Head, neck, and brain tumor embolization guidelines
E Jesus Duffis,1Chirag D Gandhi,1,2Charles Joseph Prestigiacomo,1,2,3Todd Abruzzo,4
Felipe Albuquerque,5Ketan R Bulsara,6Colin P Derdeyn,7Justin F Fraser,8
Joshua A Hirsch,9Muhammad Shazam Hussain,10Huy M Do,11
Mahesh V Jayaraman,12Philip M Meyers,13Sandra Narayanan,14on behalf of the
Society for Neurointerventional Surgery
Background Management of vascular tumors of the
head, neck, and brain is often complex and requires
a multidisciplinary approach. Peri-operative embolization
of vascular tumors may help to reduce intra-operative
bleeding and operative times and have thus become an
integral part of the management of these tumors.
Advances in catheter and non-catheter based techniques
in conjunction with the growing field of
neurointerventional surgery is likely to expand the
number of peri-operative embolizations performed. The
goal of this article is to provide consensus reporting
standards and guidelines for embolization treatment of
vascular head, neck, and brain tumors.
Summary This article was produced by a writing group
comprised of members of the Society of
Neurointerventional Surgery. A computerized literature
search using the National Library of Medicine database
(Pubmed) was conducted for relevant articles published
between 1 January 1990 and 31 December 2010. The
article summarizes the effectiveness and safety of peri-
operative vascular tumor embolization. In addition, this
document provides consensus definitions and reporting
standards as well as guidelines not intended to represent
the standard of care, but rather to provide uniformity in
subsequent trials and studies involving embolization of
vascular head and neck as well as brain tumors.
Conclusions Peri-operative embolization of vascular
head, neck, and brain tumors is an effective and safe
adjuvant to surgical resection. Major complications
reported in the literature are rare when these procedures
are performed by operators with appropriate training and
knowledge of the relevant vascular and surgical
anatomy. These standards may help to standardize
reporting and publication in future studies.
The management of vascular head and neck tumors
is often challenging and may require a multimodal
approach to treatment. Endovascular embolization
is often employed in conjunction with surgical
techniques in an attempt to minimize morbidity
and improve chances for successful tumor resec-
tion. Although endovascular embolization has been
described since the 1970s,1 2advances in technique
and embolization materials as well as the avail-
ability of experienced operators are likely to expand
the number of preoperative embolization proce-
dures performed. In this paper we propose guide-
lines for the endovascular treatment of head and
neck tumors, including indications for treatment as
well as standards for reporting outcomes and
complications of embolization techniques. The
aim of these guidelines is to provide uniform defi-
nitions and standards to allow for comparisons
between studies. These recommendations should
not be interpreted as guidelines for the standard
of care for head and neck tumor embolization
For the purposes of this discussion, tumor emboli-
zation refers to any procedure performed either
percutaneously, through a direct puncture of the
tumor, or via an endovascular approach (most
commonly through the femoral artery) in which
particles, liquid embolic agents, coils, gelfoam or
other materials are injected with the goal of reducing
the tumor vascularity (figure 1AeD). Procedures
undertaken for control of epistaxis or other bleeding
related to the tumor should be considered separately.
It is recommended that the procedure be performed
by a physician with skills and expertise in neuro-
endovascular techniques, as well as interpretation of
angiographic images and thorough knowledge of the
relevant vascular and surgical anatomy.
A computerized search of the MEDLINE database
(PubMed) from 1 January 1990 to 31 December
2010 was performed using the search terms
‘embolization’, ‘treatment’, ‘tumor’, ‘head and
‘interventional radiology’ with the purpose of
identifying published articles on endovascular
treatment of head and neck tumors. All relevant
English language articles published during this
period were included. The bibliographies of these
articles were also reviewed in order to identify
additional relevant articles. Historically relevant
articles were included based on consensus opinion.
The results of the literature review consisted
primarily of case series and non-randomized single-
center studies (level of evidence B, table 1). As such,
there is a need for additional studies including
randomized controlled studies in order to guide
The primary aim of tumor embolization is to aid
the successful surgical resection of the lesion.
