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DOI: 10.1055/s-0033-1342965
Mental Status Changes Postchemoembolization: The Role of Inflammatory Response
Publikationsverlauf
Publikationsdatum:
28. Mai 2013 (online)
![](https://www.thieme-connect.de/media/sir/201302/lookinside/thumbnails/10.1055-s-0033-1342965-1.jpg)
Case Report
A 72-year-old woman with a history of end-stage liver disease (Child class A) secondary to cryptogenic cirrhosis presented for elective transarterial chemoembolization (TACE) of hepatocellular carcinoma (HCC). Recent imaging demonstrated increased size of a hypervascular 1.3-cm nodule in the left lobe consistent with recurrence at the margin of a previous radiofrequency ablation site. She reported episodic right upper quadrant pain and infrequent encephalopathy.
Chemoembolization was completed from a right transfemoral approach. A left hepatic arteriogram demonstrated segmental branches to segments 2 and 3 with marked tortuosity and a hypervascular mass with conspicuous contrast staining. An attempt to catheterize segmental arterial branches subselectively to hepatic segment 2 and 3 was unsuccessful. LC bead chemoembolization was then performed to near stasis from the level of the undivided left hepatic artery; a total of 60 mg of doxorubicin loaded onto 100- to 300-µm beads was delivered to the left hepatic artery distribution.
Following the procedure, the patient was admitted for overnight observation while receiving intravenous fluids, antiemetics, and pain relievers in addition to her home medications. That evening she developed signs of increasing confusion. She awoke not knowing who family members were, was making nonsensical statements, and exhibited tangential thinking. On examination there was no focal neurologic deficit or asterixis. Her overnight temperature reached a maximum of 98.8°F, and other vital signs were normal. The admitting hospitalist discontinued her fentanyl patient-controlled analgesia and scopolamine patch in addition to scheduling lactulose and administering Haldol as needed.
Although the patient's mental status was clearing by the following morning, her discharge was deferred for further observation. The following night was generally uneventful, and she was discharged in the morning on a new lactulose and rifaximin regimen for presumed hepatic encephalopathy. The patient returned 11 weeks later for repeat chemoembolization of the left hepatic lobe; her overnight hospital course during this admission was uncomplicated, without evidence of delirium or significant manifestations of postembolization syndrome (PES).
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References
- 1 Marcantonio ER, Goldman L, Mangione CM , et al. A clinical prediction rule for delirium after elective noncardiac surgery. JAMA 1994; 271 (2) 134-139
- 2 de Rooij SE, van Munster BC, Korevaar JC, Levi M. Cytokines and acute phase response in delirium. J Psychosom Res 2007; 62 (5) 521-525
- 3 Leung DA, Goin JE, Sickles C, Raskay BJ, Soulen MC. Determinants of postembolization syndrome after hepatic chemoembolization. J Vasc Interv Radiol 2001; 12 (3) 321-326
- 4 Patel NH, Hahn D, Rapp S, Bergan K, Coldwell DM. Hepatic artery embolization: factors predisposing to postembolization pain and nausea. J Vasc Interv Radiol 2000; 11 (4) 453-460
- 5 Lammer J, Malagari K, Vogl T , et al; PRECISION V Investigators. Prospective randomized study of doxorubicin-eluting-bead embolization in the treatment of hepatocellular carcinoma: results of the PRECISION V study. Cardiovasc Intervent Radiol 2010; 33 (1) 41-52
- 6 Matsuda Y, Kawata S, Nagase T , et al. Interleukin-6 in transcatheter arterial embolization for patients with hepatocellular carcinoma. Effects of serine protease inhibitor. Cancer 1994; 73 (1) 53-57
- 7 Blanco Vela CI, Bosques Padilla FJ. Determination of ammonia concentrations in cirrhosis patients—still confusing after all these years?. Ann Hepatol 2011; 10 (Suppl. 02) S60-S65
