Introduction: Pediatric choroid plexus tumors are highly vascular tumors. Aggressive surgical resection is warranted as complete removal can be curative. Unfortunately, significant blood loss in small, pediatric patients can be a limiting factor to complete resection. Preoperative embolization can drastically reduce intraoperative blood loss and make complete surgical resection safer. Here we describe our experience with preoperative embolization and review the relevant literature.
Methods: Three cases of symptomatic pediatric choroid plexus tumors treated by preoperative embolization followed by immediate surgical resection are described. A PUBMED search was undertaken to identify similarly treated patients.
Results: Three children (median age 9 months) presented with either seizure or decreased mental status. MRI showed homogeneously enhancing lateral ventricular masses (257ml average volume). Acetazolamide and decadron were started; in one case, a preoperative EVD was needed. Cerebral angiography demonstrated the vascular supply with contributions from anterior and posterior choroidal artery branches. The predominant feeder was selectively catheterized and the tumor embolized with NBCA glue. In each case, the tumor blush was reduced by greater than 80%. Gross total resection was immediately performed through a superior parietal lobule approach. Embolization reduced the average blood loss to 22% of the total estimated blood volume. One patient suffered a small thalamic stroke without clinical consequences. No other complications occurred.
Conclusions: Complete surgical resection of choroid plexus tumors is an essential step in management. Preoperative embolization effectively decreases intraoperative blood loss, but must be performed with care. The deep (and more surgically inaccessible) vascular pedicle is supplied by the anterior choroidal artery. Embolization must occur distal to the plexal point and important contributors to the internal capsule, thalamus, and lateral midbrain. Posterior choroidal artery embolization should only be performed from an intraventricular location to avoid thalamic contributors.
Patient Care: Our three cases of choroid plexus tumors treated with preoperative embolization and surgical resection add to a growing body of literature describing the indications, outcomes, and complications associated with the technique and will serve to guide physicians in making appropriate patient specific treatment decisions.
Learning Objectives: By the conclusion of this session, participants should be able to: 1) identify the typical vascular pedicles of choroid plexus tumors and understand their spatial relationship to a superior parietal lobule approach; 2) describe the utility and safety of preoperative embolization for these tumors; 3) describe the nuances of embolization from the anterior or posterior choroidal arteries with emphasis on their potential complications.