Introduction

Bronchial artery embolization (BAE) is a minimally invasive and effective treatment for massive or medically refractory hemoptysis. Cerebral infarction is a rare but potentially life-threatening complication of BAE. Infarctions in the posterior circulation are the most frequently reported complications, although middle cerebral artery infarction has also been described [1-12]. Possible mechanisms of posterior circulation cerebral infarction include shunting between the bronchial artery and a systemic artery (e.g., the subclavian artery), pulmonary arteriovenous malformations, and bronchial artery–to–pulmonary artery shunting. To the best of our knowledge, 12 cases of magnetic resonance imaging (MRI)-confirmed posterior circulation infarction following BAE have been reported [1-11]. In three of these cases, a shunt was identified between the bronchial and subclavian arteries [1,2]. Herein, we report a case of posterior circulation infarction due to nontarget embolization of trisacryl gelatin microspheres (TAGMs) via anastomosis between the left bronchial and left subclavian arteries, after BAE in a 45-year-old man with massive hemoptysis.

Case

Ethics statement: The Institutional Review Board (IRB) of Yeungnam University Hospital exempted this study from review (IRB No: 2025-05-041) and waived the requirement for informed consent from the patient.

A 45-year-old male patient was admitted to our emergency department with massive hemoptysis that persisted despite 10 days of medical management using tranexamic acid and botropase. Contrast-enhanced chest computed tomography (CT) revealed bronchial artery hypertrophy.

To manage hemoptysis, the patient was referred by a pulmonologist for BAE, which was performed according to standard procedures [13]. The right femoral artery was punctured, and a 5-French introducer sheath was inserted under ultrasound guidance. A 5-French bronchial angiographic catheter was used to select the hypertrophied left bronchial artery. Angiography revealed a shunt between the bronchial and pulmonary arteries (Fig. 1A). Using a 1.98-French microcatheter and 0.016-inch microwire, the left bronchial artery was selectively catheterized. TAGMs (300–500 μm) were selected for left BAE and mixed with 20 mL of iodine contrast medium (300 mg/mL) [13]. A total of 11 mL of the mixture was injected through the microcatheter into the left bronchial artery. Follow-up angiography revealed contrast-medium stasis in the left bronchial artery. However, postembolization left bronchial angiography revealed an anastomosis between the left bronchial and left subclavian arteries (Fig. 1B), which was not observed on the initial angiogram. However, the patient complained of nausea, vomiting, headache, and dizziness after the BAE. Neurological examination revealed dysarthria and truncal ataxia without cognitive, sensory, or motor deficits. Brain MRI was performed because of the suspicion of cerebellar infarction, and multifocal acute infarctions were observed in both cerebellar hemispheres, bilateral occipital lobes, the right thalamus, splenium of the corpus callosum, and left cingulate gyrus on diffusion-weighted imaging (Fig. 2A–2E). The patient was administered aspirin to prevent further clotting in the posterior circulation of the brain, and blood pressure control was initiated. The day after BAE, the patient complained of new-onset paresthesia in the fingertips of his left hand. Follow-up brain MRI performed the next day revealed hemorrhagic transformation of the acute infarction in the right thalamus, accompanied by intraventricular hemorrhage in the right lateral ventricle (Fig. 2F). Follow-up brain CT scans performed on the same day and 1, 4, and 6 days later showed no significant changes in the right thalamic or intraventricular hemorrhage (Fig. 2G–2I).

One week after BAE, the patient’s symptoms improved, except for a mild headache.

Discussion

BAE is an effective treatment option for patients with massive, recurrent, or treatment-refractory hemoptysis [14]. BAE is a minimally invasive and relatively safe procedure; however, it is associated with many documented complications, most of which are transient and mild. These complications include chest and back pain, dysphagia, and postembolization syndrome. Nonetheless, life-threatening complications such as spinal cord infarction and cerebral infarction due to nontarget embolization have also been reported [14].

