Facial and Lower Cranial Neuropathies After Preoperative Embolization of Jugular Foramen Lesions With Ethylene Vinyl Alcohol

Abstract

Objective To report three unique cases of cranial neuropathy after super-selective arterial embolization of jugular foramen vascular tumors with ethylene vinyl alcohol. Study Design Clinical capsule report Setting Three tertiary academic referral hospitals Patients Three patients who underwent superselective arterial embolization (SSE) of head and neck paragangliomas with ethylene vinyl alcohol are described. One individual was treated with primary SSE, while the remaining tumors were treated with preoperative SSE followed by surgical extirpation within 72 hours. All patients were found to have new cranial nerve deficits following SSE. Results One patient with isolated complete cranial nerve VII palsy demonstrated no return of function. One individual experienced cranial nerve VII, X, and XII palsies and demonstrated partial recovery of function of the involved facial nerve after 19 months. One subject experienced ipsilateral cranial nerve X and XI palsies after SSE and recovered full function of the spinal accessory nerve within one week, but failed to demonstrate mobility of the ipsilateral true vocal fold. Conclusion We present the first report documenting facial and lower cranial neuropathies after super-selective embolization of head and neck paragangliomas with EVA. Although it is difficult to draw conclusions from this small number of cases, it is plausible that use of ethylene vinyl alcohol during SSE may result in a higher risk of permanent cranial neuropathy than the use of other well-established and more temporary agents. Knowledge of the arterial supply to the cranial nerves can help the clinician to choose the embolization agent that will provide maximal occlusion while minimizing the risk of complications.

Incidence of cranial nerve palsy after preoperative embolization of glomus jugulare tumors using Onyx

“…Gartrell et al highlighted the potential risk of this procedure in their series of 3 patients with postembolization cranial neuropathy. 5 They attribut ed the increased risk of embolization to anatomical varia tions in the cranial nerve blood supply. Another possible explanation is based on the frequently shared external ca rotid artery blood supply between glomus jugulare tumors and the vasa nervosa of the cranial nerves, which renders them vulnerable to occlusion with Onyx during emboliza tion.…”

Initial experience with dual-lumen balloon catheter injection for preoperative Onyx embolization of skull base paragangliomas

“…They achieved adequate tumor devascularization but encountered retrograde migration of Onyx into the vertebral artery, which required coil-mediated vessel sacrifice. Gartrell et al 5 reported the first 3 cases of postembolization cranial neuropathies after transarterial Onyx embolization of paragangliomas. In each case, near-complete tumor devascularization was achieved.…”

“…1,3,5,6,17,20,25 Its cohesive properties enable the core of the embolic material to propel forward into the tumor vasculature. Compared with earlier embolic materials, Onyx precipitates gradually and has a lower viscosity, which may enable longer, more controlled injections into the tumor nidus.…”

“…4,7 Given its flow characteristics, Onyx (Covidien) has seen increasing use in the preoperative embolization of tumors, including paragangliomas. 1,3,5,6,17,20,25 Direct percutaneous puncture is currently the most reported route for Onyx embolization of these tumors, although it is unclear whether that reflects a publication bias or if this modality is actually more common than using transarterial routes of embolization. 3,17,20,25 Problems with conventional transfemoral artery access, such as tortuosity, atherosclerosis, vasospasm, and small-caliber arterial feeders, may impede complete embolization of these tumors, and dangerabbreviatioNs EBL = estimated blood loss; ECA = external carotid artery; ICA = internal carotid artery; PVA = polyvinyl alcohol.…”

“…20 When transarterial embolization has been attempted, cranial neuropathies are a known complication. 5,6 Innovations in catheter design may augment transarterial paraganglioma embolization. The Scepter catheter (MicroVention, Inc.), a dual-lumen balloon catheter, was used recently in tumor and arteriovenous malformation embolization procedures.…”