Control of bleeding during surgery may be difficult,
For numbered affiliations see
end of article.
Dr Chirag D Gandhi, Neurological
Surgery, University of Medicine
and Dentistry of New
Jersey-New Jersey Medical
School, 90 Bergen St, Suite
8100, Newark, NJ 07103, USA;
Accepted 9 March 2012
Published Online First
26 April 2012
This paper is freely available
online under the BMJ Journals
unlocked scheme, see http://
J NeuroIntervent Surg 2012;4:251e255. doi:10.1136/neurintsurg-2012-010350251
Endovascular or percutaneous embolization is therefore under-
taken to devascularize the lesion with the goal of minimizing
blood loss and decreasing operating time. Another benefit is
better visualization of the surgical field, which may decrease the
risk to adjacent tissue and decrease the risk of tumor recurrence.3
In certain instances, embolization may be used as the sole
treatment for palliation by decreasing the size of the tumor and
reducing pain in patients who are deemed non-operable candi-
dates.4Box 1 provides a summary of specific vascular tumors
that are commonly treated with adjunct embolization prior to
operative resection. This list is far from exhaustive and may
leave out other tumor types in which embolization may
be indicated based on tumor vascularity. It is recommended that
the indication for tumor embolization should be clearly delin-
eated prior to the procedure.
The anatomic relationship of tumor to the adjacent normal
tissue is important in treatment planning. Evidence of lymph
node involvement as well as distant spread can be detected on
non-invasive imaging and is important for staging. CTscanning
allows for delineation of the extent of the tumor, its relationship
to soft tissue structure, and any bony erosion. MRI allows for
improved visualization of the brain parenchyma and dural
involvement in the case of intracranial tumors, and may allow
for early detection of metastasis via perineural pathways.5CTor
MR angiography sequences may be added when encasement of
vascular structures such as the carotid artery in the case of
carotid body tumors is suspected.
MR imaging may also provide additional information which
may be useful at the time of resection including information
regarding tumor consistency which may correlate with ease of
resection.6T2 and fractional anisotropy values calculated from
Definitions of levels of evidence
Data derived from multiple randomized clinical trials or meta-analyses
Data derived from a single randomized trial or non-randomized studies
Consensus opinion of experts, case studies or standard of care
Box 1 Vascular tumors of the head and neck that may
benefit from embolization prior to surgical resection
Juvenile nasopharyngeal angiofibroma (JNA)
Glomus jugulare and other paragangliomas
external carotid lateral view angiograms
demonstrating a large blush consistent
with a hypervascular glomus jugulare
tumor. (B, C) The patient underwent
a successful balloon occlusion test.
Note inflated balloon in the cervical right
internal carotid artery (white arrow). (D)
Post-embolization angiograms showing
occlusion of the right internal carotid
with coils (white arrow) and marked
decrease in tumor blush after
embolization of multiple external carotid
artery branches supplying the tumor.
(A) Pre-embolization right
252J NeuroIntervent Surg 2012;4:251e255. doi:10.1136/neurintsurg-2012-010350
diffusion tensor imaging may predict tumor consistency of
meningiomas.7 8Although promising for the future, the clinical
use of these techniques is not standard at present.
Digital subtraction angiography may provide additional infor-
mation to supplement the clinical examination and findings on
CT or MRI imaging. Angiography allows identification of
displaced feeders to the tumor, facilitating their localization and
ligation during surgery.9In addition, the extent of tumor growth
around the internal carotid, as well as the presence of collateral
flow distal to the involved carotid, are important pieces of
information. Combined with a balloon occlusion test, catheter
angiography can help determine the feasibility of carotid
sacrifice during surgery if needed.
