A comparison of particulate and onyx embolization in preoperative devascularization of juvenile nasopharyngeal angiofibromas

Combined Direct Tumoral Puncture Embolization with Onyx and Trans-arterial Embolization for JNA

Onyx is a safe and effective embolic agent to utilize in the treatment paradigm of JNA. We present a tandem approach that combines trans-arterial embolization (TAE) with direct puncture embolization (DPE) with Onyx to limit blood loss and facilitate safe resection. Laryngoscope, 134:3568-3571, 2024.

Direct tumoral puncture embolization of onyx before endoscopic endonasal resection of a massive juvenile angiofibroma for a patient with Von Willebrand disease - A case report and review of literature

INTRODUCTION

Standard treatment of a juvenile angiofibroma (JNA) is surgical resection, usually with an endoscopic endonasal surgery and a preoperative embolization. However, standard intra-arterial embolization may fail to completely devascularize tumors. A novel technique of direct intranasal intratumoral onyx embolization has been described. The aim of this study is to demonstrate the safety and the usefulness of this embolization technique on a pediatric case of JNA and to compare our results to previously reported cases.

PRESENTATION OF CASE

A twelve-year-old patient suffering from Von Willebrand disease presented with a voluminous JNA with intracranial extension. Internal carotid artery (ICA) branches partially vascularized the tumor. The patient had two previous incomplete surgical resections, which were preceded by a standard embolization, due to massive perioperative bleeding.

DISCUSSION

A direct intratumoral embolization of onyx safely allowed complete tumoral devascularization. Tumoral resection was then completed by an endonasal endoscopic approach. Surgery time was decreased (4,5 h versus 5,5 and 6,5 h) and blood loss were minimized (300 ml versus 1 l and 1,3 l). No complication occurred. Twelve articles previously reported this embolization technique. We present the first reported case of onyx embolization being used for a pediatric patient with a coagulation disorder and a voluminous tumor.

CONCLUSION

A direct intratumoral onyx embolization allowed complete resection of a massive JNA, for a patient with Von Willebrand disease. Our data suggest that this technique is safe and may be instrumental for a JNA's resection, even if little vascularization comes from ICA branches.

Preoperative Embolization Techniques in the Treatment of Juvenile Nasopharyngeal Angiofibroma: A Systematic Review

OBJECTIVE

Preoperative embolization has proven beneficial in the surgical treatment of juvenile nasopharyngeal angiofibromas (JNA). However, the consensus for the best embolization practices remains unclear. This systematic review seeks to characterize the reporting of embolization protocols throughout the literature and to compare differences in surgical outcomes.

DATA SOURCES

PubMed, Embase, and Scopus.

REVIEW METHODS

Studies investigating embolization in the treatment of JNA from 2002 to 2021 were selected from defined inclusion criteria. All studies underwent a 2-stage blinded screening, extraction, and appraisal process. Embolization material, time to surgery, and embolization route were compared. Embolization complications, surgical complications, and rate of recurrence were pooled.

RESULTS

Of 854 studies, 14 retrospective studies with 415 patients met the criteria for inclusion. A total of 354 patients underwent preoperative embolization. A total of 330 patients (93.2%) underwent transarterial embolization (TAE) and 24 patients had a combination of direct puncture embolization and TAE. Polyvinyl alcohol particles were the most used embolization material (n = 264, 80.0%). The most common reported time to surgery was 24 to 48 hours (n = 8, 57.1%). Pooled results showed an embolization complication proportion of 3.16% (95% confidence interval [CI]: 0.96-6.60) (n = 354), a surgical complication proportion of 4.96% (95% CI: 1.90-9.37) (n = 415), and a recurrence proportion of 6.30% (95% CI: 3.01-10.69) (n = 415).

CONCLUSION

The current data on JNA embolization parameters and their effect on surgical outcomes remains too heterogenous to provide expert recommendations. Future studies should use uniform reporting to allow for more robust comparisons of embolization parameters, which, in turn, may lead to optimized patient outcomes.

Advances in Imaging Modalities for Pediatric Brain and Spinal Cord Tumors

BACKGROUND

Neuroimaging has evolved from anatomical imaging toward a multi-modality comprehensive anatomical and functional imaging in the past decades, important functional data like perfusion-weighted imaging, permeability imaging, diffusion-weighted imaging (DWI), and diffusion tensor imaging (DTI), tractography, metabolic imaging, connectomics, event-related functional imaging, resting state functional imaging, and much more is now being offered.

SUMMARY

Precision diagnostics has proven to be essential for precision treatment. Many minimal invasive techniques have been developed, taking advantage of digital subtraction angiography and interventional neuroradiology. Furthermore, intraoperative CT and/or MRI and more recently MR-guided focused ultrasound have complemented the diagnostic and therapeutic armamentarium.

