Negative Pressure Pulmonary Edema

Acute Respiratory Distress Syndrome after Onyx Embolization of ...

Results . Shortly after the second Onyx embolization procedure, the patient declined from respiratory failure secondary to pulmonary edema. Clinical entities typically responsible for pulmonary edema including cardiac failure, renal failure, iatrogenic volume overload, negative-pressure pulmonary edema, and infectious etiologies were evaluated and excluded. The patient required mechanical ventilatory support for several days, delaying operative resection. The patient met clinical and radiographic criteria for ARDS. After excluding other etiologies of ARDS, we postulate that ARDS developed as a result of Onyx administration. The Onyx copolymer is dissolved in dimethyl sulfoxide (DMSO), a solvent excreted through the lungs and has been implicated in transient pulmonary side effects. Additionally, a direct toxic effect of the Onyx copolymer is postulated. 1. History and Presentation

This 60-year-old male initially presented with a history of seizures and progressive left-sided hemiparesis. A 3 cm AVM was discovered in the right posterior frontal lobe, just anterior to the central sulcus (Figure 1 ). The patient’s pastmedical history included hypertension, diet-controlled diabetes mellitus, and mild chronic obstructive pulmonary disease. Medications included levetiracetam for seizure control and metoprolol for hypertension. Given the progressive symptomatology, it was decided to perform an operative resection of the AVM after sequential Onyx embolization procedures.

On admission day one, the patient underwent the first of two preoperative embolization procedures. Both procedures were performed under general anesthesia with endotracheal intubation. Arteriography demonstrated feeding of the AVM via both middle cerebral artery (MCA) and anterior cerebral artery (ACA) branches, with early venous drainage via a large cortical vein near the entry into the superior sagittal sinus. An anterior feeding branch off the MCA was selectively catheterized using an UltraFlow microcatheter and Mirage microwire (Ev3 Neurovascular, Irvine, Calif, USA). When a position adjacent to the nidus was achieved, the Onyx was injected per the standard procedure. The dead space volume of the microcatheter was displaced with 0.26 mL DMSO. Onyx- 18 embolization of the prefrontal branch was performed using 0.8 mL at an injection rate of 0.1 mL/min until there was reflux into the feeding vessel. A second feeding vessel was then selectively catheterized, and due to the apparent higher flow rate, Onyx-34 was used. 1.6 mL of the Onyx was injected after the same DMSO flush. The Onyx appeared to fill the nidus well with no noted venous filling. Follow-up angiography demonstrated improvement in the transit time into the draining vein but some residual AVM. The patient was hemodynamically stable through the procedure and had no respiratory difficulties. He was extubated uneventfully and transferred to the neurosciences intensive care unit for monitoring and strict blood pressure control.

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