed in the usual fashion with relative safety. However, the blood supply to many tumors of this region is in the form of a myriad of small vessels that originate at the cavernous portion of the ICA. These small vessels are too small to be cathetenized individually, but nevertheless they provide a significant supply to the tumor and are a source of considKULL-BASE

enable bleeding at surgery. In an attempt to decrease the intraoperative blood boss, we treated seven patients preopenatively (one bilaterally) by infusing 100% ethyl alcohol through a microcatheter that was positioned as close as possible to the pathologic yessels while the distal ICA was being occluded by a temporarily placed endovascuban balloon.

tion

with

Blood

preservation

supply

stantial

of the

to each

ICA (Table).

tumor

contribution

had

from

the

a sub-

cavernous

portion of the ICA. Two patients had supply bilaterally from the cavernous portion of both ICAs. All patients had some supply from the ipsibateral external carotid artery. In most cases the external supply was embolized in either the same session or during a procedure performed with standard techniques on the previous day. All embobizations were performed in the angiography suite. Patients were awake but sedat-

ed with intravenously administered doses of fentanyl citrate (Elkins-Sinn, Cherry Hill, NJ) and Laboratories,

trated

midazobam Nutbey,

clinically.

Through

an

8-F

B Kit; femoral

catheter

(Introducer

ventional cisco,

sheath

(Radiofocus

Terumo,

troducer into the

Tokyo)

artery,

an

Cabif)

was

portion obtained

activated

tial “dead

8-F

coagulation

time

spaces”

passed

Franinto

of the ICA. A blood for measurement (1).

between

were perfused A nondetachable

was

Inter-

San

coaxiabby

with

All

the samof the

poten-

coaxial

cathe-

heparinized silicon balloon

catheter (model 1505 NDSB loon Catheter; Interventional tics)

introducer Set;

South

passed

In-

placed

Catheter

Therapeutics,

cervical ple was

ters line.

(Versed; Roche that were ti-

NJ)

through

the

sa-

Occlusion Therapeuintroducer

catheter until the balloon was just distal the vessels supplying the tumor. Five

MATERIALS Eight seven

AND

procedures patients

were

scheduled

Bal-

to

METHODS performed for

tumor

in resec-

Abbreviation:

ICA

=

internal

carotid

artery.

741

a.

c.

b.

d.

f.

C.

Images were dimeglumine;

obtained of the first Magnevist; Berlex

procedure Laboratories,

performed Wayne,

on the right ICA of the NJ) MR image (repetition

aged) demonstrates a large skull-base meningioma along the right petrous extends into the ICA and into both cavernous sinuses. (b) Lateral angiogram cavernous

portion

of the

ICA.

The tip of a microcatheter sion

of the

the distal (compare

distal

ICA

(c) Lateral

used with

fluoroscopic

for the ethanol

the

balloon

shows

ICA shows that while some tumor with d). (f) Lateral postembolization

view

infusion extensive

shows

(white tumor

vessels from angiogram

an

arrow) blush.

31-year-old patient. time = 520 msec,

(gadopentetate four signals

bone that compresses the brain stem and cerebellum. The of the right ICA shows multiple tumor vessels originating

endovascular

balloon

is also apparent.

(black

(d) Lateral

(e) Postembobization

the ICA opacified, of the ICA shows

(a) Axial contrast-enhanced echo time = 25 msec, with

arrow)

in position

angiogram

angiogram

of the

to occlude

the

of the ICA obtained ICA

obtained

the flow was almost static, and the tumor that the integrity of the ICA is maintained,

during

blush and

aver-

tumor in the distal

ICA.

during

occlu-

occlusion

of

was decreased the tumor blush

is

decreased.

thousand

units

of heparin

sodium

Pak Laboratories, Franklin administered intravenously placement

of the

crocatheter

(model

Therapeutics, passed

eter

catheter.

the

A mi-

was

then

introducer

cath-

as possible to the abnormal feeders just proximal to the balloon. Dehydrated ethanol (American Regent Laboratories, Shirley, NY) was opacified with metrizamide (Amipaque; Winthrop

the tip was

Target

Calif)

same

as close

Pharmaceuticals,

New

York)

to

a concentration of approximately 240 mg of iodine per milliliter. The balloon was inflated, and Neurobogic

the ICA testing

was occluded. ensued, including

tests of motor and sensory extremities, of visual acuity

function and

in all fields,

of

cranial nerve function, and of memory. If the patient remained stable, the ethanol mixture was infused slowly through the microcatheter with fluoroscopic control to minimize

exposure

nob. Aliquots of ethanol bowed point

742

of the

ICA

of approximately were

to wash occurred

#{149} Radiology

injected into when

tumor. the

etha-

0.1-0.4 slowly

the

to the

tumor

mL

and The

abend

vessels

no

longer

be

clearly

opacified,

and

the ICA could no longer be washed out. The total volume of ethanol injected varied from 1 to 12 mL, with 5-40 minutes required for infusion, excluding the time required to obtain serial angiograms and

Ill) were prior to

Tracker-18;

San Jose,

through

until

balloon

could

(Solo-

Park, just

to reposition

the

catheters.

Prior

to balloon

deflation, 20 mL of saline was infused into the microcatheter while a similar volume was withdrawn from the introducer catheter in an attempt to irrigate the ICA. Control angiography was performed. Infusion of more ethanol after reinflation of the balloon was performed as necessary. At the conclusion of the procedure, protamine sulfate (Eli Lilly, Indianapolis) was administered in a dose titrated according to results of a repeated activated coagubation time test (Figure).

