Interventional neuroradiology of the head and neck

Safety and histopathologic yield of percutaneous CT-guided biopsies of the skull base, orbit, and calvarium

PURPOSE

Although CT-guided biopsies of the calvarium, skull base, and orbit are commonly performed, the best approaches, efficacy, and safety of such procedures remain scantly described in the literature. This retrospective review of percutaneous biopsies illustrates several approaches to challenging biopsy targets and provides a review of procedural planning considerations and histopathologic yield.

METHODS

A retrospective review of CT-guided biopsies of the skull base, calvarium, and orbit between 1/1/2010 and 10/30/2020 was conducted. Patient demographics and procedural factors were recorded, including lesion size and location, biopsy approach, and needle gauge. Outcomes were also noted, including CT dose length product, complications, and histopathologic yield.

RESULTS

Sixty-one CT-guided biopsies were included in the final analysis: 34 skull base, 23 calvarial, and 4 orbital lesions. The initial diagnostic yield was 32/34 (94%) for skull base lesions, with one false-negative and one non-diagnostic sample. Twenty-one of twenty-three (91%) biopsies in the calvarium were initially diagnostic, with one false-negative and one non-diagnostic sample. In the orbit, 4/4 biopsies were diagnostic. The total complication rate for the cohort was 4/61 (6.6%). Three complications were reported in skull base procedures (2 immediate and 1 delayed). A single complication was reported in a calvarial biopsy, and no complications were reported in orbital biopsies.

CONCLUSION

Percutaneous CT-guided core needle biopsies can be performed safely and with a high diagnostic yield for lesions in the skull base, calvarium, and orbit.

Gantry-needle-target alignment technique for CT-guided needle approaches to the skull base and cranio-cervical junction

PURPOSE

CT-guided percutaneous procedures involving the skull base and atlanto-axial cervical spine pose particular challenges due to high density of vital vascular and nervous structures and because the ideal needle trajectory often has a cranio-caudal obliquity different from the axial scan plane. We describe how the variable CT gantry tilt, combined with gantry-needle-target alignment technique, is used to obtain precise and safe needle placement in conventional and non-conventional approaches to the skull base and the atlanto-axial spine.

METHODS

We retrospectively analyzed consecutive CT-guided needle accesses to the skull base and atlanto-axial spine performed for tissue sampling through fine-needle aspirates and core biopsies, cementoplasty of neoplastic lytic lesions of atlanto-axial spine, pain management injections, and dural puncture for cerebro-spinal fluid sampling. All the accesses were performed with the gantry-needle-target alignment technique. Procedural complications were recorded.

RESULTS

Thirty-nine CT-guided procedures were analyzed. Paramaxillary approach was used in 15 cases, postero-lateral in 11, subzygomatic in 3. Nine non-conventional approach were performed: submastoid in 3 cases, suprazygomatic in 2, trans-nasal in 2, trans-mastoid in 1, and trans-auricular in 1. Two peri-procedural complications occurred: one asymptomatic and one resolved within 24 h. All the procedures were successfully completed with successful needle access to the target.

CONCLUSION

The gantry tilt and gantry-needle-target alignment technique allows to obtain double-oblique needle accesses for CT-guided procedures involving the skull base and atlanto-axial cervical spine, minimizing uncertainty of needle trajectory and obtaining safe needle placement in conventional and non-conventional approaches.

Skull Base Neurointerventional Techniques

Neurodiagnostic and neurointerventional radiology (NIR) play a central role in the diagnosis and treatment of skull base disorders. Noninvasive imaging modalities, including computed tomography and magnetic resonance imaging, are important in lesion localization, evaluation of lesion extent, and diagnosis, but cannot always be definitive. Image-guided skull base biopsy and percutaneous and endovascular treatment options are important tools in the diagnosis and treatment of head, neck, and skull base disorders. NIR plays an important role in the treatment of vascular disorders of the skull base. This article summarizes the imaging evaluation and interventional therapies pertinent to the skull base.

The role of computed tomography angiography as initial imaging tool for acute hemorrhage in the head and neck

OBJECTIVES

Acute hemorrhage in the head and neck (AHNH) is life-threatening due to asphyxiation and hemorrhagic shock. When conservative measures fail, some patients benefit from endovascular therapy (EVT). While CTA is routinely used to localize bleeding and plan EVT in gastrointestinal hemorrhage, the diagnostic value of CTA in AHNH and role of CTA in treatment-planning are uncertain.

METHODS

We retrospectively reviewed neck CTAs from June 2015 to October 2018 indicated for AHNH. When performed, digital subtraction angiography (DSA) findings and EVT were documented. Extravasation or pseudoaneurysm on DSA was considered positive for bleed localization.

