Case Report: Cerebral lipiodol embolism in the Guangxi Zhuang autonomous region, Southwest China

Cerebral lipiodol embolism is a rare complication of transcatheter arterial chemoembolization (TACE). Its pathological mechanism remains ambiguous despite several investigations. In Case 1, a 67-year-old man with hepatocellular carcinoma (HCC) experienced neurological deficits soon after undergoing a fourth session of TACE. Computed tomography (CT) scan showed multiple hyperdense lesions along the gyrus of frontal lobes and in the subcortical white matter. Transcranial Doppler (TCD) and transesophageal echocardiogram performed during the intravenous injection of agitated saline documented the presence of a right-to-left shunt (RLS) by demonstrating microbubbles in the left middle cerebral artery and left atrium. In Case 2, a 63-year-old woman underwent a third TACE due to a large HCC. After the procedure, her mental status deteriorated. Brain CT showed multiple hyperdense lesions on the cerebral and cerebellar cortex. TCD with agitated saline showed multiple microembolic signals shortly after the injection of agitated saline. The risk of cerebral lipiodol embolism may increase with recurrence and progression of HCC in patients who have a pre-existing RLS in the heart or lung. A test for the detection of an RLS may be necessary to identify patients with a heightened risk of cerebral embolism when multiple TACE procedures are required. TACE for HCC can cause pulmonary embolism or infarction.(1,2) However, cerebral lipiodol embolism is rare after TACE. There have been several reports of cerebral embolism after TACE, but their exact mechanism has not yet been fully elucidated. We report herein 2 patients who developed cerebral lipiodol embolism after undergoing multiple TACE procedures for remnant HCC through a pre-existing RLS.

Chemoembolization and Radioembolization for Hepatocellular Carcinoma

Transcatheter arterial chemoembolization (TACE) is the mainstay of treatment for unresectable hepatocellular carcinoma (HCC). Although various complications of TACE have been reported, cerebral lipiodol embolism after TACE is rare. We report a 67-year-old man, who had patent foramen ovale and developed cerebral lipiodol embolism after TACE via the inferior phrenic artery. At 20 months after third TACE of 3 cm sized HCC in the left hepatic lobe, computed tomography (CT) revealed about 1.6 cm newly developed HCC in the anterior superior segment of right hepatic lobe. The angiogram revealed the HCC was supplied from the right inferior phrenic artery. Toward the end of TACE, there were accumulations of the iodized oil in the pulmonary vasculature. Immediately after TACE, he complained of weakness in right upper and lower limbs and sensory decrease in right limbs and right hemitrunk. Magnetic resonance imaging revealed a cerebral lipiodol embolism. Transesophageal echocardiography revealed no visible thrombi but contrast-echocardiography using hand agitated saline revealed an intracardiac right to left shunt consistent with patent foramen ovale. Motor weakness and sensory decrease were gradually improved, and all neurological symptoms disappeared over 4 weeks.

Transarterial Radioembolization for Hepatocellular Carcinoma: Who, When… and Y(90)?

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide. Transcatheter arterial chemoembolization (TACE) is a frequently performed nonsurgical therapy for localized HCC. Common adverse effects of TACE include post embolization syndrome (50-60%), hepatic decompensation, hepatic abscess and gastroduodenal ulcers. Cerebral lipiodol embolism (CLE) is a rare complication of TACE and only few reports exist describing this complication. We report a case of cerebral lipoidal embolization. 62-year-old male with history of chronic hepatitis B (on treatment for 5 years) and Child Pugh A cirrhosis. Imaging done for HCC screening showed 1 lesion in the right lobe of the liver (segment 7/8) measuring up to 10.3 cm in maximum diameter (Image 1). This was proven to be HCC on biopsy. Initial treatment plan was to perform Y90 radioembolization followed by surgical resection. However hepatic angiogram for planned radioembolization revealed 55% pulmonary shunt. He subsequently underwent TACE. Few hours after the procedure, he was moved to ICU for lethargy, weakness and fever and was also noted to have bowel and bladder incontinence. Labs notable for AST 1327, ALT 435, Alk phos 2659, WBC 13.26, INR 1.4 and NH337.5.CT of the head without contrast showed no clear acute findings but small nonspecific area of increased attenuation in the superior colliculus were noted. Given high concern for cerebrovascular event, MRI of the brain was done which showed punctate acute infarcts throughout both cerebral hemispheres and pons highly suggestive of cerebral embolization of the lipoidal chemo particles (Image 2). CT angiogram of the head and neck was unrevealing. Subsequent Cardiac ECHO did not reveal any thrombus, valvular vegetation or atrial level shunt. This patient likely had right to left shunt (pulmonary arterio-venous or hepatopulmonary syndrome which are often times not well visualized on imaging). The exact embolization route often remains undetermined in the reported CLE cases. More sensitive studies to detect the presence of shunt were not pursued since they would not have changed the management. He was managed conservatively and was sent to rehabilitation on day 9 after the TACE. CLE is a rare but potentially serious complication in HCC patients receiving TACE. The clinical characteristics of CLE summarized in our study would help facilitate the ability of clinicians to careful select patients for TACE and provide timely diagnosis and management.2436_A Figure 1. Coronal view (MRI of the head) showing HCC in segment 7/8.2436_B Figure 2. Coronal view (MRI of the brain) showing multiple punctate infracts.

