Department of Clinical Immunology and Allergy, Royal North Shore Hospital, Sydney, New South Wales, Australia
Department of Clinical Immunology and Allergy, Royal North Shore Hospital, Sydney, New South Wales, Australia.
J Neurointerv Surg. 2021 Nov;13(11):1032-1036. doi: 10.1136/neurintsurg-2020-016806. Epub 2021 Mar 15.
Endovascular procedures are standard of care for an increasing range of cerebrovascular diseases. Many endovascular devices contain plastic and are coated with a hydrophilic polymer which has been rarely described to embolize, resulting in distal granulomatous inflammatory lesions within the vascular territory.
We reviewed three cases of cerebral granulomatous reactions that occurred after endovascular intervention for internal carotid aneurysms. The patient procedure details, presentation, relevant investigations, and treatment course are described. We also provide a literature review on endovascular granulomatous reactions.
These three cases represent the largest biopsy proven series of cerebral granulomatosis following endovascular intervention. We highlight the variable clinical presentation, with two of the three cases having an unusually delayed onset of up to 4 years following the intervention. We show the characteristic histological findings of granulomatous lesions with foreign body material consistent with a type IV reaction, radiological abnormalities of enhancing lesions within the vascular territory of the intervention, and the requirement of prolonged immunosuppression for maintenance of clinical remission, with two of the three patients requiring a corticosteroid sparing agent. In comparison with the available literature, in addition to hydrophilic gel polymer, we discuss that plastic from the lining of the envoy catheter may be a source of embolic material. We also discuss the recommendations of the Food and Drug Administration and the implementation of novel biomaterials for the prevention of these reactions in the future.
There is a need for increased awareness of this severe complication of cerebral endovascular procedures and further longitudinal studies of its prevalence, optimal management and preventative measures.
血管内手术是越来越多脑血管疾病的标准治疗方法。许多血管内设备都含有塑料，并涂有亲水性聚合物，这些聚合物很少会栓塞，导致血管区域内出现远端肉芽肿性炎症病变。
我们回顾了三例因颈内动脉动脉瘤行血管内介入治疗后发生的脑肉芽肿性反应病例。描述了患者的手术细节、表现、相关检查和治疗过程。我们还对血管内肉芽肿性反应进行了文献复习。
这三例是经活检证实的血管内介入治疗后发生脑肉芽肿病的最大系列病例。我们强调了不同的临床表现，其中两例的发病时间异常延迟，高达介入治疗后 4 年。我们展示了肉芽肿病变的特征性组织学发现，有异物材料，符合 IV 型反应，血管区域内的增强病变的放射学异常，以及维持临床缓解需要长期免疫抑制，三例中有两例需要皮质类固醇保留剂。与现有文献相比，除了亲水性凝胶聚合物外，我们还讨论了特使导管衬里的塑料可能是栓塞物质的来源。我们还讨论了食品和药物管理局的建议以及未来为预防这种反应而采用新型生物材料。
需要提高对这种严重的脑血管内手术并发症的认识，并进一步进行其患病率、最佳管理和预防措施的纵向研究。
