Superselective Endovascular Embolization as an Adjunct to Safe and Effective Surgical Resection of Cerebral and Spinal Tumors

Abstract Surgical resection is one option in the treatment of large high-grade brain arteriovenous malformations (AVMs). Resection of AVMs with skull-eroding components can be challenging due to the risk of excessive bleeding from these components during craniotomy and bone flap removal. We present a case of a 25-yr-old woman who presented with an acute onset right-sided frontal headache. She was found to have a large, frontal Spetzler-Martin grade IV AVM with an associated dural AVM. The AVM had caused focal erosions of the right frontal bone by a venous varix traversing the region of the calvarial defect. An elective staged endovascular embolization followed by surgical resection was recommended considering the patient's young age and the large size of the AVM located in a noneloquent area. Given the high risk of intraoperative hemorrhage during the craniotomy portion of the procedure, a “craniotomy within craniotomy” approach was planned. During this approach, a small rectangle of bone, including the portion eroded by the venous varix, was left in place, while the larger bone flap surrounding it was removed for an initial approach to the AVM. The small bony piece was safely removed at later stages of resection once the arterial feeders had been reasonably obliterated. Immediate postoperative catheter angiogram demonstrated good filling of the intracranial vascular territories with no residual AVM. The patient developed mild left facial and left hand weakness postoperatively, which resolved after 2 wk of follow-up. The patient remained neurologically intact on further follow-up.

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Surgical Resection of Intradural Extramedullary Spinal Tumors: Patient-Reported Outcomes and Minimum Clinically Important Difference

The Spine Journal ◽

10.1016/j.spinee.2016.07.246 ◽

2016 ◽

Vol 16 (10) ◽

pp. S319-S320

Author(s):

Scott L. Zuckerman ◽

Silky Chotai ◽

Clinton J. Devin ◽

Scott L. Parker ◽

David Stonko ◽

...

Keyword(s):

Surgical Resection ◽

Patient Reported Outcomes ◽

Minimum Clinically Important Difference ◽

Spinal Tumors ◽

Clinically Important Difference ◽

Patient Reported ◽

Intradural Extramedullary

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Surgical Resection of a Recurrent Intramedullary Spinal Epidermoid Cyst: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opz019 ◽

2019 ◽

Vol 17 (5) ◽

pp. E204-E204 ◽

Cited By ~ 1

Author(s):

Noah Nichols ◽

Ketan Yerneni ◽

Joseph A Osorio ◽

Michael McDermott ◽

Lee A Tan

Keyword(s):

Surgical Resection ◽

Epidermoid Cyst ◽

Radiation Treatment ◽

Tumor Location ◽

Gross Total Resection ◽

Spinal Tumors ◽

Adjuvant Radiation ◽

Total Resection ◽

Epidermoid Cysts ◽

Patient Consent

Abstract Intramedullary spinal epidermoid cysts are rare tumors and only account for 1% of all spinal tumors in adults. Epidermoid cysts can develop from ectodermal tissue that was inappropriately positioned in the primitive neural tube during closure; acquired forms exist for epidermoid cysts as they can emerge in an iatrogenic manner following repeated lumbar punctures. Malignant progression of epidermoid cysts is extremely rare, and symptoms typically depend on tumor location. Surgical resection is the preferred treatment. Gross total resection is ideal; however, partial resections have demonstrated satisfactory long-term outcomes. We present a 54-yr-old man with symptomatic recurrence of thoracic intramedullary epidermoid cyst after two prior resections (25 yr and 11 yr ago, respectively). The patient noted worsening back pain, leg spasticity and weakness. Magnetic resonance imaging (MRI) of the thoracic spine demonstrated interval expansion of the upper thoracic intramedullary epidermoid cyst compared to surveillance MRI from 3 yr prior. Given the progressive nature of symptoms, the patient elected to have surgical resection of the tumor. This operative video highlights the technique and surgical nuances of gross-total resection of a recurrent thoracic intramedullary spinal epidermoid cyst. This patient was noted to have a stable neurological exam at the 6-mo follow-up visit with planned adjuvant radiation treatment. There is no identifying information in this video. Patient consent was obtained for publishing of the material included in the video.

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Treatment of Pulmonary Sequestrations by Means of Endovascular Embolization: Future or Fashion?

Case Reports in Medicine ◽

10.1155/2011/173918 ◽

2011 ◽

Vol 2011 ◽

pp. 1-3 ◽

Cited By ~ 3

Author(s):

Jeroen Diks ◽

P. Ronald Schütte ◽

David Cheung ◽

J. Marco Schnater

Keyword(s):

Surgical Resection ◽

Arterial Embolization ◽

Primary Treatment ◽

Endovascular Embolization ◽

Endovascular Techniques ◽

Female Adult ◽

Unsuccessful Attempt ◽

Bronchopulmonary Sequestration ◽

Rare Malformation ◽

Methods Of Treatment

Bronchopulmonary sequestration is a rare malformation of the lower respiratory tract. Several methods of treatment have been described since the first publication. We present two cases of female adult patients with bronchopulmonary sequestration. In the first patient an unsuccessful attempt to treat the bronchopulmonary sequestration by means of arterial embolization is described. She was subsequently treated by means of surgical resection, which was the primary treatment for the second patient. Although endovascular techniques are becoming promising, in our opinion surgical resection remains the unique treatment for bronchopulmonary sequestration.

