Cerebral Lipiodol Embolism after Transcatheter Arterial Chemoembolization of Hepatocellular Carcinoma

Pil-Jin Chung; Seon-Young Park; Young-Il Kim; Kyoung-Won Yoon; Sung-Bum Cho; Sung-Kyu Choi; Jong-Sun Rew

doi:10.4166/kjg.2009.54.2.130

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Chung, Park, Kim, Yoon, Cho, Choi, and Rew: Cerebral Lipiodol Embolism after Transcatheter Arterial Chemoembolization of Hepatocellular Carcinoma

Original Article

Korean J Gastroenterol 2009;54(2):130-134.

Published online: 21 February 2009

DOI: https://doi.org/10.4166/kjg.2009.54.2.130

Cerebral Lipiodol Embolism after Transcatheter Arterial Chemoembolization of Hepatocellular Carcinoma

Pil-Jin Chung, M.D.^∗, Seon-Young Park, M.D., Young-Il Kim, M.D., Kyoung-Won Yoon, M.D., Sung-Bum Cho, M.D., Sung-Kyu Choi, M.D., Jong-Sun Rew, M.D.

^∗Miraero 21 Medical Center, Chonnam National University Medical School, Gwangju, Korea

Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea

Correspondence to: Sung-Kyu Choi, M.D. Department of Internal Medicine, Chonnam National University Medical School, 8, Hak-dong, Dong-gu, Gwangju 501-757, Korea Tel: +82-62-220-6296, Fax: +82-62-228-1330 E-mail: choisk@chonnam.ac.kr

Received 10 April 2009 Accepted 21 April 2009

Abstract

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.

Keywords: Carcinoma, Hepatocellular, Cerebral embolism, Iodized oil

REFERENCES

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Fig. 1.

Computed tomography (CT) revealed previous lipiodol uptake in the medial segment of the left hepatic lobe and a newly developed HCC in the anterior superior segment of the right hepatic lobe, approximately 1.6 cm in size.

Fig. 2.

(A) Right inferior phrenic angiogram showed a hypervascular tumor in the right lobe of the liver (arrow). (B) Transar-terial infusion of adriamycin emulsified in iodized oil was infused into the right inferior phrenic artery. Delayed angiogram showed a lipiodol uptake in the right lower lung field (arrow).

Fig. 3.

(A) Magnetic resonance images of the brain revealed multiple, discrete, high signal intensities in the frontal lobe, parietal lobe, occipital lobe, and cerebellum on T2-weighted and diffusion-weighted imaging. (B) A non-contrast-enhanced CT scan of the brain obtained 7 days after the procedure revealed disseminated hyperattenuation along the gyri of both frontal lobe and subcortical white matter of the parietal lobe, suggesting deposition of iodized oil.

Fig. 4.

Agitated saline injections were performed at rest and during maximal Valsalva maneuver. Transesophageal echocardiogram showed visualization of an injected saline microbubble in the left atrium within three cardiac cycles of right atrial opacification, consistent with the presence of an intracardiac shunt (left). Transcranial Doppler through the temporal bone showed agitated saline bubbles passing through the middle cerebral artery (right).

Table 1.

Cases of Cerebral Lipiodol Embolism after TACE in the Literature

	Wu et al.⁷	Yoo et al.⁸	Yoo et al.⁸	Yoo et al.⁸	Matsumoto et al.¹⁴	Takao et al.⁹
Year	2005	2004	2004	2004	2007	2005
Age	81	52	58	56	70	76
Gender	Female	Male	Male	Male	Female	Male
Child-Pugh class	A	NA	NA	NA	A	NA
Size of HCC	14×10 cm	NA	NA	NA	NA	NA
Frequency of	2^nd	2^nd	NA	3^rd	1^st	16^th
TACE
Supplying artery	Right IPA,	Hepatic artery	NA	NA	RHA, MHA,	Epicholedochal
	right IMA				right IPA,	artery, right IPA,
					right RCA	proper artery
Dose of	20 mL	35 mL	8 mL	NA	12 mL	NA
iodized oil
Use of gelatin	Yes	NA	NA	NA	Yes	Yes
sponge particles
Echocardiography	No intracardiac	No intracardiac	No intracardiac	No intracardiac	NA	NA
	shunt	shunt	shunt	shunt
Symptoms	- Mild tachypnea	- Headache	- Shortness of	- Disorientation,	- Drowsy to	- Hypoxia
	- Loss of vision	- Confusion	breath	irritability, and	comatose	- Comatose mental
	- Weakness in the	- Left upper	- Frontal and	blindness	mental state	state
	upper and lower	extremity	occipital	- Tachypnea,
	extremities	weakness	headache	hypoxia
		- Mild hypoxia	- Chest pain
Follow-up	Died from	Recovered	Vision quickly	Recovered	Died from	All neurologic
	respiratory	completely	returned to	completely two	multiple organ	sign disappeared
	complications	when discharged	baseline over	weeks later	failure 2 weeks	over 6 weeks
	45 days later	3 weeks later	several days		later

NA, not available; IPA, inferior phrenic artery; IMA, internal mammary artery; RHA, right hepatic artery; MHA, middle hepatic artery; RCA, renal capsular artery, HCC, hepatocellular carcinoma; TACE, transcatheter arterial chemoembolization.

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