Facial palsy after embolization with Squid® 12

Abstract

Endovascular procedures with liquid embolic agents such as ethylene-vinyl alcohol (EVOH) copolymers are indicated before surgical treatment of cervical paraganglioma. Consequently, these agents are now available as low viscosity formulations, one of which is Squid 12, which are demonstrating superior vascular penetration. Cases of facial paralysis secondary to embolization of cervical vascular lesions with classic embolic agents have been reported in the English literature, however, this complication has not been described with new generation options such as Squid 12.We describe the case of a 43-year-old patient with a left neck carotid paraganglioma. Embolization was performed under general anaesthesia before surgical excision. In the immediate postoperative period, the patient developed total left facial palsy. Since the imaging tests (Computed Tomography (CT) and Magnetic Resonance Imaging (MRI)) and neurological examination showed no involvement of additional cranial nerves (CN), we hypothesise that the main cause of this complication is ischemia of the vasa nervorum of CN VII secondary to embolization. Almost six months later, the patient continues to present total facial paralysis (Grade VI House-Brackmann facial paralysis scale), and palsy of the left CN X and XII as a complication secondary to surgical resection of the paraganglioma.This case is relevant since it is the first clinical case of permanent facial paralysis secondary to embolization with Squid 12.

Liquid Embolic Agents for Endovascular Embolization: A Review

“…Table 1 summarizes the liquid embolics that are discussed in this review. Shear-Thinning Biomaterials [88,89] Silk Elastin Protein (SELP) [90][91][92] Poly(Ethylene Glycol) Hydrogel Embolization System (HES) Instylla Embrace [92][93][94][95][96] Eudragit [97][98][99][100] Calcium Alginate [101][102][103][104][105][106] Ethylene vinyl alcohol copolymers Squid and Squid Peri [107][108][109][110][111][112][113][114][115][116][117] Onyx Poly(lactide-co-glycolide) and poly(hydroxyethyl methacrylate) PHIL [159][160][161][162][163][164][165][166][167] Iodinated polyvinyl alcohol EASYX [168][169][170][171] 3.1. Polymerizing Liquid Embolics…”

“…This complication was treated with complete safe removal of the embolic material and antibiotherapy. In 2021, Moreno-Paredes reported the first clinical case of permanent facial paralysis secondary to embolization with Squid 12 [117].…”

Preoperative Transarterial Embolization of a Large Petrotentorial Angiomatous Meningioma Using Combination of Liquid Embolic Materials: A Case Report

“…Due to lower viscosity of Squid 12, it can favor penetration in all vascular pedicles and their more distal branches, affecting the vasa nervorum of the facial nerve, causing facial nerve palsy after embolization. 16 Our case had facial palsy and hearing loss, probably from tumor invasion, before embolization. However, the microcatheter was always navigated in the proximity of the tumor as near as possible and injected contrast for searching dangerous extracranial-intracranial anastomoses and blood vessels supplying the cranial nerves before embolization.…”

Parapharyngeal Space Tumors: Our Experience

“…This result was associated with shorter operative times and lower risks of intraoperative bleeding complications. Furthermore, preoperative embolization through Contour, for which endovascular access is required rather than percutaneous / intralesional, is burdened by a greater theoretical risk of retrograde reflux and systemic dispersion of the drug, occurrences never ascertained in our patients, but described in scientific literature [ 43 , 44 , 45 , 46 ].…”