Correspondence:
Dr.K.G.Ramakrishan
Dept. of Intereventional Radiology,
Malabar Institute of Medical Sciences, Calicut, Kerala – 673016
E mail : mimsrad@yahoo.co.in  


Abstract

Interventional Radiological techniques have wide spread applications in the management of various diseases involving head neck. This rapidly advancing field has gained increasing acceptance among the related specialties. The major reason for this has been the realization that optimal treatment outcome is possible only with a multi disciplinary approach in the management of complex problems. Growth in knowledge of anatomy and pathology, experience gained in treating complex problems and the improvements that have occurred in various endovascular hardware, have provided us with options that are safe, simple and effective.
Objective: To evaluate the safety, efficacy and advantage of incorporating Interventional Radiology techniques in the management of diseases of Head and Neck.
Materials and Methods: 22 patients were subjected to endovascular procedures over a period of 18 months. Indications for procedures were intractable epistaxis, pre operative tumour embolisation, carotico-cavernous fistula and dural sinus thrombosis. All procedures were performed with DSA equipment using diagnostic and microcatheters. Embolic agents included Gelfoam, PVA particles, absolute alcohol and coils.


Embolisation in Intractable Epistaxis



Ongoing haemorrhage despite adequate nasal packing after 96 hours, is a challenging problem in clinical practice. Prior to the days of the interventional radiology, the treatment option was ligation of ECA or in selected situations ligation of Internal Maxillary Artery (IMAX) (1)

Selective embolisation of IMAX is currently the treatment of choice in intractable epistaxis. The technique involves selective angiography of bilateral ECA to evaluate the vasculature of sinonasal cavity and delineate the site and cause of haemorrhage. In certain patients who have undergone nasal packing, no obvious angiographic abnormality will be demonstrated and in such cases the ipsilateral IMAX is catheterized and branches of sphenopalatine artery embolised. Most often , the site of haemorrhage happens to be in the vascular territory of the branches of spheno-palatine artery and the branches are embolised after selective catherisation of IMAX.

The principle is to occlude the arterioles leaving the capillary bed intact. The aim is to reduce the arterial pressure head. This is achieved by carrying out embolisation using medium size PVA particles or Gelfoam. Optimal catheterization is possible using diagnostic catheters and in selected patients microcatheters may have to be used.



In our series 100 % technical success and favourable clinical outcome could be achieved which is in agreement with the experience of other authors (2,3).

IMAX embolisation is a safe procedure in the hands of experienced radiologists. Minor side effects due to post embolisation syndrome such as pain, oedema and fever occur almost always but can be treated symptomatically. Major complications are rare and include non-target embolisation into ICA territory through collaterals.

Case I :- Intractable Epistaxis following facial fracture.

Fig 1: Selective Right IMAX (AP) - Contrast extravasation from branches of Spheno-palatine artery.	Fig 2: Selective Right IMAX (Lateral) - Injury to branch of Spheno-palatine artery	Fig 3: Post Embolisation IMAX (AP) – Obliteration of IMAX branches with no extravasation of contrast.	Fig 4: Post Embolisation IMAX (Lateral) – Obliteration of IMAX branches with no extravasation of contrast.
Click on Image to Enlarge

Case II:- Intractable epistaxis following surgery.

Fig 1: Selective IMAX angiogram (Lateral) – Pseudo aneurysm with extravasation from spheno-palatine artery.	Fig 2: Selective IMAX angiogram (AP) – Pseudo aneurysm with extravasation from spheno-palatine artery.	Fig 3: Post embolisation (Lateral) – Total Occlusion of aneurysm following embolisation with gelfoam.	Fig 4: Post embolisation ECA angiogram – Occlusion of IMAX with no evidence of refilling of aneurysm.
Click on Image to Enlarge

Embolisation in Head and Neck Tumours


Surgery for head and neck tumours can pose challenges due to tumour size, peri procedural bleeding and the need to perform extensive dissection. Pre surgical embolisation is an extremely useful technique, which will facilitate safe and easy surgery in patients with head and neck tumors. (4).

Large, hyper vascular tumours such as Nasopharyngeal Angiofibroma, Paraganglioma and Meningioma tend to bleed profusely resulting in increased risk of complications, prolonged time taken for surgery and incomplete tumor removal which in turn leads to recurrence. Pre surgical embolisation , render the tumor surgery easy and safe by selectively devascularising surgical field to facilitate easy dissection.

Tumors considered suitable for embolisation are generally extracranial tumors with the exception of Meningioma.

Embolisation is carried out to achieve occlusion of pre capillary intratumoural arterioles followed by occlusion of feeding artery. Intratumoural arteriolar embolisation is necessary to prevent recruitment of additional vascular supply and to prevent bleeding during surgery (5). Blocking the feeding artery aims at minimising bleeding during dissection around the tumor. Preserving the microvasculature of surrounding tissue is important to facilitate post surgical wound healing.

Complications are rare and occur predominantly due to poor technique, limited understanding of anatomy and failure to recognize dangerous intra and extra cranial collateral channels.

Case I: Sphenoid Meningioma – Pre-op embolisation.

