Cerebral Lipiodol Embolization After Trans-Arterial Chemoembolization for Hepatocellular Carcinoma: 2436

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide. Transcatheter arterial chemoembolization (TACE) is a frequently performed nonsurgical therapy for localized HCC. Common adverse effects of TACE include post embolization syndrome (50-60%), hepatic decompensation, hepatic abscess and gastroduodenal ulcers. Cerebral lipiodol embolism (CLE) is a rare complication of TACE and only few reports exist describing this complication. We report a case of cerebral lipoidal embolization. 62-year-old male with history of chronic hepatitis B (on treatment for 5 years) and Child Pugh A cirrhosis. Imaging done for HCC screening showed 1 lesion in the right lobe of the liver (segment 7/8) measuring up to 10.3 cm in maximum diameter (Image 1). This was proven to be HCC on biopsy. Initial treatment plan was to perform Y90 radioembolization followed by surgical resection. However hepatic angiogram for planned radioembolization revealed 55% pulmonary shunt. He subsequently underwent TACE. Few hours after the procedure, he was moved to ICU for lethargy, weakness and fever and was also noted to have bowel and bladder incontinence. Labs notable for AST 1327, ALT 435, Alk phos 2659, WBC 13.26, INR 1.4 and NH337.5.CT of the head without contrast showed no clear acute findings but small nonspecific area of increased attenuation in the superior colliculus were noted. Given high concern for cerebrovascular event, MRI of the brain was done which showed punctate acute infarcts throughout both cerebral hemispheres and pons highly suggestive of cerebral embolization of the lipoidal chemo particles (Image 2). CT angiogram of the head and neck was unrevealing. Subsequent Cardiac ECHO did not reveal any thrombus, valvular vegetation or atrial level shunt. This patient likely had right to left shunt (pulmonary arterio-venous or hepatopulmonary syndrome which are often times not well visualized on imaging). The exact embolization route often remains undetermined in the reported CLE cases. More sensitive studies to detect the presence of shunt were not pursued since they would not have changed the management. He was managed conservatively and was sent to rehabilitation on day 9 after the TACE. CLE is a rare but potentially serious complication in HCC patients receiving TACE. The clinical characteristics of CLE summarized in our study would help facilitate the ability of clinicians to careful select patients for TACE and provide timely diagnosis and management.2436_A Figure 1. Coronal view (MRI of the head) showing HCC in segment 7/8.2436_B Figure 2. Coronal view (MRI of the brain) showing multiple punctate infracts.