RESULTS

Thirty CTA exams were performed for AHNH in 18 patients (mean age = 56.6, male% = 55.6%). Eleven out of 30 exams (36.7%) had immediate DSA follow-up within 24 h. Etiologies of hemorrhage included malignancy 11/18 (61.1%) and coagulopathy (4/18, 22.2%) among others. CTA reports identified definite or possible source of bleeding in 7/30 (23.3%) exams. Seven out of 7 (100%) patients with definite or possible source of bleeding on CTA underwent DSA and 4/23 (17.4%) patients underwent DSA despite negative CTA. With DSA as the gold standard, CTA had a sensitivity of 70% and a specificity of 100%.

CONCLUSIONS

CTA has high specificity and reasonable sensitivity for detecting arterial source of bleeding in patients presenting with AHNH. Patients with negative CTA may avoid catheter angiography in most cases; however, false-negative CTA should not preclude angiography in high-risk patients.

Interventional Management of Head and Neck Tumors

Advancements in medical imaging and device technology allow minimal invasive procedures for the diagnosis and treatment of various disorders. For the management of tumors in head and neck region, these image-guided interventions play essential role in the often used multidisciplinary approach. Tissue sampling under ultrasound or computed tomography guidance is generally the first step to reach a pathological diagnosis. For head and neck tumors with high vascularity, embolization using particulate matter, liquid embolic agents, or coils is used to achieve successful tumor resection with minimal blood loss. Hemorrhage related to head and neck tumors can be evaluated and managed with endovascular techniques with minimal morbidity and mortality. Intra-arterial chemotherapy, radiofrequency ablation, and cryotherapy are new techniques for the management of advanced head and neck cancer which may serve as an alternative to achieve locoregional control and survival when curative resection may not be feasible.

Blood loss mitigation and replacement in facial surgery: a review

PURPOSE OF REVIEW

To provide a comprehensive overview of the predisposing factors that contribute to a risk of excess bleeding for surgical therapy in the head and neck regions, provide a thorough overview of techniques and tools for managing blood loss complications, and provide intervention algorithms to help guide clinical decision making.

RECENT FINDINGS

With the current landscape of medications and reversal agents, protocols for intervention in a variety of situations, and new tools for blood loss management all rapidly changing and being developed it is critical to stay up to date to provide patients the best care in the most critical of situations.

SUMMARY

With the risk of blood loss complications in head and neck surgery ranging from minimal to extreme surgeons require a comprehensive understanding risk factors, patient evaluation tools, and proper management algorithms. The first opportunity to prevent unnecessary blood loss and blood loss complications is the health history and physical appointment where a clinician can identify any medications, conditions, or other predisposing factors that would elevate a patient's risk of excess bleeding and the necessity for treatment augmentation. Although not all complications can be prevented because of the natural physiological variation that occurs from patient to patient, despite proper and proper diagnostics, a full working knowledge of most likely complications, hemostatic tools, and concise communication with team members can prevent a lot of blood loss and the complications associated.

Successful sclerotherapy of a recurrent, benign parotid cyst

Benign parotid lesions can grow to be a cosmetic deformation with psychological sequelae for a patient. Although surgical resection is the treatment of choice, cyst aspiration has also been attempted. This, however, has been shown to recur, requiring repeat intervention. An alternative therapeutic method not as widely recognized, but which has been reported to be both effective and less invasive than surgery for treating parotid cyst lesions, is sclerotherapy. Here we describe a report of a patient with a benign, localized, cystic neck mass refractory to 2 trials of fine needle aspiration. After the patient refused surgical resection, a trial of sterile ethanol sclerotherapy was performed. Our patient tolerated the procedure well with a significant reduction in the size of the lesion.

Techniques and Approaches for Safe, High-Yield CT-Guided Suprahyoid Head and Neck Biopsies

OBJECTIVE

The purpose of this article is to present imaging approaches and key technical, safety, and patient care best practices critical for safe, successful image-guided biopsy of head and neck masses.

CONCLUSION

Image-guided sampling is an important adjunct to the diagnosis and management of head and neck masses and may be particularly useful when lesions are not accessible via an endoscope or by palpation-guided sampling. Appropriate workup is mandatory before the patient is scheduled for such a procedure. Once the procedure has been initiated, needle selection and technique are critical for increasing the diagnostic yield. Knowledge of the various head and neck biopsy approaches and their associated complications is important for optimal tissue sampling and minimization of morbidity.

Interventional Radiology and Bleeding Disorders: What the Oral and Maxillofacial Surgeon Needs to Know

Endovascular techniques are essential for controlling acute head and neck bleeding that cannot be controlled by local or systemic measures. Detailed knowledge of the head and neck vascular anatomy, advances in catheterization techniques, and the availability of new embolic materials have improved the safety, efficacy, and predictability of these procedures. To improve patient safety, the oral and maxillofacial surgeon must be familiar with these techniques.