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Contemporary management of adult intramedullary spinal tumors—pathology and neurological outcomes related to surgical resection

Spinal Cord ◽

10.1038/sc.2008.51 ◽

2008 ◽

Vol 46 (8) ◽

pp. 540-546 ◽

Cited By ~ 57

Author(s):

G Manzano ◽

B A Green ◽

S Vanni ◽

A D Levi

Keyword(s):

Surgical Resection ◽

Spinal Tumors ◽

Neurological Outcomes ◽

Contemporary Management

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Surgical Resection of Intradural Extramedullary Spinal Tumors

Spine ◽

10.1097/brs.0000000000001653 ◽

2016 ◽

Vol 41 (24) ◽

pp. 1925-1932 ◽

Cited By ~ 15

Author(s):

Scott L. Zuckerman ◽

Silky Chotai ◽

Clinton J. Devin ◽

Scott L. Parker ◽

David P. Stonko ◽

...

Keyword(s):

Surgical Resection ◽

Spinal Tumors ◽

Intradural Extramedullary

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Intraoperative Transpedicular Onyx Injection to Reduce Vascularity of a Thoracic Hemangiopericytoma After Unsuccessful Preoperative Endovascular Embolization: a Technical Report

Operative Neurosurgery ◽

10.1093/ons/opx102 ◽

2017 ◽

Vol 14 (2) ◽

pp. E17-E22

Author(s):

Hazem Mashaly ◽

Zoe Zhang ◽

Andrew Shaw ◽

Patrick Youssef ◽

Ehud Mendel

Keyword(s):

Central Nervous System ◽

Nervous System ◽

Blood Loss ◽

Surgical Resection ◽

Central Nervous System Involvement ◽

Vascular Tumor ◽

Massive Bleeding ◽

Endovascular Embolization ◽

Intraoperative Blood Loss ◽

Percutaneous Injection

Abstract BACKGROUND AND IMPORTANCE Hemangiopericytoma is a rare vascular tumor with central nervous system involvement representing only 1% of central nervous system tumors. They rarely affect the vertebral column. Complete surgical resection is the treatment of choice for hemangiopericytoma given their high rates of local recurrence. However, the high vascularity of such tumors with the risk of massive bleeding during surgery represents a significant challenge to surgeons. Therefore, preoperative endovascular embolization via the transarterial route has been advocated. CLINICAL PRESENTATION In the current study, we present a case of a T12 hemangiopericytoma that was managed by a 2-stage surgical resection, with the use of intraoperative transpedicular onyx injection to reduce intraoperative blood loss following an unsuccessful trial of preoperative endovascular embolization. CONCLUSION Preoperative endovascular embolization is not feasible in some cases due to the location of the segmental or radiculomedullary arteries in relation to tumor feeders and, rarely, small size of these arterial feeders. Percutaneous injection of onyx is an option. In this case report, we discuss direct intraoperative injection via a transpedicular route as a safe and effective method for decreasing the vascularity of some lesions and improving intraoperative blood loss.

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Urticarial reaction following endovascular embolization of an orbital arteriovenous malformation (AVM) with n-butyl cyanoacrylate (nBCA) glue

Interventional Neuroradiology ◽

10.1177/1591019917728400 ◽

2017 ◽

Vol 23 (6) ◽

pp. 666-668 ◽

Cited By ~ 4

Author(s):

Kunal R Sinha ◽

Gary Duckwiler ◽

Daniel B Rootman

Keyword(s):

Arteriovenous Malformation ◽

Surgical Resection ◽

Arteriovenous Malformations ◽

Vascular Inflammation ◽

Endovascular Embolization ◽

Vascular Lesions ◽

Hypersensitivity Reactions ◽

Potential Complication ◽

Skin Allergy ◽

Systemic Hypersensitivity

Orbital arteriovenous malformations (AVMs) are rare vascular lesions that may be managed with endovascular embolization followed by surgical resection. Embolization is often accomplished with n-butyl-2-cyanoacrylate (nBCA), which is considered to be a safe and effective liquid occlusive agent. Localized vascular inflammation has been associated with endovascular nBCA use in histopathologic studies, but reports of systemic hypersensitivity reactions following endovascular embolization with nBCA are rare. We present a case of a 26-year-old male who developed an intermittent systemic urticarial reaction without cardiopulmonary compromise beginning four weeks after nBCA embolization of an orbital AVM. Subsequent skin allergy testing performed by an allergist confirmed hypersensitivity to nBCA glue and the patient has since been successfully managed with daily oral antihistamines. Awareness of this rare potential complication of endovascular embolization with nBCA will aid in the counseling and management of patients with AVMs.

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