Posterior Cerebral Artery Compression and Subsequent Infarction after Implantation of a GliaSite™ Balloon

Abstract

Objective and Importance: Brachytherapy with the GliaSite balloon system, is a recently-developed treatment option for recurrent malignant glioma. We report a complication with the intent of supplementing the limited published clinical experience with this device. Clinical Presentation: Following resection of recurrent glioblastoma in the right temporal lobe of a 66 year-old man, a GliaSiteTM balloon was implanted. Ninety minutes postoperatively, the patient developed left hemiparesis. Imaging revealed an acute infarct within the distribution of the right posterior cerebral artery. Technique: Prior reported clinical experiences were explored to elucidate the potential frequency of neurological deficits associated with balloon inflation, with emphasis on the relative geometries of the balloon and resection cavity. Conclusion: Risk of acute neurological deficits and possible stroke may be underappreciated with the GliaSiteTM system. Additional investigations into the pressure-volume relationships as a function of resection cavity deviation from spherical shape may be helpful in patient selection and device utilization. OBJECTIVE AND IMPORTANCE Despite advances in surgery, radiation, and chemotherapy, long-term survival of patients with glioblastoma multiforme (GBM) remains poor, with the vast majority of patients suffering recurrent tumor. Options for treating recurrent GBM include surgery, chemotherapy (systemic or implanted), and/or radiation. Retreatment with radiation requires focal therapy to minimize the volume of normal brain tissue receiving high cumulative doses. Consequently, various forms of brachytherapy have been used to administer radiation in the setting of recurrent GBM. Recently, brachytherapy using the GliaSiteTM (Proxima Therapeutics Inc., Alpharetta, Georgia, USA) intra-cavitary radiation system has been reported for recurrent malignant glioma.1,2 The GliaSiteTM device consists of a silicone balloon that comes in a variety of sizes which can be intraoperatively fitted to relatively spherical resection cavities. The device is then after-loaded by filling with an aqueous iodine-125 solution. Consistent spatial localization of the radiation dose is achievable with this relatively rigid spherical balloon system.3 We present a complication associated with use of this system that may be more common than previously recognized. CLINICAL PRESENTATION A 66 year-old man presented for resection of a recurrent right temporal GBM (Figure 1). Posterior Cerebral Artery Compression and Subsequent Infarction after Implantation of a GliaSiteTM Balloon