Intraperitoneal hemorrhage after endovascular embolization of a cerebellar hemangioblastoma

May 25, 2007
Surgical Rounds®, July 2006, Volume 0, Issue 0

Luz P. Angel, Assistant Attending of Surgery, Division of Colon and Rectal Surgery Moses DeGraft-Johnson, Surgical Resident, Division of Colon and Rectal Surgery Kambhampaty Krishnasastry, Chief of Vascular Surgery, Division of Vascular Surgery, Department of Surgery Avi Setton, Chief of Neurointerventional Radiology, Department of Radiology John A. Procaccino, Chief, Division of Colon and Rectal Surgery, North Shore University Hospital, Manhasset, NY

Luz P. Angel, MD Assistant Attending of Surgery

Division of Colon and Rectal Surgery Moses DeGraft-Johnson, MD

Surgical Resident

Division of Colon and Rectal Surgery Kambhampaty Krishnasastry, MD

Chief of Vascular Surgery

Division of Vascular Surgery

Department of Surgery Avi Setton, MD Chief of Neurointerventional Radiology

Department of Radiology

John A. Procaccino, MD Chief Division of Colon and Rectal Surgery

North Shore University Hospital

Manhasset, NY

Hemangioblastomas are histologically benign tumors that account for 7% to 10% of all posterior fossa lesions in adults. Surgical resection of these tumors is often complicated by their significant vascularity. Endovascular embolization of hemangioblastomas is a useful preoperative tool in facilitating complete surgical removal.1-3 Our patient developed acute hypotension during preoperative endovascular embolization of a cerebellar hemangioblastoma. A computed tomography (CT) scan of the abdomen and pelvis was immediately undertaken and showed hemoperitoneum. No iliac or femoral injuries or retroperitoneal hematoma were evident. Emergency laparotomy with ileocolic resection was performed. Unexplained hypotension during an endovascular procedure can be fatal. Aggressive evaluation, including expeditious CT scanning of the abdomen and pelvis, and early surgical intervention are critical. ?

Case report

A 51-year-old, right-handed man underwent a resection of a cerebellar hemangioblastoma in the past. The patient had a history of type II diabetes mellitus and depression, but no history of von Hippel-Lindau disease. One year later, magnetic resonance imaging (MRI) of the brain detected a 3.8 x 2.5 x 2.1-cm tumor recurrence in the right posterior fossa. His neurosurgeon admitted him to the hospital for cerebral angiography and preoperative endovascular tumor embolization. The patient's medications included rosiglitazone, metformin, and venlafaxine. He was not on any anticoagulants or blood thinners. ?

While under monitored anesthesia, a 5-French long sheath was introduced into the right femoral artery using the Seldinger technique, and the guidewire position was observed at all times. The aortic arterial anatomy appeared normal. A 5-French catheter was advanced into the cerebral circulation under fluoroscopy, and selective cerebral angiography was performed. A right superior cerebellar hypervascular tumor supplied predominantly by dural branches of the right middle meningeal artery was noted.

Before superselective embolization, with the patient stable neurologically and hemodynamically, monitored anesthesia was converted to general anesthesia. Using a guiding catheter in the right external carotid artery trunk and a microcatheter, embolization was performed via branches of the right middle meningeal artery. Multiple polyvinyl alcohol microparticles and injectable coils were used to obliterate the tumor's dural blood supply completely (Figure 1).

Before completion of the embolization, the patient experienced acute unexplained hypotension (systolic blood pressure, 60?70 mm Hg), which required treatment with neosynephrine. After embolization, the final control angiographic studies confirmed normal intracranial circulation, minor residual peripheral pial blood supply by way of the right superior cerebellar artery, and complete obliteration of most of the tumor vascularity without any residual dural supply. Upon extubation, the groin sheath was removed and hemostasis was achieved with manual compression and a vascular hemostasis device. No inguinal hematoma was noted. The patient did not exhibit any neurologic deficits upon awakening from anesthesia nor did he receive any anticoagulation during or after the procedure. He was transferred to the recovery room where his blood pressure remained labile and his urine output decreased. His hemoglobin dropped to 8.3 g/dL and his coagulation parameters were within normal limits. He was resuscitated with fluids and blood products. His abdomen was noted to be distended and tender on palpation. A noncontrast CT scan of the abdomen and pelvis showed hemoperitoneum and blood in the mesentery in the right lower quadrant (Figure 2). There was no evidence of a retroperitoneal hematoma or vascular injury.

Based on the patient's clinical examination, he was taken to the operating room for an emergency exploratory laparotomy and 1 L of blood was evacuated from his abdomen. A large bleeding rent in the mesentery of the distal ileum with devascularization was noted, which necessitated an ileocolic resection.

The patient was subsequently transferred to the intensive care unit for postoperative management, where he recuperated without complications. He was discharged home on postoperative day 9. Intestinal pathologic findings showed no abnormalities and coagulation studies demonstrated no bleeding diathesis. The patient was readmitted electively to the hospital approximately 6 weeks later for an uneventful resection of the cerebellar hemangioblastoma (Figure 3).