RESULTS Tumor blush depicted in the ICA at angiography decreased on was ebiminated in all cases. Surgical findings were difficult to quantify precisely with respect to the benefit of preoper-

ative embolization. However, in one case a first surgical attempt had been aborted as a result of difficulty in controlling hemorrhage; after embolization, the resection was completed with minimal difficulty. In a second case,

embolization

with

alcohol

re-

subted in the tumor becoming a firm dry mass that remained nonhemonrhagic even when sectioned. Four additional cases seemed far less bloody than expected. In one case, no obvious benefit was gained. Pathologic findings in tumor specimens included scattered areas of necrosis that were possibly secondary to embobization but were not diagnostic for embobization. In no sected. Neurobogically, mained unchanged. ported a subjective tion in the maxillary ipsilaterab trigeminal bess than 1 minute.

case

was

four One

the

ICA

patients patient

ne-

nene-

decrease in division of nerve that One patient

sensathe lasted had a

December

1991

contralateral that basted

of these rally

less

upper than

transient

extremity 5 minutes.

deficits

paresis Both

were

tempo-

related to balloon deflation and presumably embolic in origin.

of considerable

morbidity accompanies surgery. Ideally, preoperative embolization should not have a risk of morbidity or mortality, but to be effective that may not be possible. How-

were One patient had worsening of panesis of the ocubomotor and trochbean nerves (the abducens nerve was already paralyzed by the tumor prior to

ever, any surgical advantage be gained with embolization well worth the risk. As was least

one

the

under-

able

on nearby

Mild

be converted

procedure).

went

bilateral

transient

nerve dune. days

One

patient

embolization.

paresis occurred

of the abducens after the first pnoce-

After

second

the

later,

occurred ethanol

complete

cab cases

procedure

2

ophthabmopbegia

several infusion

minutes after the but resolved in less

than 1 hour; however, the deficit neturned 6 hours later and required 3 months to resolve totally. All patients

experienced nob. The but was

some degree tolerable

travenously and fentanyb.

pain

from

of discomfort with the

administered No deaths

curred. All seven patients quently performed

with cranial embolization,

persisted

postoperatively.

etha-

varied use of in-

midazobam have oc-

survived surgery.

two cases following

the

nerve the

subseIn the

palsy deficit

DISCUSSION Management

of this

group

of pa-

tients is difficult. Extensive masses in the skull base may invade one on both cavernous sinuses, compress the brain stem, encase major vessels and cranial nerves, and be histologically benign. Surgical which multiple

resection of these tumors, must often be performed in stages, involves vascular,

nerve, tients

and

tissue

grafting.

typically present neurobogic impairment,

The with and

pa-

marked the risk

case

from

series,

inoperable

into after

our

that can may be true in at

manageable

tumors

mopermay

surgi-

embolization.

In a previously published article, performance of alcohol infusion after permanent occlusion of the distal ICA was described (2). In contrast, our senies ICA

consisted of patients in whom the was to be preserved, and therefore we only temporarily occluded the vessel during embolization. In addition, in our patients the infusions were performed with a microcatheter to limit the exposure of the ICA to ethanol as much as possible. Our choice of a liquid embobization agent also reflects the fact that at the conclusion of the procedure the balloon was deflated, and the blood flow in the ICA was reestablished. Particulate embolization has the additional theoretic risk that some particles might remain in the ICA despite thorough irrigation and might cause a cerebral infarction after balloon deflation. The two cases of transient neunobogic deficit in our series were rebated temporally to balloon deflation and were most likely embolic in origin, probabby secondary to the induction of small aggregates of blood products by the ethanol. The long-term effect of ethanol on the ICA is not clear. In studies of canine renal arteries, tissue necrosis and endothebiab damage with secondary vascular thrombosis were observed in areas exposed to concentrated ethanob but not in vessels exposed to di-

luted ethanol (3,4). No delayed neurologic deficits have occurred in our group of patients in the 9 months since the first embolization was penformed. Quantification of effect is difficult. Dramatic decreases in tumor blush have been demonstrated at fluonoscopy. One case in which a repeat angiognam was obtained 2 days after embobization showed no evidence of revasculanization. Performance of a controlled study to compare the results of surgery performed with and without embolization is conceivable but would be difficult. The impression of the surgeons has been favorable regarding preoperative embolization because of the achievement of a reduction in expected blood boss, a drier than expected surgical field, and a savings in time needed to perform surgery. In conclusion, we emphasize that appropriate patient selection is crucial since ethanol embolization of skullbase tumors involving the cavernous ICA has substantial risk. Nevertheless, significant benefit may be gained. U

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Scott JA, Berenstein A, Blumenthal D. Use of the activated coagulation time as a measure of anticoagubation during interventional procedures. Radiology 1986; 158:849850.

2.

Lasjaunias roangiography.

ment 3.

4.

P. Berenstein A. Surgical Vol 2. Endovascular

of craniofacial

lesions.

neutreat-

New York:

Springer-Verlag, 1987; 62-63. ElIman BA, Green CE, Eigenbrodt E, GarriottJC, Curry TS. Renal infarction with absolute ethanol. Invest Radiol 1980; 15:318322. Buchta K, Sands J, Rosenkrantz H, Roche WD. Early mechanism of action of arteri-

ally infused ization.

alcohol

Radiology

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Radioboev

#{149} 743

Skull-base tumors: ethanol embolization of the cavernous carotid artery.

Tumors of the skull base frequently have some blood supply from cavernous branches of the internal carotid artery (ICA). Preoperative embolization of ...
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