Of all procedures in interventional radiology, percutaneous transhepatic biliary drainage (PTBD) is amongst the most technically challenging. Successful placement requires a high level of assorted skills. While this procedure can be life-saving, it can also lead to significant iatrogenic harm, often manifesting as bleeding. Readers of this article will come to understand the pathophysiology and anatomy underlying post-PTBD bleeding, its incidence, its varied clinical manifestations and its initial management. Additionally, a structured approach to its treatment emphasizing endovascular and percutaneous methods is given.
This report illustrates the unusual occurrence of a pseudoaneurysm arising in the setting of a skull base mass and describes the first reported use of endovascular flow diversion therapy in such a setting. A 63-year-old man with occasional headaches during the preceding month presented with the acute onset of severe left retroorbital headache and oculomotor nerve palsy. Computed tomography (CT) and CT angiogram revealed a destructive skull base mass with an associated giant probable pseudoaneurysm of the cavernous segment of the left internal carotid artery. The patient underwent endoscopic transsphenoidal biopsy with a subsequent diagnosis of prolactinoma. Endovascular therapy utilizing two Pipeline™ flow diversion embolization devices was performed with subsequent resolution of the patient's headache and improvement in his cranial nerve deficits/cavernous sinus syndrome.A neurysms coincident with invasive skull base masses are unusual. An association between pituitary neoplasms and intracranial aneurysms has been documented. Th e acute development of a cavernous sinus syndrome with associated cranial nerve defi cits in conjunction with an aneurysm entirely encased within a neoplastic lesion supports the diagnosis of an acutely enlarging pseudoaneurysm, and we describe the fi rst reported use of endovascular fl ow diversion therapy in such a setting. Th is case illustrates a diagnostic pitfall with the potential for grave implications in patient outcome if an associated vascular lesion is not appreciated at the time an intracranial mass is diagnosed.
CASE PRESENTATIONA 63-year-old man with minor headaches in the preceding month presented to the emergency department following the acute onset of severe left retroorbital headache, ptosis, mydriasis, ophthalmoplegia, and diplopia. Noncontrast head computed tomography (CT) ( Figure 1a ) revealed a large destructive central skull base mass. Subsequently pre-and postgadolinium brain magnetic resonance imaging (MRI) ( Figure 1b, 1c ) delineated the margins and character of the skull base mass, which was centered in the clivus and extended to encase the left greater than right cavernous segments of the internal carotid arteries (ICAs) with partial destruction of the ( Figure 2 ), which revealed additional dysplastic irregular lobular projections arising from the pseudoaneurysm sac. Th e patient underwent an endoscopic transsphenoidal biopsy of the lesion. Histopathologic fi ndings showed a pituitary adenoma, and subsequent laboratory testing showed serum prolactin levels to be 14191.5 ng/mL (normal range 2.1-17.7), compatible with the diagnosis of a prolactinoma.Th e patient was loaded with aspirin and clopidogrel for 1 day and subsequently underwent endovascular therapy utilizing two overlapping Pipeline TM fl ow diversion embolization devices (Medtronic, Minneapolis, MN) measuring 4.25 × 30 mm and 4.5 × 16 mm ( Figure 3 ), extending to the supraclinoid ICA. Th is resulted in an immediate and marked decrease in contrast fl ow within the pseudoaneurysm sac and contras...
Materials and Methods: The study was designed as prospective, single arm, multicenter registry study with target number of patients of 200. The primary endpoint of the study was 6-month tumor response assessed by mRECIST. The inclusion criteria of the study included: single nodular or multinodular HCCs, measurable lesion Z 1 cm, no evidence of vascular, biliary invasion or distant metastasis, performance status 0 or 1, Child-Pugh score 5-7. Review of medical records were performed to find any adverse event following the treatment. The study protocol was terminated when a patient had progression of disease, had additional treatment other than DEB-TACE, was lost to follow-up, was transferred to other institute or expired. Results: The patients were enrolled in the study between May 2011 and April 2013. On central review, 48 patients were excluded from analysis and 152 patients (M:F¼125:27, mean age 61) remained. Child-pugh class was dominantly A (143/ 152, 94.1%). The tumor was single nodular in 84 (55.3%) and BCLC stage was O in 15 (9.9%), A in 103 (67.8%) and B in 34 (22.4%). After first DEB-TACE procedure, 111 (73.0%) of the patients suffered from post-embolization syndrome (PES), and there was serious adverse event (SAE) in 8 (5.3%). Total 73 sessions of additional treatment was performed in 59 patients (38.8%). There were 2 patients with SAE after additional treatments. There was 51 (33.6%) patients with bile duct injury confirmed by follow-up imaging. According to mRECIST, 1month response was CR in 64 (42.1%), PR in 77 (50.6%), SD in 8 (5.3%) and PD in 3 (2.0%) patients. Before 6-month followup, the protocol was terminated in 45 (29.6%) patients. Total 120 patients (including patients with protocol termination with PD) were eligible for 6-month response evaluation, and the response was CR in 55 (45.8%), PR in 13 (10.8%) and SD in 2 (2.0%) and PD in 50 (41.7%). There was 2 mortality until 6month follow up.
Conclusion:In nodular HCC, DEB-TACE had 92.7% 1month and 56.6% 6-month response rate. PES and bile duct injury was common, and there were 2 cases with mortality.
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