The blood supply to the tumor can be predicted based on the
location and extent of the tumor as well as the tumor type. For
example, paragangliomas are almost universally supplied by
branches of the ascending pharyngeal artery.9
surrounding the internal carotid may derive blood supply from
clival branches. Selective catheterization of the external and
internal carotid branches is thus required to adequately delineate
the blood supply. Superselective catheterization of external
carotid branches confirms the blood supply and may reveal
dangerous intracranial anastomoses for which care should be
taken during embolization. Evaluation of the contralateral
carotid branches should be done to exclude contribution to
tumor blush, particularly in cases when the tumor has crossed
the midline. Intracranial tumors, particularly posterior fossa
tumors, may require additional imaging of the posterior circu-
lation. Of note, there may be anastomoses between external
carotid branches (particularly the occipital artery) and the
posterior circulation; such vascular connections can represent
potential pitfalls for embolization if not documented and
Highly vascular tumors of the head and neck are uncommon and
the literature is composed primarily of case series with relatively
few patients. Often, for the purposes of reporting, tumors are
grouped according to similar histologic features and cell type of
origin. The location, presenting symptoms, patient characteris-
tics, demographics as well as prognosis and outcome vary
depending on tumor type, and it is important to clearly delineate
the type of tumor for which the embolization procedure is being
reported. This will allow for comparison across series for any
given tumor type.
Systems for classifying tumors according to size and extent of
involvement of surrounding structures have been devised and are
specific to each tumor type.12 13These classification systems
may correlate with surgical morbidity during resection.14 15
When available, it is important to note the specific tumor type
or class within the classification system.
Advances in surgical techniques have reduced the mortality
associated with resection of certain head and neck tumors.
Complete resection of the tumor may require a multidisciplinary
approach that can include vascular, otolaryngology, endovas-
cular and skull-based techniques.16e18The expertise contributed
by each field can add to an improved operative approach and
visualization of the surgical field, aiding in complete resection
and decreased incidence of recurrence.17Ideally, patients with
vascular head and neck tumors should be evaluated using
a multidisciplinary team approach for optimal staging and
Embolic material and particle size
The choice of embolic material may be determined by various
factors including anatomic considerations or operator preference
and experience. Each embolic material has its own advantages
and limitations.19Commonly employed embolic materials
include both particulate and liquid embolic agents such as
N-butyl cyanoacrylate (glue) and ethylene vinyl alcohol copol-
ymer (Onyx). In the case of particulate materials such as poly-
vinyl alcohol or trisacryl gelatin microspheres (TAGM), the size
of the particles has been linked to both efficacy and complication
rates.20 21While smaller particles are able to penetrate more
distally into tumor capillary beds, they can also cause injury to
the vasa nervorum resulting in cranial nerve palsies or enter the
intracranial circulation through anastomoses of the external and
internal carotid arteries. A comparison of TAGM and polyvinyl
alcohol particles suggests that TAGM particles may be able to
penetrate deeper into tumor vascular beds.22Given the differ-
ences in outcomes achieved by different materials, the type and
(whenever appropriate) the size of the embolic material should
be mentioned and compared when possible.
Route of embolization
Traditionally, tumor embolization has been achieved via a trans-
arterial route with superselective catheterization and emboliza-
tion of feeding vessels. Percutaneous direct puncture techniques
(DPT) using liquid embolic agents such as Onyx have also
recently been described.23e27DPT can be used in conjunction
with transarterial embolization or as a primary mode of embo-
lization. In rare cases where the vascular anatomy or pathology
may make endovascular access difficult or impossible, DPT may
be the only option for preoperative embolization. There have
been no systematic comparisons of the two techniques, but some
authors have claimed that DPT allow for improved tumor
penetration and thus decreased operative blood loss when using
liquid embolic agents and may ease resection by demarcating the
tumor from surrounding tissue.25At present, the role of DPT for
the treatment of uncomplicated tumors is uncertain and the
technique is not without the potential for major complications.28
Further comparisons between DPT alone and transarterial
embolization are needed before recommendations can be made
about their relative merits. The route of embolization and
a description of the technique should be included. Comparisons
between techniques should be made when possible.