Postirradiated carotid blowout syndrome in patients with nasopharyngeal carcinoma: a case-control study

BACKGROUND

Carotid blowout syndrome is one of the most devastating complications of nasopharyngeal carcinoma (NPC) therapy.

METHODS

A retrospective review was conducted from January 2004 to April 2013. Thirty-one patients with carotid blowout syndrome were enrolled and a case control study was conducted to analyze the risk factors.

RESULTS

When a comparison was made between the carotid blowout syndrome and matched non-bleeding group, there was a significantly higher local recurrence rate and prevalence of skull base osteoradionecrosis (ORN) in the carotid blowout syndrome group compared to those of the control group (both p < .001). The hazard ratio of carotid blowout syndrome was 3.599 between patients with or without reirradiation (95% confidence interval, 1.465-8.839; p = .005, adjusted for nasopharyngectomy and chemotherapy) using a Cox proportional hazard model.

CONCLUSION

Reirradiation and skull base ORN are strong predisposing factors for carotid blowout syndrome, and therefore they should be mentioned in the informed consent form before treatment.

Endovascular Treatment of Vertebral Column Metastases Using Intra-Arterial Cisplatin: Pilot Experience

Background and Importance. Treatment of spinal column metastatic tumors is challenging, especially in the setting of progressive disease despite previous radiation and chemotherapy. Intra-arterial chemotherapy is an uncommonly used but established treatment for head and neck cancers, retinoblastoma, and glioblastoma. The author reports extension of the IAC concept to vertebral metastatic tumors. Clinical Presentation. Two patients with intractable spinal pain secondary to spinal metastatic involvement at T11-L1 segments were treated with intra-arterial injections of cisplatin, with simultaneous sodium thiosulfate chelation. The first patient, a 60-year old female with metastatic lung carcinoma underwent, three cycles of therapy over a 9-week period; the treated regions demonstrated bone remodeling and sclerosis. The second case was a 40-year old male with malignant pheochromocytoma, who underwent a single treatment and succumbed 5 weeks later from progressive widespread disease. Both patients reported significant pain relief and neither of them exhibited a decline in neurologic function. Conclusion. The intra-arterial delivery of cisplatin appeared to be well tolerated in the two cases. In the case with the longest survival, the treated vertebral segments became more sclerotic, consistent with biomechanical stabilization. Endovascular treatment of spinal metastases may hold promise, especially as newer categories of biologic agents become more widely available.

Epistaxis in patients with hereditary hemorrhagic telangiectasia treated with selective arterial embolization

BACKGROUND

Hereditary hemorrhagic telangiectasia (HHT) is a rare systemic fibrovascular dysplasia also known as Rendu-Osler-Weber disease. Epistaxis is often the first and foremost symptom of the disease and recurrent epistaxis is the main complaint.

PURPOSE

Evaluation of effectiveness and safety of endovascular treatment of epistaxis in HHT patients.

MATERIAL AND METHODS

Between June 2004 and January 2008, 14 patients with HHT underwent embolization of external carotid artery (ECA) branches due to severe epistaxis. There were eight men and six women aged 27-42 years. Patients were referred for endovascular treatment when primary management with electrocautery and nasal packing was ineffective. Arteries suspected of bleeding were catheterized super-selectively with micro-catheters to perform embolization. Polyvinyl alcohol particles (PVA) or embospheres in diameter of 500-700-µm were used as an embolic material.

RESULTS

Embolization was technically successful in 11 (78.5%) patients. Immediate, complete control of bleeding was achieved in 12 (85%) patients. During long-term follow-up recurrent nasal bleeding occurred in six (43%) patients 6-24 months after treatment. There were no severe complications after embolization. Nine patients experienced mild facial pain which resolved within three days after the treatment. Three patients in whom arterial spasm was observed, suffered from facial paraesthesia lasting for 3-5 days after embolization. Out of 14 patients, 12 were available for 24-month follow-up evaluation. All except one claimed reduction in frequency and severity of epistaxis which had a positive impact on their quality of life.

CONCLUSION

Endovascular embolization of epistaxis in patients with HHT is an effective and safe procedure although it cannot provide a long-term cure in most cases. Embolization reduces the frequency, severity and duration of nasal bleeding in patients with HHT, improving patients' quality of life.

Direct Percutaneous Alcohol Sclerotherapy for Venous Malformations of Head and Neck Region without Fluoroscopic Guidance: Technical Consideration and Outcome

PURPOSE

Alcohol is not used directly to the vascular lesion without mixing with the contrast agent because alcohol itself cannot be seen on the fluoroscopy. Since we have used alcohol for the venous malformations in the head and neck area, we realized that alcohol can be safely and effectively used without using fluoroscopy. We present the method of direct sclerotherapy using absolute alcohol without using fluoroscopy.

