Transcatheter Arterial Embolization for Shock Caused by Intratumoral Hemorrhaging in Neurofibromatosis Type 1: A Report of Two Cases
A 77-year-old man fell off his bicycle and bruised the back of his head. He was examined at a local hospital. A computed tomography (CT) scan revealed a hemorrhage in the occipital region so he was admitted to the hospital, where he went into shock and was transferred to our hospital 9 h after the injury.\nOn examination, he was found to be alert, his blood pressure was 91/54 mm Hg, his pulse rate was 126 beats/min, and his oxygen saturation level was 100% whilst breathing through a face mask (5 liter/min). Anemia of the palpebral conjunctiva subsequently developed. Severe swelling and tenderness were observed from the left occipital region to the left side of the neck (fig. ). Laboratory analysis revealed a blood hemoglobin level of 6.2 g/dl, but this recovered to 10.0 g/dl after the transfusion of 14 units of erythrocytes. We immediately performed a contrast-enhanced CT scan. However, during the scan a mass in the patient's neck suddenly began to swell and obstruct his airway. He underwent emergency intubation. A second contrast-enhanced CT scan revealed an intratumoral hemorrhage, extending from the lower jaw to the left side of the neck and the displacement of the trachea to the right (fig. ). Thus, he immediately underwent transcatheter arterial embolization (TAE). A left vertebral artery angiogram demonstrated that the branches of the vertebral artery extending into the rear of the neck had expanded and proliferated markedly, and extravasation of contrast material was detected in the peripheral branches (fig. ). We superselectively embolized the artery using an infusion catheter before injecting gelatin sponge. A subsequent left subclavian artery angiogram depicted extravasation of contrast material in the peripheral branches of the transverse cervical artery. We embolized the artery by injecting an emulsion of n-butyl-2-cyanoacrylate and iodized oil at a ratio of 1:4 (Histoacryl/Lipiodol) (fig. ).\nThe TAE was successful, and the hemorrhage gradually reduced in size. Since the narrowing of the patient's airway improved, the patient was extubated at 8 days after admission. Subsequently, the hemorrhagic region exhibited autolysis, and the ulcers on the back of the patient's head and left shoulder were drained. He underwent a free skin grafting at 21 days after admission. The patient's wounds completely healed, and he was discharged at 41 days after admission (fig. ).