Full recovery after non-target cerebral embolization of n-butyl-cyanoacrylate occurred during emergency treatment of a facial arteriovenous malformation

Abstract

Background: Non-target embolization is a well-known complication of endovascular procedures for arteriovenous malformation. However, few reports have described non target encephalic embolization, detailing its temporal evolution. Case presentation: A 41-year-old man presented with a massive hemorrhage in the oral cavity due to an arteriovenous malformation involving the left hemiface and tongue. Under conscious sedation, selective angiography was followed by endovascular embolization with a mixture of n-butyl-cyanoacrylate-methacryloxy-sulfolane (NBCA-MS) with Lipiodol. The hemorrhage was successfully arrested, but the procedure was complicated with a reflux of embolic material from the right external carotid artery into the common carotid, caused by strong unexpected coughing. Non-target embolization was confirmed by emergency CT and subsequent MRI. After initial neurological impairment, the patient recovered fully and was discharged after one week. No sequelae were confirmed by 9-months follow-up with CT and MRI. We describe technical aspects, multimodality imaging, clinical presentation, and follow-up of this peculiar case. Conclusion: Endovascular embolization of AVM fed by the external carotid is at risk for non-target brain embolization and general anesthesia should be considered to prevent inadvertent movements and master the delivery of the embolic agent A small amount of Lipiodol / NBCA-MS may be fully tolerated by the brain matter and partially reabsorbed without permanent deficit.