KEY MESSAGES

In the current manuscript, we discuss standard imaging sequences including advanced techniques like DWI, DTI, susceptibility-weighted imaging, and 1H magnetic resonance spectroscopy, various perfusion weighted imaging approaches including arterial spin labeling, dynamic contrast enhanced imaging, and dynamic susceptibility contrast imaging. Pre-, intra, and postoperative surgical imaging including visualize imaging will be discussed. The value of connectomics will be presented for its value in neuro-oncology. Minimal invasive therapeutic possibilities of interventional neuroradiology and image-guided laser ablation and MR-guided high-intensity-focused ultrasound will be presented for treatment of pediatric brain and spinal cord tumors. Finally, a comprehensive review of spinal cord tumors and matching neuropathology has been included.

The Role of Preoperative Onyx Embolization by Transnasal Direct Puncture in the Treatment of an Advanced Juvenile Nasopharyngeal Angiofibroma

Juvenile nasopharyngeal angiofibroma (JNA) is a rare and locally aggressive tumor that commonly presents with painless nasal obstruction and severe, recurrent epistaxis. In this case report, we describe the successful management of a Radkowski stage IIIA JNA with extensive arterial supply from the internal carotid artery (ICA). Transnasal direct puncture embolization using Onyx (Medtronic, Minneapolis, Minnesota) was employed to effectively devascularize the tumor, enabling radical surgical resection in a single piece via endonasal and transmaxillary endoscopic approaches. The patient did not require blood transfusion and was discharged without neurological impairment. The effectiveness of preoperative embolization as a treatment strategy for JNA is also discussed.

Embolization in Juvenile Nasopharyngeal Angiofibroma Surgery: A Systematic Review and Meta-Analysis

OBJECTIVE

To compare outcomes of juvenile nasopharyngeal angiofibroma (JNA) resection between embolized and non-embolized cohorts, and between transarterial embolization (TAE) and direct puncture embolization (DPE).

DATA SOURCES

Per PRISMA guidelines, PubMed, Embase, Web of Science, Scopus, and Cochrane databases were searched for publications prior to or in 2021.

MATERIALS AND METHODS

Original English manuscripts investigating the resection of JNA with and without preoperative embolization were included. Embolization type, recurrence rate, complication rates, blood loss, and transfusions were extracted. Risk of bias was assessed by the Risk of Bias in Non-randomized Studies-of Interventions method.

RESULTS

There were 61 studies with 917 patients included. Preoperative embolization was performed in 79.3% of patients. Of those embolized, 75.8% (N = 551) underwent TAE and 15.8% (N = 115) underwent DPE. JNA recurrence in embolized patients was lower than in non-embolized patients (9.3% vs. 14.4%; odds ratio [OR]: 0.61, 95% confidence interval [CI]: 0.35, 1.06). DPE resulted in lower rates of disease recurrence (0% vs. 9.5%; OR: 0.066, 95% CI: 0.016, 0.272) and complications (1.8% vs. 21.9%; OR: 0.07, 95% CI: 0.02, 0.3) than TAE. A random effects Bayesian model was performed to analyze the difference in mean blood loss in 6 studies that included both embolized and non-embolized patients. This analysis showed a mean reduction in blood loss of 798 mL in the embolized group.

CONCLUSIONS

We found embolization decreases blood loss in JNA resection. DPE led to improved recurrence and complication rates when compared to TAE, but future prospective studies are needed to further evaluate which embolization technique can optimize outcomes in JNA.

LEVEL OF EVIDENCE

NA Laryngoscope, 2023.

Single-Center Experiences of Preoperative Juvenile Nasal Angiofibroma Embolization With Gelfoam, Reducing Financial Burden on Patients in Developing Country

Introduction

Juvenile nasal angiofibroma (JNA) is a highly vascular tumor of the nasopharynx. Endovascular embolization followed by surgery is the treatment of choice. This study aimed to determine that single catheter technique with Gelfoam is an effective and safe technique for embolization to reduce the financial burden on patients in a developing country.

Materials and methods

We retrospectively reviewed the imaging, surgical, and histopathological records of 108 patients who underwent preoperative endovascular tumor embolization followed by surgical resection between March 2017 and March 2021.

Results

After embolization no major complication was observed in any patient. Complete devascularization of tumor was done in 87.8%. Intraoperative blood loss resulting in transfusion was almost the same as with other embolization techniques.

Conclusion

Single catheter with Gelfoam is a cost-effective and safe technique for JNA embolization.

