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E-011 Neuroendovascular procedures for skull base neoplasia
  1. Dmytriw1,
  2. D Sarma2,
  3. M Cusimano3,
  4. A Bharatha2
  1. 1Departments of Neurosurgery and Radiology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA
  2. 2Department of Medical Imaging, St. Michael’s Hospital, Toronto, ON, Canada
  3. 3Departmentsof Neurosurgery, St. Michael’s Hospital, Toronto, ON, Canada

Abstract

Purpose Neuroendovascular procedures are performed in skull base neoplasias with the objective of achieving preoperative embolization to increase the safety of surgical procedures by limiting intraoperative hemorrhage, reduce the need for blood transfusion, increase visibility in the surgical field, and shortening hospitalization length. While the benefits are significant, this procedure within itself carries a substantial range of repercussions including tissue ischemia, stroke, and death, thus a risk-benefit profile should be considered in each case. Hence embolization should be reserved for lesions with numerous, deep, surgically inaccessible tributaries, where a significant bleed is anticipated, or the tumor is surrounded by critical neurovascular structures.

Materials and methods We present an evidence-based review of the perioperative process involved in endoscopic embolization of skull base tumors. This summary will outline the risk-benefit profile as well as indications and contraindications taken into consideration when determining suitability of radiologic intervention, and resultant scope of outcomes. Additional parameters including circumstances in which temporary or liquid embolic agents are more amendable, preoperative imaging features, procedural details of angioembolization, and subsequent follow up monitoring are also discussed.

Results Angiography often precedes embolization to establish tumor supply and collateralization as well as occluding anastamoses with coils. Additionally, it provides the interventionalist with the opportunity to become familiarized with the vasa nervorum and arteries supplying cranial nerves, as well as the tributaries supplying the tumor, thereby informing selection of an appropriate embolic agent. With encasement of large arteries like the ICA or vertebral, where inadvertent or deliberate sacrifice may be anticipated, preoperative balloon test occlusions may be utilized. Surgery often occurs within 72 hours of angioembolization to maximize benefits, while simultaneously occurring at increased risk of tissue necrosis, migration into collateral channels, and injury to the vasa nervorum in certain pedicles. The primary skull base tumors that most commonly benefit include meningioma, juvenile angiofibroma, and paraganglioma.

Conclusion Neurointerventional procedures play a pivotal role in the management of skull base neoplasms. Pre-operative embolization must performed judiciously in the context of the potential harms and benefits imposed on the patient. While effective intervention can yield improved perioperative visualization with reduced tumor size and resultant blood loss, important risks for consideration include cranial nerve injury, tissue necrosis, access vessel injury, and death from inadvertent non-target embolization.

Disclosures A. Dmytriw: None. D. Sarma: None. M. Cusimano: None. A. Bharatha: None.

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