Clinical and radiographic efficacy
As stated earlier, the goal of tumor embolization is to decrease
tumor vascularity either to facilitate surgical excision or for
palliation. However, some authors have questioned the utility of
preoperative embolization.29 30The literature supports the effi-
cacy of tumor embolization to reduce operative blood loss,31 32
surgical times33 34and recurrence.17Despite added resources used
for embolization procedures compared with resection alone, the
benefits of embolization may still be cost-effective.35To date
there have been no randomized controlled trials comparing
preoperative embolization and surgical resection of vascular
tumors with resection alone. Given the rarity of most vascular
tumors of the head and neck, this would be difficult to achieve
without multicenter cooperation. Although feasible and of proven
benefit, embolization may not be required for all vascular tumors.
The decision to use preoperative embolization should be
J NeuroIntervent Surg 2012;4:251e255. doi:10.1136/neurintsurg-2012-010350 253
individualized based on several factors including the amount of
tumor vascularity and size, anticipated ease of resection, prefer-
ence and experience of the surgeon, among others.
When reporting on efficacy, the amount of tumor blush
or staining should be reported as a radiographic measure of
vascularity. The goal of embolization should be to reduce the
amount of tumor blush by approximately 80% or more.4 11DSA
images should be reviewed after the completion of embolization
and the percentage in reduction should be quantified. Intra-
proceduaral MR and CT angiography imaging have also been
embolization.36e38However, these techniques may be impractical
and their added clinical utility remains investigational. Operative
measures of blood loss, need for transfusion during surgical
resection and length of surgery are additional quantitative
measures which should be reported. In the case of embolization
procedures performed for palliative purposes, the presenting
symptoms and subsequent regression or improvement in these
symptoms have been reported as a measure of efficacy.4
Timing of surgery relative to embolization
The radiographic and clinical effects of embolization may be
transient or permanent depending on the embolic material used.
The timing of embolization with respect to surgery is therefore
important. Very early resection of tumor (<24 h) after emboli-
zation may negate the benefits of embolization by not allowing
enough time for devascularization and tumor necrosis to occur,
thus leading to greater operative blood loss.39Histologic exam-
ination of tumor embolized with particles shows thrombus
formation and multinucleated giant cell reaction within 7 days
of embolization. Thereafter, recanalization and partial revascu-
larization can be observed in 30% of embolized vessels.40Soft-
ening of tumor and ease of resection has been shown to be
maximal at 7e9 days after embolization of meningiomas.41
Thus, surgical resection should be carried out 1e8 days after
embolization in order to maximize the benefits of the emboli-
zation procedure. However, surgery may sometimes need to be
delayed for various reasons. Steroids should be given for large
tumors and tumors at risk of post-embolization edema such as
meningiomas, particularly if surgery is delayed. Transarterial
embolization for meningiomas and other vascular skull-based
tumors can lead to dramatic tumor infarction, swelling and
herniation. For these cases, embolization just prior to surgery
should be strongly considered.
Use of anesthesia and provocative testing
Tumor embolization may be performed under general or local
anesthesia. Local anesthesia and conscious sedation allows for
neurologic examination during provocative testing maneuvers
and avoids the potential complications of intubation and
exposure to general anesthetic agents. General anesthesia, on the
other hand, avoids potential issues related to patient agitation
and movement during the procedure, which could be dangerous
during critical portions of the embolization. In addition, patients
with rare catecholamine-secreting paragangliomas may benefit
from additional monitoring by anesthesia during the procedure
to control blood pressure fluctuations.42To date, no studies have
compared complication rates using local anesthesia versus
general anesthesia during tumor embolization. Furthermore,
embolization can be performed safely using either method.43
The choice of anesthesia should therefore be guided by patient-
specific characteristics such as the presence of airway obstruc-
tion by the tumor or coexisting medical conditions, at the
discretion of the endovascular operator.