MATERIALS AND METHODS

After obtaining and carefully analyzing direct puncture venogram, we used this technique in 22 patients who underwent alcohol sclerotherapy. Because fluoroscopy was not used during alcohol injection, the angiotable can be placed outside of C-arm so that alcohol was comfortably injected without any obstacle around the patients. Venogram can also be obtained between the injections to detect whether there is any dangerous venous outflow drainage such as the superior ophthalmic vein to the cavernous sinus. To control the venous outflow, local compression to the draining vein was applied. The result and complication such as skin necrosis, infection, and nerve injury were evaluated during mean follow-up period of 13 months (range, 1-63 months).

RESULTS

The frequency of sclerotherapy was one in 16 and 2-5 in 6 patients. The volume of alcohol used per treatment session ranged from 2 to 18 mL (mean, 8.5 mL). There was the minimum change in 1 (4.5%), moderately decreased lesion in 12 (54.5%), and markedly decreased lesion in 9 (41%) patients. The patients did not reveal any complications during 12.9 months follow-up period.

CONCLUSION

Direct puncture alcohol sclerotherapy without using fluoroscopy can be a safe and effective technique for treating venous malformation of the head and neck areas. In addition, the procedure can be performed in the comfortable position because biplane fluoroscopy would not be necessary.

Endovascular treatment of penetrating traumatic injuries of the extracranial carotid artery

PURPOSE

To describe the clinical and angiographic results of endovascular therapy for traumatic injuries of the extracranial carotid artery.

MATERIALS AND METHODS

The clinical and angiographic features of 36 traumatic injuries of the carotid artery during a 12-year period were reviewed. There were 35 male patients (97.2%) and 1 female patient (2.8%) with an average age of 28.8 years (range 13-60 years). Of the 36 lesions of the carotid artery, 29 (80.6%) were the result of gunshot injury, and 7 (19.4%) were secondary to stab wounds. In 24 (66.7%) instances, the injury resulted in a pseudoaneurysm; in 7 (19.4%), in an arteriovenous fistula (AVF); in 4 (11.1%), in a dissection; and in 1 (2.8%), in inactive bleeding. All patients were treated with an endovascular approach using different techniques (balloon occlusion, embolization, or stent deployment).

RESULTS

Endovascular therapy resulted in documented lesion occlusion in 34 (94.4%) patients. Two patients declined any follow-up postprocedural imaging; however, they have remained asymptomatic. Clinical improvement was documented in 35 (97.2%) patients, and there was one procedure-related complication with fatal consequences.

CONCLUSIONS

In this series, endovascular techniques were an effective method of treatment. It was possible to use different endovascular reconstructive techniques or parent artery occlusion depending on the degree of vessel damage, with resolution of clinical symptoms and avoidance of surgery in most cases.

Novel application of percutaneous cryotherapy for the treatment of recurrent oral bleeding from a noninvoluting congenital hemangioma involving the right buccal space and maxillary tuberosity

Cryotherapy is the application of varying extremes of cold temperatures to destroy abnormal tissue. The intent of this article is to describe a novel technique using percutaneous cryotherapy for treating a noninvoluting congenital craniofacial hemangioma (NICH). An 18-year-old woman with type 1 von Willebrand's disease, as well as a qualitative platelet aggregation disorder, presented with multiple recurrent episodes of oral bleeding from a NICH involving the right buccal space and maxillary tuberosity. The patient was initially treated with a combination of endovascular particulate embolization, percutaneous sclerotherapy, tissue cauterization, and laser therapy between the ages of 4 and 8 years of age. At 18 years of age, the patient presented with recurrent episodes of oral bleeding related to the NICH. Endovascular embolization was performed using particulate and a liquid embolic agent with limited success. Due to the refractory nature of this bleeding, the patient underwent successful lesion ablation using percutaneous cryotherapy. At 9-month follow-up, the patient is asymptomatic with no episodes of recurrent bleeding.

State of the art head and neck imaging for the endovascular specialist

Recent technologic advances including multidetector CT, dynamic CT angiography, high-field MR imaging, four-dimensional MR angiography, and physiologic studies, such as perfusion imaging, have revolutionized the imaging work-up of head, neck, and skull base lesions. These techniques not only provide accurate diagnostic information, but also help plan endovascular therapy. The future holds great promise for interventional neuroradiologists because excellent imaging tools are becoming available that are capable of providing morphologic, hemodynamic, and physiologic information. Furthermore, availability of faster, real-time guidance systems and hybrid systems improves the ability to perform procedures not only in a rapid and safe manner but also with great precision.