Direct Percutaneous Embolization of Head, Neck and Spine Tumors: A Single Center Experience

IntroductionTransarterial embolization is a well-established adjunct in the management of hypervascular head, neck, and spine tumors. Few case-series have described the role of direct percutaneous embolization (DPE). MethodWe report our experience with DPE (with or without transarterial embolization) in patients with head, neck, and spine tumors treated between 2012-2023. Baseline demographics, angiographic imaging, tumoral pathology, and relevant clinical variables were retrospectively reviewed and descriptively analyzed. ResultA total of 55 patients underwent direct percutaneous embolization (19 of whom also received transarterial embolization either before [n=7] or after [n=12] DPE). The most commonly embolized lesions were malignant carcinomas (n=16), followed by juvenile nasopharyngeal angiofibromas (n=11), paragangliomas (n=8), hemangiomas (n=7), and others (hemangioblastoma, schwannoma, neurofibroma, esthesioneuroblastoma, meningioma and hemangiopericytoma). The most common locations were sinonasal/nasopharyngeal (n=21), followed by scalp/subcutaneous (n=18), carotid body (n=6), spinal/paraspinal (n=4), skull base (n=5), and intracranial (n=1). A median of 4 (interquartile range 4-6) twenty-two-gauge spinal needles were used per embolization with a median fluoroscopy time of 50.5 (23.2-77.8) minutes resulting in median radiation exposure of 3055 (840.5-5053.5) mGy. Seven patients received more than one embolic agent, with n-butyl cyanoacrylate (glue, n=44, 81.5%) being the mostly commonly used embolic, followed by ethylene-vinyl alcohol copolymer (Onyx, n=7, 12.9%), 98% dehydrated ethanol (n=7, 12.9%), sodium tetradecyl sulfate (n=2, 3.7%) and poly-vinyl alcohol particles (n=1, 1.8%). The median volume of embolic agent injected was 5.5(4-7.6) mL resulting in total/near-total (90%-99%) angiographic devascularization in 74.5% cases. The median operative blood-loss was 250(75-700) mL. One patient underwent trans-calavarial DPE for a cerebellar hemangioblastoma and suffered diffuse subarachnoid hemorrhage from profuse tumoral bleeding. One patient had an asymptomatic parent-vessel occlusion from retrograde embolic extension. ConclusionOur single-center study reinforces prior experience that DPE of Sino-nasal carcinomas, angiofibromas and paragangliomas with adhesive and non-adhesive liquid embolic agents is safe, feasible and effective. Further, it suggests that these benefits may also be extended to non-traditional head, neck and spine tumors. Caution must be exercised when applying these techniques to intracranial tumors with robust intratumoral arteriovenous shunting.