Provocative testing such as superselective amytal and lido-
caine injection to identify intracranial anastomoses and blood
supply to the cranial nerves has been used prior to embolization
in order to minimize the risk of cranial nerve palsy.44Electro-
encephalography and somatosensory evoked potentials may be
used during intracranial embolization procedures and may be
helpful during embolization performed under general anesthesia
where a neurologic examination is lacking. Balloon occlusion
testing is obligatory in cases where internal carotid artery
sacrifice is necessary. Whether outcomes are improved using the
above testing is not known, so the decision to use adjunct
testing or monitoring should be individualized. The use of
monitoring or provocative testing should be mentioned when
Complications may be classified as either procedure-related or
non-procedure-related. The most common complications related
to tumor embolization procedures are shown in table 2 and
include cranial nerve palsies, skin or mucosal necrosis, as well as
unintended vascular occlusions.9 45Procedure-related complica-
tions may be subclassified based on clinical relevance and impact
into minor or major complications.
Major complications are rare with extracranial tumor emboli-
have been reported in up to 3e6% during intracranial emboli-
zation.20 46Major complications are defined as complications
requiring additional therapy, higher level of care, prolonged
hospitalizations, permanent sequelae or death. These may
include (but are not limited to) stroke, cranial nerve palsy, tissue
damage or death.
Minor complications are those requiring no specific treatment
beyond observation and are without clinical consequence. These
may include (but are not limited to) puncture site complications
not requiring transfusion or affecting neural structures as well as
localized pain and swelling.
All complications and death occurring within 30 days should
be reported. However, when tumor embolization is undertaken
prior to surgical resection, complications may be attributable to
either the embolization procedure or the resection. An attempt
to distinguish between the two should be made.
In summary, the management of head, neck and intracranial
vascular tumors may benefit greatly from endovascular tech-
niques aimed at decreasing tumor blood flow. To date,
randomized controlled trials evaluating safety and efficacy are
lacking, in large part due to the rarity of hypervascular tumors.
Standard definitions and uniformity across reports will aid in
establishing best practice measures.
1Department of Neurosurgery, University of Medicine and Dentistry of New
Jersey-New Jersey Medical School, Newark, NJ, USA
Potential complications of head and neck tumor embolization
Minor complicationsMajor complications
Puncture site complications
Cranial nerve palsy
Skin and mucosal tissue necrosis
Stroke including intracerebral hemorrhage
254J NeuroIntervent Surg 2012;4:251e255. doi:10.1136/neurintsurg-2012-010350
2Department of Radiology, University of Medicine and Dentistry of New Jersey-New
Jersey Medical School, Newark, NJ, USA
3Department of Neurology and Neurosciences, New Jersey Medical School, University
of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, NJ,
4Neurosurgery, Radiology, Pediatrics and Biomedical Engineering, University of
Cincinnati, Mayfield Clinic and Cincinnati Children’s Hospital, Cincinnati, OH, USA
5Barrow Neurosurgical Associates, LTD, Phoenix, AZ, USA
6Director of Neuroendovascular and Skull Base Surgery, Yale Department of
Neurosurgery, New Haven, CT, USA
7Mallinckrodt Institute of Radiology and Washington University School of
Medicine/Barnes Jewish Hospital, St. Louis, MO, USA
8Department of Neurological Surgery University of Kentucky, Lexington, KY, USA
9Massachusetts General Hospital, Boston, MA, USA
10Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
11Department of Radiology, Stanford University Medical Center, Stanford, CA, USA
12Warren Alpert School of Medicine at Brown University, Rhode Island Hospital,
Providence, RI, USA
13Radiology and Neurological Surgery, Columbia University, College of Physicians &
Surgeons and Neuroendovascular Service New York Presbyterian-Columbia,
Neurological Institute of New York, NY, USA
14Deptartments of Neurosurgery and Neurology, Wayne State University School of
Medicine, Detroit, MI, USA
Acknowledgments The authors would like to thank and acknowledge all members
of the SNIS Executive Committee for their review and endorsement of this
Contributors JD and CDG contributed significantly to the writing of the manuscript
and CJP had important input into the final editing of the manuscript. Significant
contributions were also made by the members of the Standards of Practice
Competing interests None.
Provenance and peer review Commissioned; internally peer reviewed.
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