Case Report: Multiple Scattered Ischemic and Hemorrhagic Strokes after Transarterial Chemoembolization for Hepatocellular Carcinoma (P6.253)

Introduction: Transarterial chemoembolization (TACE) is selective delivery of a chemotherapeutic agent mixed with radio-opaque contrast and embolization materials into the vessel supplying a liver tumor. We report the case of a 20-year-old male who underwent first time TACE for hepatocellular carcinoma. He suffered from cardiogenic cirrhosis secondary to complex congenital heart disease: a single ventricle with tricuspid and pulmonary atresia. Method: We conducted a literature review of TACE neurological complications. Fewer than 20 cases of TACE-induced cerebral embolism were reported worldwide. No case of hemorrhagic infarct after TACE was reported. Findings: During the TACE procedure, 75 mg of doxorubicin mixed with 100-300 micron LC Beads TM , iohexol, and lipiodol were infused. A 2 cm vascular mass was noted in the left hepatic lobe with prominent shunting into the left hepatic vein. Immediately after the chemoembolization, he developed intractable nausea, vomiting, and severe headache. Vital signs and neurological examination were normal. Head CT and brain MRI showed small subarachnoid hemorrhage in bifrontal cerebral sulci and multiple punctate diffusion restriction foci across bilateral cerebral and cerebellar hemispheres. Two weeks later, he developed severe left retro-orbital pain with persistent dull headache and gait imbalance. Imaging showed widepread microhemorrhages throughout the brain and a large left parieto-occipital hypodense lesion plus hyperdense hemorrhage. Discussion: We hypothesize that the mechanism behind these cerebral ischemic infarcts was likely embolic due to the presence of hepatic arterio-venous shunting and the single cardiac ventricle. Hemorrhagic transformation of prior ischemic infarcts can explain the parenchymal hemorrhage. The extensive microhemorrhages could be related to the direct effect of the chemotherapeutic and embolization agents on the cerebral and cerebellar vasculature. Conclusion: Screening for hepatic and cardiac shunts is a crucial measure to prevent TACE-associated strokes. The possible hemorrhagic effects of both chemotherapeutic and embolization agents can be better clarified by further pathological and radiological studies of the brain. Disclosure: Dr. Al-Bayati has nothing to disclose. Dr. Smith has nothing to disclose. Dr. Haddad has nothing to disclose.