Cerebral iodized lipid embolization via a pulmonary arteriovenous shunt: rare complication of transcatheter arterial embolization for hepatocellular carcinoma

Abstract

We report the first European case of cerebral iodized lipid embolism post transcatheter arterial embolization for hepatocellular carcinoma. Lipiodol emboli and corresponding multifocal brain ischemia were documented with computed tomography (CT) and magnetic resonance (MR) in the acutely symptomatic patient. Transcranial Doppler sonography with contrast indicated a right-to-left shunt, while on a follow-up CT scan lipiodol embolization was detected in both lungs. Dilated pulmonary vessels and thick vascular channels were seen in the vicinity of the right diaphragm suggestive of pulmonary arteriovenous shunt. The patient symptoms regressed with supportive care alone, but he died 5 months later due to hepatic failure unrelated to the procedure.

Cerebral lipiodol embolism related to a vascular lake during chemoembolization in hepatocellular carcinoma: A case report and review of the literature

“…To reach the cerebral arteries, lipiodol must pass through two pathways, one from the tumor to the pulmonary artery (PA) and the other from the pulmonary artery to the left atrium (LA). Lipiodol accumulation in the lung was identified simultaneously in 17 of 27 previously reported cases[ 2 - 4 , 6 , 8 - 10 , 14 , 16 , 18 ].…”

“…In most previously reported cases of CLE, including the case described herein, a large dose of lipiodol was infused (Table 1 ). Cerebral and pulmonary lipiodol embolisms have been reported in patients receiving more than 20 mL of iodized oil after TACE of HCC[ 4 , 6 , 16 , 18 ]. According to Kishi et al[ 26 ], when lipiodol was infused into the dog’s hepatic artery, the amount of lipiodol oil deposition in the lungs was proportional to the lipiodol dose infused.…”

Cerebral Lipiodol Embolism in Hepatocellular Carcinoma Patients Treated with Transarterial Embolization/Chemoembolization

“…The route of lipiodol through tumor embolized artery to brain has been widely discussed. Previous reports stated that the existence of shunting between systemic vessels and pulmonary vessels would facilitate the extravasation of lipiodol into the systemic circulation and increase the risk of CLE [ 9 , 21 ]. In our case series, 3 patients had tumor invasion of right lung, and angiography revealed the tumor-feeding artery directly shunting to the pulmonary vein.…”

Toxicity of Liver-Directed Therapies for Hepatocellular Carcinoma

“…119 However, many other cases have not shown an associated right-to-left shunt, and these have been hypothesized to be secondary to arteriovenous or hepatopulmonary shunts, or perhaps another mechanism. [120][121][122]…”