- 8 Dhand S, Gupta R. Hepatic transcatheter arterial chemoembolization syndrome. Semin Intervent Radiol 2011; 28 (2) 207-211
- 9 Patel NH, Hahn D, Rapp S, Bergan K, Coldwell DM. Hepatic artery embolization: factors predisposing to postembolization pain and nausea. J Vasc Interv Radiol 2000; 11 (4) 453-460
- 10 Groupe d'Etude et de Traitement du Carcinome Hepatocellulaire. A comparison of Lipiodol chemoembolization and conservative treatment for unresectable hepatocellular carcinoma. N Engl J Med 1995; 332 (19) 1256-1261
- 11 Lopez Jr RR, Pan SH, Lois JF , et al. Transarterial chemoembolization is a safe treatment for unresectable hepatic malignancies. Am Surg 1997; 63 (10) 923-926
- 12 Brown KT, Nevins AB, Getrajdman GI , et al. Particle embolization for hepatocellular carcinoma. J Vasc Interv Radiol 1998; 9 (5) 822-828
- 13 Patel NH, Hahn D, Rapp S, Bergan K, Coldwell DM. Hepatic artery embolization: factors predisposing to postembolization pain and nausea. J Vasc Interv Radiol 2000; 11 (4) 453-460
- 14 Paye F, Farges O, Dahmane M, Vilgrain V, Flejou JF, Belghiti J. Cytolysis following chemoembolization for hepatocellular carcinoma. Br J Surg 1999; 86 (2) 176-180
- 15 Lammer J, Malagari K, Vogl T , et al; PRECISION V Investigators. Prospective randomized study of doxorubicin-eluting-bead embolization in the treatment of hepatocellular carcinoma: results of the PRECISION V study. Cardiovasc Intervent Radiol 2010; 33 (1) 41-52
- 16 Lewandowski RJ, Mulcahy MF, Kulik LM , et al. Chemoembolization for hepatocellular carcinoma: comprehensive imaging and survival analysis in a 172-patient cohort. Radiology 2010; 255 (3) 955-965
- 17 Lance C, McLennan G, Obuchowski N , et al. Comparative analysis of the safety and efficacy of transcatheter arterial chemoembolization and yttrium-90 radioembolization in patients with unresectable hepatocellular carcinoma. J Vasc Interv Radiol 2011; 22 (12) 1697-1705
- 18 Castells A, Bruix J, Ayuso C , et al. Transarterial embolization for hepatocellular carcinoma. Antibiotic prophylaxis and clinical meaning of postembolization fever. J Hepatol 1995; 22 (4) 410-415
- 19 Paye F, Farges O, Dahmane M, Vilgrain V, Flejou JF, Belghiti J. Cytolysis following chemoembolization for hepatocellular carcinoma. Br J Surg 1999; 86 (2) 176-180
- 20 Wigmore SJ, Redhead DN, Thomson BN , et al. Postchemoembolisation syndrome—tumour necrosis or hepatocyte injury?. Br J Cancer 2003; 89 (8) 1423-1427
- 21 Matsuda Y, Kawata S, Nagase T , et al. Interleukin-6 in transcatheter arterial embolization for patients with hepatocellular carcinoma. Effects of serine protease inhibitor. Cancer 1994; 73 (1) 53-57
- 22 Itoh Y, Okanoue T, Ohnishi N , et al. Hepatic damage induced by transcatheter arterial chemoembolization elevates serum concentrations of macrophage-colony stimulating factor. Liver 1999; 19 (2) 97-103
- 23 Ikei S, Ogawa M, Beppu T , et al. Changes in IL-6, IL-8, C-reactive protein and pancreatic secretory trypsin inhibitor after transcatheter arterial chemo-embolization therapy for hepato-cellular carcinoma. Cytokine 1992; 4 (6) 551-564
- 24 Kohles N, Nagel D, Jüngst D, Durner J, Stieber P, Holdenrieder S. Prognostic relevance of oncological serum biomarkers in liver cancer patients undergoing transarterial chemoembolization therapy. Tumour Biol 2012; 33 (1) 33-40
- 25 Pirisi M, Fabris C, Soardo G , et al. Hepatic release of erythropoietin induced by transarterial chemoembolization in patients with hepatocellular carcinoma. Hepatology 1995; 22 (1) 148-152
- 26 Ramlawi B, Rudolph JL, Mieno S , et al. C-Reactive protein and inflammatory response associated to neurocognitive decline following cardiac surgery. Surgery 2006; 140 (2) 221-226
- 27 Adamis D, Lunn M, Martin FC , et al. Cytokines and IGF-I in delirious and non-delirious acutely ill older medical inpatients. Age Ageing 2009; 38 (3) 326-332 , discussion 251