Twenty Years of Experience in Juvenile Nasopharyngeal Angiofibroma (JNA) Preoperative Endovascular Embolization: An Effective Procedure with a Low Complications Rate

Juvenile nasopharyngeal angiofibroma (JNA) is a benign tumor of the nasal cavity that predominantly affects young boys. Surgical removal remains the gold standard for the management of this disease. Preoperative intra-arterial embolization (PIAE) is useful for reductions in intraoperative blood loss and surgical complications. In our series of 79 patients who underwent preoperative embolization from 1999 to 2020, demographics, procedural aspects, surgical management and follow-up outcome were analyzed. Embolization was performed in a similar fashion for all patients, with a superselective microcatheterization of external carotid artery (ECA) feeders and an injection of polyvinyl alcohol (PVA) particles, followed, in some cases, by the deployment of coils . Procedural success was reached in 100% of cases, with no complications such as bleeding or thromboembolic occlusion, and surgical intraoperative blood loss was significantly decreased. In conclusion, PIAE is a safe and effective technique in JNA treatment, minimizing intraoperative bleeding.

Preoperative Embolization of Fisch Grades II-IVa Juvenile Nasopharyngeal Angiofibromas: Transarterial Embolization in the Age of Onyx

Objective

The current mainstay treatment for juvenile nasopharyngeal angiofibromas (JNAs) is surgical resection, but embolization of primary feeding arteries through endovascular transarterial and direct tumoral puncture embolizations with various agents has been described. We describe a single institutional experience with JNA embolization utilizing Onyx (Medtronic, Dublin, Ireland).

Methods

A retrospective records review was performed to identify patients who underwent embolization for devascularization of Fisch grades II-IVa JNA (tumor extension beyond the sphenopalatine region) before surgical resection between 2010 and 2019. Fluoroscopy time, grade, intraoperative blood loss, and clinical follow-up data were compiled. Tumor devascularization percentage was calculated using ImageJ software (public domain, BSD-2) by measuring the ratio of preoperative and postoperative embolization tracing.

Results

Five consecutive patients (ages 12-16 years [average 14 years]; all male) with JNAs underwent preoperative transarterial embolizations performed under general anesthesia. All patients presented with epistaxis; two also presented with headaches. Fisch grades were II in two patients, IIIa in two, and IVa in one. The patient with the grade IVa lesion underwent direct transtumoral puncture and Onyx embolization. The mean percentage of all tumor devascularizations postembolization was 86.0±9.7%.Complete resection 24-48 hours postembolization was obtained for grades II and IIIa lesions with <700 mL blood loss. No embolization-related complications and no clinical sequelae were present in the five cases after embolization.

Conclusion

In our experience, Onyx embolization of JNAs was safely conducted with adequate tumor penetration beyond the sphenopalatine region through transarterial routes.

A safer endovascular technique for pre-operative embolization of juvenile nasopharyngeal angiofibroma: avoiding the pitfalls of external carotid artery - internal carotid artery anastomoses

Intra-arterial embolization of juvenile nasopharyngeal angiofibroma (JNA) prior to surgical resection is the preferred approach to minimize blood loss during surgical resection of the tumor. However, the presence of external carotid artery–internal carotid artery (ECA-ICA) anastomoses may hinder complete tumor embolization due to the associated risk for embolic complications. Here, we evaluate the use of a balloon-assisted embolization (BAE) technique in the treatment of JNA. We conducted a retrospective review of JNA patients who underwent tumor embolization with injection of Onyx in a single session between 2013–2018. All cases displayed tumor arterial supply from ECA and ICA circulations on 2-D catheter angiograms. Procedural and surgical outcome data were analyzed. Results are given as mean±standard deviation (range). Among 9 patients with JNA, all were males and mean age was 14.1±6.3 years (range, 9–29 years). The mean tumor volume embolization was 84.4±12.4% (range, 60–100%) and in 89% patients ≥80% of tumor volume embolization was achieved. There were no embolization-related complications reported. During surgical resection of the tumor there was a low average surgical blood loss of 722±651.5 mL (range, 50–2,000 mL) and the mean procedure time was 282.6±85.4 mins (range, 151–403 mins). In this series, the BAE technique showed to be a safe and effective approach to achieve successful tumor embolization while avoiding embolic complications and effectively reducing the risk for blood loss during surgical resection.

Trimodal embolization of juvenile nasopharyngeal angiofibroma with intracranial extension

OBJECTIVES/PURPOSE

1. Understand three different techniques for embolization of juvenile nasal angiofibroma (JNA) and assess their combined efficacy. 2. Perform successful endoscopic intralesional embolization of highly vascular sinonasal neoplasms.