Discussion

Advances in interventional neuroradiology have facilitated the surgical management of hemangioblastomas. The development of endovascular techniques has permitted the highly selective delivery of advanced, soft microcatheters and embolic material to the tumors. The vascularity of these central nervous system neoplasms is an appealing target for the superselective intra-arterial injection of embolic particles such as gelatin foam powder, polyvinyl alcohol particles, fi-brin glue, microfibrillar collagen, or gelatin microspheres before surgery. Transarterial embolization has already become standard procedure in the preoperative management of meningiomas.4,5 Numerous studies have shown that preoperative embolization of meningiomas is safe and facilitates surgical removal with less blood loss, fewer transfusions during surgery, and more complete resection.6,7

Preoperative embolization of hemangioblastomas has been shown to be safe and useful in aiding surgical resection of these highly vascular tumors. Few complications have been described in the literature. Takeuchi and colleagues reported no permanent neurological deficits and one cerebellar infarction in one of eight patients who underwent presurgical embolization of hemangioblastomas.2 Eskridge and associates reported acute obstructive hydrocephalus resulting from tumor swelling in one of nine patients with hemangioblastomas after embolization that required emergency craniotomy, ventricular decompression, and surgical resection of the tumor.8 Thus far, no hemorrhagic complications have been described in the literature from endovascular preoperative embolization of hemangioblastomas. Generally, hemorrhage that occurs from any arterial puncture site can cause external blood loss or a subcutaneous hematoma. Retroperitoneal bleeding can occur if the arterial puncture is above the inguinal ligament. The catheter or guidewire may produce vascular injuries distant from the puncture site. The importance of observing guidewire positioning at all times cannot be overstated.

Our patient developed acute hypotension during an endovascular procedure performed for embolization of a cerebellar hemangioblastoma. Following the procedure, he developed a distended and tender abdomen with a drop in hemoglobin. A CT scan showed hemoperitoneum, and an exploratory laparotomy showed a mesenteric tear of the distal ileum with devascularized small bowel. Although the exact cause of the mesenteric trauma was unclear, the injury may have resulted from traumatic guidewire or catheter perforation, but the distal location of the hemorrhage in the superior mesenteric arterial tree makes it difficult to explain.

Mesenteric bleeding can lead to significant hemorrhage, hypotension, and devascularization of the bowel. Our patient required an ileocolic resection. The pathologic results did not support any arterial pathology in the surgical specimen. An early CT scan of the abdomen and pelvis was critical in confirming an intra-abdominal hemorrhage as the source of the patient's hypotension and excluding a retroperitoneal hematoma or a vascular injury. The patient underwent timely surgery to control the hemorrhage. Aggressive evaluation of unexplained hypotension during an endovascular procedure is mandatory.

To our knowledge, this is the first reported case of an intraperitoneal hemorrhage that occurred during an endovascular procedure performed for embolization of a cerebellar hemangioblastoma. Although new technological developments in the expanding field of interventional neuroradiology are expected to improve the safety and efficacy of endovascular procedures, the endovascu-lar and general surgeon should be aware of this potential complication and pursue aggressive measures to evaluate any unexplained hypotension. Adherence to strict postoperative monitoring and initiation of early imaging to exclude occult hemorrhage are critical for a safe outcome. If needed, the patient should be sent for a timely and appropriate surgical referral. ?

Conclusion

Our report describes the case of a patient who developed hemoperitoneum shortly after preoperative endovascular embolization of a cerebellar hemangioblastoma and required emergency laparotomy. Early diagnosis with CT scanning and prompt surgical management of this potentially fatal complication are critical for a safe outcome. To our knowledge, this is the first report of hemoperitoneum resulting after an interventional neuroradiologic procedure.

Acknowledgment

We would like to thank Gae O. Decker-Garrad for her editorial assistance in preparing this manuscript.

References

1. Leonov MA, Makhmudov UB, Shimanskii VN. Hemangioblastomas of central nervous system [in Russian]. Zh Vopr Neirokhir Im N N Burdenko. 2003;Oct-Dec(4):39-44.

2. Takeuchi S, Tanaka R, Fujii Y, et al. ?Surgical treatment of hemangioblastomas with presurgical endovascular embolization. Neurol Med Chir (Tokyo). 2001;41(5):246-252.

3. Standard SC, Ahuja A, Livingston K, et al. Endovascular embolization and surgical excision for the treatment of cerebellar and brain stem hemangioblastomas. Surg Neurol. 1994;41(5): 405-410.

4. Engelhard HH. Progress in the diagnosis and treatment of patients with meningiomas. Part I: diagnostic imaging, preoperative embolization. Surg Neurol. 2001;55(2):89-101.

5. Chun JY, McDermott MW, Lamborn KR, et al. Delayed surgical resection reduces intraoperative blood loss for embolized meningiomas. Neurosurgery.?2002;50(6):1231-1237.

6. Dean BL, Flom RA, Wallace RC, et al. Efficacy of endovascular treatment of meningiomas: evaluation with matched samples. AJNR Am J Neuroradiol. 1994;15(9):1675-1680.

7. Kai Y, Hamada J, Morioka M, et al. Appropriate interval between embolization and surgery in patients with meningioma. AJNR Am J Neuroradiol.?2002;23(1):139-142.

8. Eskridge JM, McAuliffe W, Harris B, et al. Preoperative endovascular embolization of craniospinal hemangioblastomas. AJNR Am J Neuroradiol.?1996;17(3):525-531.