Spinal metastasis from malignant meningeal intracranial hemangiopericytoma: one-staged percutaneous Onyx™ embolization and resection - a technical innovation

BACKGROUND: We are the first to report one-staged resection of a spinal metastasis from malignant cranial hemangiopericytoma after preoperative Onyx™-20 embolization by direct percutaneous puncture. Spinal metastases from cranial hemangiopericytoma are extremely rare. Surgical morbidity of these highly vascularized tumours results mainly from excessive blood loss. Preoperative embolization of hyper vascular tumours has been used to reduce intraoperative blood loss for a long time. To avoid complications from arterial catheter intervention, direct percutaneous puncture has been advocated as a safe and effective alternative. METHODS: A 46-year-old man with a history of malignant cranial hemangiopericytoma deriving from the left frontal skull base presented with a short history of lower back pain. A magnetic resonance imaging scan revealed an intra- and extra spinal mass lesion of the thoracic spine at Th 12. Indication for tumour resection was made and the patient’s written consent was obtained. Preoperatively, arterial catheter angiography was performed to reveal the tumour’s angioarchitecture, revealing high-flow arteriovenous shunts. In order to impede the expected perioperative blood loss, tumour embolization by direct percutaneous puncture and application of Onyx™-20 was performed prior to surgery. RESULTS: After percutaneous Onyx™-20 embolization, complete and safe resection of the lesion could be achieved. There was only minimal blood loss perioperatively. A pathohistological report confirmed malignant, anaplastic hemangiopericytoma. CONCLUSIONS: In our case Onyx™-20 embolization via direct percutaneous puncture of a highly vascularized tumour was shown to be a safe and efficient tool prior to surgery. Despite high-flow arteriovenous shunts, direct percutaneous administration of non-adhesive ethanol liquid was an efficient alternative to transarterial catheter embolization. The perioperative blood loss could be substantially diminished.