Cerebral and pulmonary embolisms after transcatheter arterial chemoembolization for hepatocellular carcinoma

Choi, Chang Soo; Kim, Ki Hoon; Seo, Geom Seog; Cho, Eun Young; Oh, Hwa-Suk; Choi, Suck Chei; Kim, Tae Hyeon; Kim, Haak Cheoul; Roh, Byung Suk

doi:10.3748/wjg.14.4834

Cited by 24 publications

(30 citation statements)

References 17 publications

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“…[2][3][4][5][6][7][8] Hyperdensities on initial head CT are unusual in other causes of ischemic stroke. This is a useful early sign of ethiodized oil embolization.…”

Section: Discussionmentioning

confidence: 96%

“…All other reported patients, as well as our patient, demonstrated no evidence of PFO on TEE. [2][3][4][5][6][7][8]14 TCD with emboli detection has a sensitivity of 95%-97% and a specificity of 75% for identifying a right-to-left shunt. 15,16 TCD detected emboli in 11% of the patients who had a negative TEE.…”

Section: Discussionmentioning

confidence: 99%

“…Some cases of cerebral embolism occurring after this procedure have been reported recently. [2][3][4][5][6][7][8] This is the first report of autopsy findings in a man with HCC who suffered multiple ischemic strokes during TACE. Based on the pathology, we suggest a possible mechanism for this complication.…”

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confidence: 89%

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Multiple Ischemic Strokes after Transcatheter Arterial Chemoembolization for Hepatocellular Carcinoma with a Radiographic and Pathological Correlate

Zach

Rapaport

Yoo

et al. 2012

Journal of Stroke and Cerebrovascular Diseases

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“…[2][3][4][5][6][7][8] Hyperdensities on initial head CT are unusual in other causes of ischemic stroke. This is a useful early sign of ethiodized oil embolization.…”

Section: Discussionmentioning

confidence: 96%

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Multiple Ischemic Strokes after Transcatheter Arterial Chemoembolization for Hepatocellular Carcinoma with a Radiographic and Pathological Correlate

Zach

Rapaport

Yoo

et al. 2012

Journal of Stroke and Cerebrovascular Diseases

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“…Previous case reports suggest the following potential mechanisms: (1) intracardiac right-to-left shunt of the heart, (2) the shunt between the pulmonary vein and hepatic artery/IPA, (3) hepatic artery/IPA-intrapulmonary arteriovenous shunt, and (4) microemboli through the sinusoids of the liver to the pulmonary capillaries, which were induced by an increased lipiodol dose. 3,[5][6][7][8] According to the study by Choi et al, 3 CLE could be occured by communication between the right IPA and pulmonary vein via inflammatory pleura. In our case, the dynamic abdominal CT scan also showed inflammation of right lower lobe and pleura (Fig.…”

Section: Discussionmentioning

confidence: 99%

“…The severity and type of symptoms may depend on the site of lipiodol deposition. 3 By the report of Wu et al, 4 the symptoms of CLE included visual loss, headache, weakness of motor strength, and change in the mental state. In our case, the patient experienced right facial palsy and motor weakness in both the right upper and lower limbs.…”

Section: Discussionmentioning

confidence: 99%

Lipiodol brain embolism through right inferior phrenic artery-pulmonary vein shunt after transcatheter arterial chemoembolization

Jang

Kim

Choi

et al. 2018

Int J Gastrointest Interv

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Lipiodol brain embolism is a rare complication associated with transcatheter arterial cheomoembolization (TACE). The present case describes a patient with lipiodol brain embolism who presented with several symptoms, including drowsy mental state, right facial palsy, and weakness in the right upper and lower limbs. The patient's non-enhanced computed tomography scan and magnetic resonance imaging (MRI) findings revealed multifocal lipiodol deposition and an acute infarction of the brain. A retrospective review of the angiography findings revealed a right inferior phrenic arterypulmonary vein shunt, which was not observed during the previous TACE. Three days after TACE, the patient's symptoms improved; however, the extent of the brain hyperintensity had widened further on the following MRI. The patient gradually recovered and was finally discharged.

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Lipiodol brain embolism during hepatic transcatheter arterial chemoembolization

et al. 2009

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Sir,Transcatheter arterial chemoembolization (TACE) for advanced hepatocellular carcinoma, i.e., the injection of a mixture of iodized oil (lipiodol) and a chemotherapeutic via the tumor feeding artery, hitherto has been complicated by lipiodol brain embolism (LBE) in a few cases [1][2][3][4][5]. Only two of these patients had repeat MRI that documented extensive reversion of the initial DWI abnormalities [5]. We present a case of TACE-associated LBE that demonstrated near-complete resolution of DWI lesions suggesting cytotoxic edema.During his fourth course of TACE, a 71-year-old man with advanced hepatocellular carcinoma presented a modest monoparesis of the right arm along with transient dysarthria and dizziness. CT scan immediately after the procedure showed multiple infra-and supratentorial brain lesions consistent with the deposition of iodized oil. Three hours later, MRI disclosed multiple nonenhancing cortical and subcortical hyperintense lesions, which represented areas of decreased diffusion on DWI. In particular, the magnitude of ADC decrease in the lesioned areas ranged roughly between 15 and 25% compared to contralateral normal-appearing brain tissue. The patient recovered completely over the following 48 h. A repeat MRI after 1 month documented near-complete resolution of the lesions (Fig. 1).Hyperintense DWI lesions that exhibit low ADC values are typically suggestive of cytotoxic edema in a setting of acute brain ischemia. Although ischemia-associated DWI hyperintensities can be reversible to a certain extent, it is remarkable that in a setting of both cerebral fat [6, 7] and LBE post-TACE [5], widespread areas of presumed cytotoxic edema have been reported not to evolve to complete infarction (established T2 or FLAIR lesions). To the best of our knowledge, such an extensive reversal of DWI abnormalities has not been reported in acute ischemic stroke. A possible explanation would be that what looks like cytotoxic edema in DWI is actually an overestimation of the true extent of the lesion or a cytotoxic edema ''mimic.'' A MRI spectroscopy study [6] has suggested that soon after fat embolism, areas of restricted diffusion may simply reflect the presence of large quantities of ''sluggish'' lipids compared to water. However, secondary ischemia [6] or a neurotoxic effect of free fatty acids [7] may occur later if the embolic material is not rapidly cleared from the brain circulation. This would also explain the ''preference'' of the lipid emboli and of the associated permanent lesions for the watershed areas of the brain where a slow blood flow cannot be compensated quickly and adequately by collaterals. In our patient, fast clearance of the lipid burden may account for the rapid clinical recovery and the reversion of DWI abnormalities.Concerning the etiology of brain embolism in patients undergoing TACE, right-to-left shunt (either via a patent foramen ovale or intrapulmonary arteriovenous shunts), shunt from the inferior phrenic artery to the pulmonary vasculature, and an increased dose of infused li...

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Cerebral and pulmonary embolisms after transcatheter arterial chemoembolization for hepatocellular carcinoma

Cited by 24 publications

References 17 publications

Multiple Ischemic Strokes after Transcatheter Arterial Chemoembolization for Hepatocellular Carcinoma with a Radiographic and Pathological Correlate

Multiple Ischemic Strokes after Transcatheter Arterial Chemoembolization for Hepatocellular Carcinoma with a Radiographic and Pathological Correlate

Lipiodol brain embolism through right inferior phrenic artery-pulmonary vein shunt after transcatheter arterial chemoembolization

Lipiodol brain embolism during hepatic transcatheter arterial chemoembolization

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