Initial experience with dual-lumen balloon catheter injection for preoperative Onyx embolization of skull base paragangliomas.
OBJECT Paragangliomas are highly vascular head and neck tumors for which preoperative embolization is often considered to facilitate resection. The authors evaluated their initial experience using a dual-lumen balloon to facilitate preoperative embolization in 5 consecutive patients who underwent preoperative transarterial Onyx embolization assisted by the Scepter dual-lumen balloon catheter between 2012 and 2014. OBJECT The authors reviewed the demographic and clinical records of 5 patients who underwent Scepter-assisted Onyx embolization of a paraganglioma followed by resection between 2012 and 2014. Descriptive statistics of clinical outcomes were assessed. RESULTS Five patients (4 with a jugular and 1 with a vagal paraganglioma) were identified. Three paragangliomas were embolized in a single session, and each of the other 2 were completed in 3 staged sessions. The mean volume of Onyx used was 14.3 ml (range 6-30 ml). Twenty-seven vessels were selectively catheterized for embolization. All patients required selective embolization via multiple vessels. Two patients required sacrifice of parent vessels (1 petrocavernous internal carotid artery and 1 vertebral artery) after successful balloon test occlusion. One patient underwent embolization with Onyx-18 alone, 2 with Onyx-34 alone, and 1 with Onyx-18 and -34. In each case, migration of Onyx was achieved within the tumor parenchyma. The mean time between embolization and resection was 3.8 days (range 1-8 days). Gross-total resection was achieved in 3 (60%) patients, and the other 2 patients had minimal residual tumor. The mean estimated blood loss during the resections was 556 ml (range 200-850 ml). The mean postoperative hematocrit level change was -17.3%. Two patients required blood transfusions. One patient, who underwent extensive tumor penetration with Onyx, developed a temporary partial cranial nerve VII palsy that resolved to House-Brackmann Grade I (out of VI) at the 6-month follow-up. One patient experienced improvement in existing facial nerve weakness after embolization. CONCLUSIONS Scepter catheter-based Onyx embolization seems to be safe and effective. It was associated with excellent distal tumor vasculature penetration and holds promise as an adjunct to conventional transarterial Onyx embolization of paragangliomas. However, the ease of tumor penetration should encourage caution in practitioners who may be able to effect comparable improvement in blood loss with more conservative proximal Onyx penetration.
Vanderbilt University School of Medicine, and 
Travis R
TR
Ladner
Departments of 2 Neurological Surgery and.
Lucy
L
He
Departments of 2 Neurological Surgery and.
Brandon J
BJ
Davis
Vanderbilt University School of Medicine, and 
George L
GL
Yang
Departments of 2 Neurological Surgery and.|Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee.
George B
GB
Wanna
Departments of 2 Neurological Surgery and.
J
J
Mocco
D021721:Balloon Occlusion / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods*; D057785:Catheters; D002533:Cerebral Angiography; D004121:Dimethyl Sulfoxide; D004338:Drug Combinations; D004621:Embolization, Therapeutic / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods*; D005500:Follow-Up Studies; D006801:Humans; D019635:Neurosurgical Procedures / Q000009:adverse effects / Q000379:methods; D010235:Paraganglioma / Q000000981:diagnostic imaging / Q000601:surgery / Q000628:therapy*; D011145:Polyvinyls; D011183:Postoperative Complications / Q000000981:diagnostic imaging / Q000453:epidemiology; D057234:Preoperative Period; D012189:Retrospective Studies; D019292:Skull Base Neoplasms / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000628:therapy*; D013635:Tantalum; D013997:Time Factors; D016896:Treatment Outcome
D004338:Drug Combinations; C558446:Onyx 18; C000598428:Onyx 34; D011145:Polyvinyls; D013635:Tantalum; D004121:Dimethyl Sulfoxide
EBL = estimated blood loss; ECA = external carotid artery; ICA = internal carotid artery; Onyx; PVA = polyvinyl alcohol; catheter; interventional neurosurgery; liquid embolic material; paraganglioma; tumor embolization