Embolization in the Head and Neck

Abstract

In this article, we review current practices in therapeutic embolization of the head and neck. Major applications including vascular malformations, highly vascular tumors, trauma, and other sources of hemorrhage are discussed. We emphasize the importance of a thorough knowledge of head and neck vascular anatomy, especially of potential connections to critical territories not intended for embolization. The choice of embolic agent and its effect on safety and efficacy of treatment are presented. KEYWORDS:Intervention, head and neck, vascular malformation, tumor, bleedingObjectives: On completion of this article, the reader should (1) appreciate the importance of preprocedural evaluation of vascular anatomy of the head and neck, (2) be familiar with important potential collateral pathways posing risk in intervention, and (3) understand basic principles of intervention in the head and neck. Accreditation: Tufts University School of Medicine (TUSM) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Credit: TUSM designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit TM . Physicians should only claim credit commensurate with the extent of their participation in the activity.Intricate anatomy greatly complicates the diagnostic and therapeutic management of head and neck pathology. Intimate anatomic relationships provide risks of visual loss, cranial nerve injury, and airway compromise related to treatment. Advances in endovascular techniques have expanded the role for catheter-based therapies beyond acute hemorrhage and into secondary and primary treatment of vascular anomalies and tumors of the face, neck, and skull base. This article is a concise review of the current practices in endovascular management of head and neck pathologies. ANATOMYThe embryonic development of the great vessels is a complex process involving the formation and regression of six paired arterial arches, creating the internal and external carotid arteries. The vascular commonalities during this process create redundancy in external and internal distributions, as well as varying degrees of interconnection between the external and internal and the anterior and posterior cerebral circulation. [1][2][3] As an operator, a firm understanding of these collateral pathways and potential anastomoses is paramount to the safety and efficacy of head and neck intervention. For the purposes of this article, we will limit discussion to extracranial and skull base vasculature. INTERNAL CAROTID ARTERYThe internal carotid artery (ICA) is a terminal branch of the common carotid artery that originates at the level of

Intraorbital access using fluoroscopic flat panel detector CT navigation and three-dimensional MRI overlay

“…The utility of trans-arterial or percutaneous embolization is well established for hypervascular lesions within the head and neck 12. Percutaneous techniques are often performed under ultrasound guidance given the ability to delineate anatomy, real time instrument visualization and demonstration of vessels and other vascular tissues 13–17.…”

“…The use of trans-arterial or percutaneous embolization is well established for vascular malformations and hypervascular masses within the head and neck 12. Ultrasound is often used to aid in the percutaneous access of such lesions given its ability to define soft tissues, real time instrument visualization and demonstration of vessels and other vascular tissues although it can be limited by osseous anatomy or in accessing less superficial lesions 13–17.…”

Three Case Reports of Simple Vascular Malformations: Inappropriate, Perplexing and Interchangeable Use of Nosology by Clinicians and Pathologists

“…The management of VMs depends on the type and flow characteristics of the malformation, the functional impairment, disfigurement, the threat to life, and on the expertise of the surgeon or the interventional radiologist [9,21]. The therapeutic modalities include sclerotherapy, embolization, laser photocoagulation, and surgical excision and are beyond the scope of this article [9,21].…”

“…Diagnosis of vascular anomalies can be made by clinical history and physical findings, with a minority requiring imaging studies and even smaller number requiring biopsy and histopathological examination [9,21]. Doppler-ultrasound, magnetic resonance imaging, computerized topography, and angiography are necessary to identify the size, location, extent, and collateral feeders before any therapeutic or surgical interventions are attempted [9,21].…”

“…Doppler-ultrasound, magnetic resonance imaging, computerized topography, and angiography are necessary to identify the size, location, extent, and collateral feeders before any therapeutic or surgical interventions are attempted [9,21]. The management of VMs depends on the type and flow characteristics of the malformation, the functional impairment, disfigurement, the threat to life, and on the expertise of the surgeon or the interventional radiologist [9,21]. The therapeutic modalities include sclerotherapy, embolization, laser photocoagulation, and surgical excision and are beyond the scope of this article [9,21].…”