Thirteen cases of posterior circulation infarction confirmed by MRI, including our case, are summarized in Table 1 [1-11]. Among these, four cases, including ours, demonstrated suspected or clearly visible shunts between the bronchial and subclavian arteries. In the present case, the anastomosis between the left bronchial and left subclavian arteries, which was unclear on the initial angiogram, was clearly visualized after embolization. This may have occurred because the shunt, initially too small to detect, became more prominent after the dominant pulmonary flow was occluded, enabling nontarget embolization through the left subclavian–vertebral artery pathway. In one case, the findings were suggestive of an intrapulmonary shunt on transcranial Doppler ultrasonography using a saline-based contrast medium [8]. Another case showed a small pulmonary arteriovenous malformation on postembolization angiography [11]. The underlying mechanisms in these seven cases are unclear. Bronchial artery–subclavian artery shunting, bronchial artery–vertebral artery shunting, pulmonary arteriovenous malformation, and bronchial artery–pulmonary artery shunting are possible mechanisms underlying posterior circulation cerebral infarction. In three of the seven cases, hypervascular lesions were present in the upper lobe on angiography. This underscores the need for careful assessment for the presence of a shunt between the bronchial and systemic arteries, particularly during upper lobe lesion embolization.

Superselective catheterization and precise angiographic assessment are crucial for minimizing the risk of neurological complications [15]. Potential anastomoses should be identified before embolization because small-caliber connections that are not apparent on the initial angiogram may become evident after embolic material injection. Intermittent angiography is required during embolization to detect shunts. Special caution is warranted if the lesion is in the upper lobes. Furthermore, embolic agents and particle sizes must be carefully selected. Smaller particles, such as TAGMs in the 300 to 500 μm range, carry a higher risk of traversing small anastomotic vessels [16].

Ten of the 12 patients with known outcomes recovered, whereas the remaining two died. Our patient was administered aspirin to prevent further aggravation of the infarction. However, the hemorrhagic transformation in the right thalamic infarction was accompanied by intraventricular hemorrhage. The patients who had adequate bed rest and blood pressure control recovered without any neurological sequelae except for a mild headache. Anticoagulation therapy is indicated in the event of cerebral infarction. Of the 12 reported cases, one demonstrated improved neurological symptoms without symptom exacerbation after clopidogrel treatment (Table 1) [1-11]. Similarly, our patient showed improvement without symptom aggravation following aspirin treatment. Furthermore, mannitol, a vasodilator effective in reducing intracranial pressure, is considered a potentially beneficial adjunct to the treatment approach.

This case highlights the need for caution when performing BAE in the presence of a potential systemic anastomosis. Despite their rarity, infarctions can have life-threatening consequences. Therefore, careful procedural planning, real-time monitoring, and repeat angiography are essential for identifying systemic shunts. In addition, special caution during BAE is required if the lesion is in the upper lobes. Recognizing this complication and its mechanisms is crucial for interventional radiologists to maintain both therapeutic efficacy and patient safety.

Article information

Conflicts of interest

No potential conflict of interest relevant to this article was reported.

Funding

None.

Author contributions

Conceptualization: all authors; Data curation: JP, KH; Formal analysis, Supervision: SK; Writing-original draft: KH, SK; Writing-review & editing: JP, SK.

Fig. 1.

(A) Initial left bronchial angiogram reveals shunting between the left bronchial and pulmonary arteries (arrows). However, an anastomosis between the left bronchial and subclavian arteries is also present, although initially unclear. (B) Follow-up left bronchial angiogram performed after embolization demonstrates the anastomosis between the left bronchial and subclavian arteries more clearly (arrow).

Fig. 2.

Diffusion-weighted sequences of brain magnetic resonance imaging show acute infarctions in (A) both cerebellar hemispheres (arrows), (B) the left occipital lobe (arrow), (C) the right occipital lobe (arrow), (D) the right thalamus (upper arrow) and splenium of the corpus callosum (lower arrow), and (E) the left cingulate gyrus (arrows). Follow-up magnetic resonance imaging performed 1 day later shows hemorrhagic transformation of the patient’s right thalamic infarction with intraventricular hemorrhage. (F) Brain computed tomography scans performed (G) on the same day, and at (H) 1 day, (I) 4 days, and (J) 6 days post-onset show no changes in brain hemorrhage.

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Figure & Data

References

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