Korean J Gastroenterol.  2009 Aug;54(2):130-134. 10.4166/kjg.2009.54.2.130.

Cerebral Lipiodol Embolism after Transcatheter Arterial Chemoembolization of Hepatocellular Carcinoma

• Chung PJ
• Park SY
• Kim YI
• Yoon KW
• Cho SB
• Choi SK
• Rew JS

• KMID: 1775969
• DOI: http://doi.org/10.4166/kjg.2009.54.2.130

Abstract

Transcatheter arterial chemoembolization (TACE) is the mainstay of treatment for unresectable hepatocellular carcinoma (HCC). Although various complications of TACE have been reported, cerebral lipiodol embolism after TACE is rare. We report a 67-year-old man, who had patent foramen ovale and developed cerebral lipiodol embolism after TACE via the inferior phrenic artery. At 20 months after third TACE of 3 cm sized HCC in the left hepatic lobe, computed tomography (CT) revealed about 1.6 cm newly developed HCC in the anterior superior segment of right hepatic lobe. The angiogram revealed the HCC was supplied from the right inferior phrenic artery. Toward the end of TACE, there were accumulations of the iodized oil in the pulmonary vasculature. Immediately after TACE, he complained of weakness in right upper and lower limbs and sensory decrease in right limbs and right hemitrunk. Magnetic resonance imaging revealed a cerebral lipiodol embolism. Transesophageal echocardiography revealed no visible thrombi but contrast-echocardiography using hand agitated saline revealed an intracardiac right to left shunt consistent with patent foramen ovale. Motor weakness and sensory decrease were gradually improved, and all neurological symptoms disappeared over 4 weeks.

Keyword

Carcinoma, Hepatocellular; Cerebral embolism; Iodized oil

MeSH Terms

Aged
Carcinoma, Hepatocellular/complications/diagnosis/*therapy
*Chemoembolization, Therapeutic
Contrast Media/*adverse effects/diagnostic use
Humans
Intracranial Embolism/*diagnosis/*etiology/ultrasonography
Iodized Oil/*adverse effects/diagnostic use
Liver Neoplasms/complications/diagnosis/*therapy
Magnetic Resonance Imaging
Male
Tomography, X-Ray Computed

Figure

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  Fig. 1. Computed tomography (CT) revealed previous lipiodol uptake in the medial segment of the left hepatic lobe and a newly developed HCC in the anterior superior segment of the right hepatic lobe, approximately 1.6 cm in size.

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  Fig. 2. (A) Right inferior phrenic angiogram showed a hypervascular tumor in the right lobe of the liver (arrow). (B) Transar-terial infusion of adriamycin emulsified in iodized oil was infused into the right inferior phrenic artery. Delayed angiogram showed a lipiodol uptake in the right lower lung field (arrow).

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  Fig. 3. (A) Magnetic resonance images of the brain revealed multiple, discrete, high signal intensities in the frontal lobe, parietal lobe, occipital lobe, and cerebellum on T2-weighted and diffusion-weighted imaging. (B) A non-contrast-enhanced CT scan of the brain obtained 7 days after the procedure revealed disseminated hyperattenuation along the gyri of both frontal lobe and subcortical white matter of the parietal lobe, suggesting deposition of iodized oil.

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  Fig. 4. Agitated saline injections were performed at rest and during maximal Valsalva maneuver. Transesophageal echocardiogram showed visualization of an injected saline microbubble in the left atrium within three cardiac cycles of right atrial opacification, consistent with the presence of an intracardiac shunt (left). Transcranial Doppler through the temporal bone showed agitated saline bubbles passing through the middle cerebral artery (right).

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