Impact of Surveillance on Survival of Patients With Initial Hepatocellular Carcinoma: A Study From Japan

Transcatheter arterial chemoembolization (TACE) is an established treatment for unresectable hepatocellular carcinoma (HCC). However, it is unclear which chemotherapeutic agent should be selected for TACE. The aim of this study was to compare the efficacy of cisplatin (CDDP) with that of epirubicin (EPI) in TACE for patients with unresectable or relapsed HCC. We performed a historical cohort study involving 131 patients treated with a first TACE, defined as either an initial treatment for previously untreated HCC or a first treatment for relapsed HCC after curative resections or ablations. Efficacy was estimated as the response rate (RR) and it was adjusted for the confounding factors that were defined in this study. The RR were 62.5% (20/32) for the first TACE with CDDP and 51.5% (51/99) for that with EPI. In the adjusted analysis for a history of hepatectomy, percutaneous treatment combined with TACE and tumor factors, the odds ratio was 1.72 (95% confidence interval [CI] = 0.70-4.48). However, a test for interaction between the number of tumors and the chemotherapeutic agent was statistically significant (P = 0.016). In multiple HCC, the RR were 66.7% (10/17) for CDDP and 39.6% (30/46) for EPI. The odds ratio was 4.11 (95% CI = 1.14-17.2). CDDP may be more effective than EPI in TACE for multiple HCC. A randomized controlled study is needed to clarify the efficacy of CDDP in TACE in patients with multiple HCC.

Quality Improvement Guidelines for Transhepatic Arterial Chemoembolization, Embolization, and Chemotherapeutic Infusion for Hepatic Malignancy

Focus

Objectives: Transarterial chemoembolization (TACE) plays an essential role in the management of unresectable hepatocellular cell carcinoma and other hepatic neoplasms. Cerebral lipiodol embolism (CLE) is a rare complication of TACE and its prognostic factors have not been well studied. The aim of this paper was to elucidate the prognostic factors of CLE based on clinical data obtained from our patients and cases published since 2004.Methods: We present two patients with CLE, analyze the clinical data, and review all CLE cases published since 2004. A poor outcome was defined as stupor, coma, quadriplegia, or death within 45 days. Patients who had other neurological conditions within 45 days were considered as having a good outcome.Results: The rate of poor outcome was 25.7% (9/35). Compared with the patients with good outcome, those with poor outcome were older (mean age 68.3 ± 7.3 vs. 58.3 ± 10.6 years, p = 0.03), more often female (76.9% vs. male 33.3%, p = 0.02), and more likely chemoembolized via both the right hepatic and right inferior phrenic arteries (44.4 vs. 8.7%, p = 0.02).Discussion: The prognosis of CLE was related to age, gender, and the arteries selected for injection.

New Developments in the Treatment of Hepatocellular Carcinoma: The Concept of Adjuvant and Neoadjuvant Chemotherapy

Unresectable hepatocellular carcinoma: the need for an individualized multidisciplinary approach.

Evaluating transcatheter arterial chemoembolization for primary hepatic cancer by magnetic resonance diffusion-weighted imaging

Pulmonary and cerebral lipiodol embolism after transcatheter arterial chemoembolization (TACE) of hepatocellular carcinoma is rare. To our knowledge, only 7 cases have been reported in the literature. We present a case of pulmonary and cerebral lipiodol embolism, and analyzed retrospectively the imaging and clinical data of the patient and conclude the most probable mechanism of pulmonary and cerebral lipiodol embolism, which is different from that of the cases reported previously.

Evolution of Transarterial Chemoembolization for the Treatment of Liver Cancer.