METHODS

In this study, we present the case of a 10-year-old male patient diagnosed with juvenile nasal angiofibroma (JNA) who successfully underwent trimodal embolization and resection at a tertiary academic medical center after failed coil embolization in his home country. We examine the clinical details of the case and a review of pertinent literature.

RESULTS

Preoperative embolization is common in the treatment of JNA, but there is little consensus as to the proper timeframe and techniques utilized. In our case, preoperative imaging revealed a vascular tumor with intracranial extension consistent with UPMC Stage V JNA. Diagnostic angiogram revealed significant arborization from the internal and external carotid systems. A trimodal embolization technique, utilizing transarterial, percutaneous, and direct endoscopic intralesional injection of n-Butyl Cyanoacrylate (n-BCA) was performed. A two-staged endoscopic and open resection was subsequently performed one week later with minimal blood loss. In our case, combining intralesional embolization with traditional transarterial techniques resulted in an improved operative field and a successful clinical result.

CONCLUSION

Embolization of highly vascular sinonasal tumors with n-BCA is not limited to endovascular techniques, but can be safely combined with percutaneous and endoscopic intralesional embolization up to one week prior to surgical resection.

Strategies for Improving Visualization During Endoscopic Skull Base Surgery

The nasal cavity has a robust vascular supply, and bleeding is a primary obstacle to the minimally invasive skull base technique. Venous bleeding, including the cavernous sinus, can be managed with various techniques using hemostatic materials and pressure. A thorough understanding of the skull base vascular anatomy is vital for avoiding injury to major arteries and having confidence to control venous bleeding to optimize the endoscopic view and tumor resection.

Paragangliomas of the Head and Neck

Paragangliomas of the head and neck are rare vascular skull-base tumors derived from the paraganglionic system with an estimated incidence of 1:30,000 accounting for 3% of all paragangliomas. The most common paraganglioma locations of the head and neck in descending order are the carotid body, jugular, tympanic, and vagal paragangliomas. This article discusses the clinical characterics, normal anatamy, imaging findings and protocols, pathology, staging, and differential diagnosis for paragangliomas of the head and neck.

Combined percutaneous and transarterial devascularisation of juvenile nasopharyngeal angiofibroma with protection of internal carotid artery: A modification of the technique

Juvenile nasal angiofibroma (JNA) is a hypervascularised, benign, but locally aggressive tumour that grows in the posterior, upper part of the nasal cavity and invades surrounding anatomical structures. The treatment of choice is surgical removal, but complete resection of the tumour can be hampered because of profuse perioperative bleeding. Preoperative embolisation of the tumour has been proposed as an effective method for prevention of perioperative bleeding, thereby shortening of the time of the operation. In this report of five cases, we describe successful preoperative devascularisation of the tumour by applying a modified method of direct intratumoural injection of the liquid embolic agent Onyx combined with protection of the internal carotid artery. The control of bleeding during the embolisation and occlusion of the maxillary or sphenopalatine artery was achieved by using a bi-luminal balloon catheter. Such use of the dual-lumen catheter in treatment of JNA has not been reported so far in the medical literature.

Supporting information retrieval from electronic health records: A report of University of Michigan's nine-year experience in developing and using the Electronic Medical Record Search Engine (EMERSE)

OBJECTIVE

This paper describes the University of Michigan's nine-year experience in developing and using a full-text search engine designed to facilitate information retrieval (IR) from narrative documents stored in electronic health records (EHRs). The system, called the Electronic Medical Record Search Engine (EMERSE), functions similar to Google but is equipped with special functionalities for handling challenges unique to retrieving information from medical text.

MATERIALS AND METHODS

Key features that distinguish EMERSE from general-purpose search engines are discussed, with an emphasis on functions crucial to (1) improving medical IR performance and (2) assuring search quality and results consistency regardless of users' medical background, stage of training, or level of technical expertise.

RESULTS

Since its initial deployment, EMERSE has been enthusiastically embraced by clinicians, administrators, and clinical and translational researchers. To date, the system has been used in supporting more than 750 research projects yielding 80 peer-reviewed publications. In several evaluation studies, EMERSE demonstrated very high levels of sensitivity and specificity in addition to greatly improved chart review efficiency.

DISCUSSION

Increased availability of electronic data in healthcare does not automatically warrant increased availability of information. The success of EMERSE at our institution illustrates that free-text EHR search engines can be a valuable tool to help practitioners and researchers retrieve information from EHRs more effectively and efficiently, enabling critical tasks such as patient case synthesis and research data abstraction.

CONCLUSION

EMERSE, available free of charge for academic use, represents a state-of-the-art medical IR tool with proven effectiveness and user acceptance.