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

Abstract

Background and purpose: Liver cancer is the third leading cause of cancer mortality worldwide. The aim of this study was to investigate the frequency and characteristics of cerebral lipiodol embolism (CLE) in patients with hepatocellular carcinoma (HCC) receiving transarterial embolization/chemoembolization (TAE/TACE).

Methods: We reviewed all HCC patients who received TAE/TACE during the period of 2007 and 2013 at a university medical center. The frequency of CLE per procedure and the clinical manifestations of CLE, including the review of previous reported cases (n = 24), were analyzed.

Results: During the study period, a total of 7855 TAE/TACE procedures were conducted on 3277 patients. There were 8 patients (mean age 59±11 years; 5 males and 3 females) who developed CLE. The frequency of TAE/TACE-related CLE was 1.02 (95% CI, 0.44-2.01) per 1000 procedures. Acute disturbance of consciousness and respiratory distress after TAE/TACE were the most common presentations of CLE. All patients had disseminated infarcts involving both the anterior and posterior cerebral circulations. For 3 patients with shunting between the tumor feeding artery and the pulmonary vein, a specific imaging pattern of coexisting scattered hyperdense spots was found. Furthermore, combined with our 8 cases, the total of 32 cases indicated that old age and female sex were the two risk factors for poor outcome after CLE.

Conclusions: CLE is a rare but potentially serious complication in HCC patients receiving TAE/TACE. The clinical characteristics of CLE summarized in our study would help facilitate the ability of clinicians to provide timely diagnosis and management.

Fig 1. Head imaging findings in a patient with hepatocellular carcinoma who had cerebral lipiodol embolism (CLE) after transarterial chemoemobolization.

Head CT and MRI were performed at 9 hours and 1 day after the symptoms, respectively. Row A: Head non-contrast CT showed disseminated high-density lesions mainly at gray matter (arrow), Row B and C: diffusion weighted imaging (DWI) and T2 fluid attenuation inversion recovery (FLAIR) of head MRI. The scans showed multiple disseminated hyperintensity/high signal lesions mainly at the gray matter of the cerebrum and cerebellum. The larger areas on FLAIR than on DWI for the same lesions indicate the existence of peri-stroke edema.

Fig 2. Head and abdominal imaging findings in HCC patients with pulmonary vein shunting due to direct diaphragm and pleura invasion.

A right inferior phrenic artery angiogram showed prior embolized hepatic tumor with large adjacent recurrence. An early opacified pulmonary vein branch was seen (arrow head) (A); non-contrast chest CT at 2 days after CLE showed lipiodol pneumonitis at bilateral collapsed basal lung (arrow head) (B); on head non-contrast CT there were several hyperdense spots (arrow) in addition to typical disseminated lesions of increased attenuation of CLE at the cerebral hemispheres (C) and brain stem (D). At 3 weeks follow-up, head CT of the same patient showed disappearance of the previous hyperdense lesions (E & F).