Fig 1: Selective ECA angiogram (lateral) - Hypertrophied middle Meningeal artery with pronounced tumor blush.	Fig 2: Selective ECA angiogram (AP) - Hypertrophied middle Meningeal artery with pronounced tumor blush.	Fig 3: Selective Middle Meningeal angiogram with micro catheter prior to embolisation.	Fig 4: Post embolisation - Occlusion of the vascular bed & stagnant contrast column in middle meningeal artery (arrow)	Fig 5: Post embolisation – ECA angiogram – Obliteration of vascular blush, superficial temporal artery is preserved.
Click on Image to Enlarge

Case II:- Juvenile nasopharyngeal angiofibroma – pre-op embolisation.

Fig 1: CCA angiogram – Tumor blush of JNA and hypertrophied IMAX	Fig 2: Selective catheterization of distal IMAX	Fig 3: Post embolisation – Total occlusion of the vascular bed	Fig 4: Post embolisation ECA – Obliteration of entire vascular bed with occlusion of the feeding artery.
Click on Image to Enlarge

Dural sinus thrombosis – Regional Fibrinolysis


Standard treatment for dural sinus thrombosis consists of heparinisation and hydration besides correction of underlying causative factor. However, in patients who fail to respond adequately to conservative treatment, aggressive therapeutic measures may be required (6).These patients often continue to have symptoms and signs of raised intracranial pressure such as headache, vomiting, papilloedema and diminished vision, Fibrinolytic therapy is the best way to treat this patient population and is achieved by regional thrombolytic infusion.

CT and MRI provide information regarding the site, extent of dural sinus thrombosis, presence of venous infarct and associated haemorrhage.(7,8) Cerebral angiogram is required to provide road map for planning regional fibrinolysis. The occluded dural sinus is catheterized after advancing the delivery system through ipsilateral or contralateral IJV after a femoral venous puncture. Optimal catheter position requires the use of micro guide-wire and micro catheter. Pre fibrinolytic clot maceration is performed either with a Guide-wire, loop snare or Balloon to reduce the thrombus burden and facilitate faster recanalization.

Urokinase infusion is started and continued until optimal recanalization is achieved which is evaluated on venous phase of angiography. Simultaneous heparinisation is continued to prevent formation of fresh thrombus. Infusion period can be variable and can range from several hours to a few days. Haemorrhagic complications do occur occasionally but can be minimized by careful patient selection and paying attention to procedural details.

Case I: Dural sinus thrombosis, not responding to conservative management treated by regional Fibrinolysis.

Fig 1: Venous phase of cerebral angiogram – occlusion of the right transverse and sigmoid sinus.	Fig 2: Angiogram performed through the micro catheter within the transverse sinus – multiple filling defects representing clot (arrow).	Fig 3: Micro catheter injection midway through the Fibrinolysis (Urokinase infusion) – Marked lysis of thrombus.	Fig 4: Micro catheter injection towards the end of Fibrinolysis (Urokinase infusion) – Complete lysis of thrombus.	Fig 5: Venous phase of Cerebral angiogram post Fibrinolysis - Adequate restoration of flow through the transverse sinus.
Click on Image to Enlarge

Carotico-Cavernous Fistula – Trans Arterial Coil Embolisation


Carotico-cavernous fistula (CCF) represents communication between internal or external carotid artery and the cavernous sinus. CCF can be classified into direct or indirect. In direct CCF the ICA communicates with the cavernous sinus (9). In indirect CCF communication occurs between the cavernous sinus and the dural branches of the Internal carotid artery (ICA) or 
External carotid artery (ECA).

The clinical presentation depends upon the type, duration, size and the nature of venous drainage. In CCF, the reversal of flow occurs in the ophthalmic veins leading to orbital venous congestion, proptosis, increased intra ocular pressure and glaucoma. The increased venous pressure and intra ocular pressure leads to diminished retinal perfusion and decline in visual acuity. Venous outflow into the cerebral cortical veins can lead to cortical venous hypertension wherein there is an increased risk of intra cerebral haemorrhage.(10,11,12)

Selective cerebral angiography is absolutely essential for characterization of fistula and planning management options. Indications for emergency treatment are rapid visual decline, increasing intracranial pressure and cortical venous drainage. Treatment of choice in direct CCF is embolisation. This is most often performed by trans arterial balloon embolisation. Alternately trans catheter coil embolisation can be carried out either through arterial or venous route.(13). Asymptomatic indirect CCF can be conservatively managed by carotid compression maneuver. When treatment is required the choice is embolisation either through arterial or venous route.

Case I: Indirect CCF, treated by coil embolisation.

Fig 1: ECA angiogram – Fistulous communication between the middle meningeal artery and cavernous sinus.	Fig 2: Super selective angiogram of middle meningeal artery through micro catheter - Site of fistula.	Fig 3: Post coil embolisation angiogram - Total closure of fistula.	Fig 4: Post embolisation ECA angiogram - Total occlusion of fistula.
Click on Image to Enlarge

Results: 

Of the 7 patients who underwent embolisation for intractable epistaxis, complete and immediate cessation of haemorrhage occurred in all the patients. In the patients who underwent tumoural pre-operative embolisation, significant reduction in peri-operative haemorrhage, shortened procedure time and complete tumour removal could be recorded. Immediate closure of fistula was achieved in two patients with CCF following coil deployment. Regional fibrinolysis performed in one patient with dural sinus thrombosis resulted in complete recanalisation following Urokinase infusion.

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