CardioVascular and Interventional Radiology | 2021
Acute Bilateral Decrease in Vision Acuity Following Cryoablation of a Painful L5 Spinal Metastasis
Abstract
Dear Editor, Percutaneous cryoablation of spinal metastases is a wellestablished treatment [1]. The technique is considered safe with reported complications often being minor and selflimiting [1, 2]. Hereby, we report the case of a 47-year-old female patient who experienced an acute bilateral decrease of visual acuity secondary to palliative cryoablation, and epidural hydrodissection, of a painful L5 metastasis. Patient’s permission was obtained for the publication of this report. The patient was treated due to a focal lumbar pain (5/10 in the 24 h without focal neurologic symptoms) related to a 20 mm metastasis in L5. Patient’s medical history included high-blood pressure; previous C6-C7 discal prosthesis, systemic oncologic therapies, surgery and radiation therapy of her primary breast cancer; pathological non-painful L1 fracture associated with a non-compressive metastatic anterior epidural involvement. Given the osteoblastic aspect of the L5 metastasis, the patient underwent palliative cryoablation under general anesthesia and CT-guidance. One cryoprobe (Ice-Sphere, Boston Sc) was deployed into the metastasis with a transpedicular approach (Fig. 1A). A thermocouple was medially deployed to the cryoprobe to monitor the temperature at the level of the posterior vertebral wall (Fig. 1A). A 22G needle was deployed with a trans-laminar approach to provide epidural hydrodissection. Following the injection of 2 mL of contrast-diluted saline, opacification of the subdural space was noted (Fig. 1B). The 22G needle was withdrawn, and 2 additional mL saline were injected into the epidural space (Fig. 1B). Three consecutive 2.5-min. freezing cycles were performed and for each freezing cycle, 10–15 ml of saline were injected. In the immediate post-operative period, the patient experienced bilateral blurred vision along with scintillating scotomas. No headache was reported. Ophthalmologists advised for an outpatient consultation if symptoms persisted more than 48 h. Accordingly, the patient was discharged the following day. Nevertheless, due to persistent symptoms, the patient came back to the emergency department. A new ophthalmological consultation revealed significant decrease in visual acuity bilaterally (4/10 and 2/10 on the left and right eye, respectively) along with multiple bilateral retro-hyaloidal, sub-retinal and parapapillary hemorrhages. MRI ruled out intra-cranial ruptured aneurysm and hemorrhage. The patient underwent vitrectomy and evacuation of retro-hyaloidal hemorrhage of the left eye. Two weeks later, the patient was seen in consultation by the interventional radiologist; she referred a persistent blurred vision and decreased lumbar pain (2/10 in the 24 h). This case was retrospectively and collegially analyzed at our Institution. A final diagnosis of a variant of Terson’s syndrome was made, in association with a Valsalva’s & Roberto Luigi Cazzato [email protected]