Preoperative Devascularization of Choroid Plexus Tumors: Speciﬁc Issues About Anatomy and Embolization Technique

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Case Report Preoperative Devascularization of Choroid Plexus Tumors: Speciﬁc Issues about Anatomy and Embolization Technique

Valentina Baro 1,*, Joseph Domenico Gabrieli 2, Giacomo Cester 2 , Ignazio D’Errico 2, Andrea Landi 1 , Luca Denaro 1 and Francesco Causin 2

1 Academic Neurosurgery, Department of Neuroscience, University of Padova, 35100 Padova, Italy; [email protected] (A.L.); [email protected] (L.D.) 2 Neuroradiology Unit, University of Padova, 35100 Padova, Italy; [email protected] (J.D.G.); [email protected] (G.C.); [email protected] (I.D.); [email protected] (F.C.) * Correspondence: [email protected]

Abstract: (1) Background: Surgical treatment of choroid plexus tumors is challenging, burdened by a notable risk of bleeding. Neoadjuvant chemotherapy and preoperative embolization have been attempted, with encouraging results; however, the consensus on these procedures is lacking. (2) Methods: We present a case of a 10-month-old girl who underwent preoperative embolization of a hemorrhagic choroid plexus carcinoma of the lateral ventricle via the anterior choroidal artery, followed by total resection. (3) Results: The endovascular procedure was successfully completed, despite the rectification of the anterior choroidal artery associated with the absence of flow proximal to the plexal point. Minimal bleeding was observed during resection and the patient remained neurologically intact. (4) Conclusions: The time from entrance to exit in the anterior choroidal artery Citation: Baro, V.; Gabrieli, J.D.; Cester, G.; D’Errico, I.; Landi, A.; should be monitored and regarded as a potential ‘occlusion time’ in this specific group of patients. Denaro, L.; Causin, F. Preoperative Nevertheless, our case supports the feasibility and effectiveness of preoperative embolization of a Devascularization of Choroid Plexus choroid plexus carcinoma of the lateral ventricle via the anterior choroidal artery, without complica- Tumors: Specific Issues about tions. Furthermore, we suggest the use of a fast-embolic agent, such as N-butyl cyanoacrylate glue, Anatomy and Embolization as the preferred agent for this specific pathology and patient population. Technique. Brain Sci. 2021, 11, 540. https://doi.org/10.3390/ Keywords: tumor embolization; pediatric neurosurgery; pediatric brain tumor brainsci11050540

Academic Editor: Helen L. Fillmore 1. Introduction Received: 15 March 2021 Choroid plexus tumors (CPT) are rare neoplasms of neuro-ectodermal origin, account- Accepted: 23 April 2021 Published: 25 April 2021 ing for less than 1% of all brain tumors and 1%–4% of all pediatric brain tumors. Children younger than 2 years of age are mostly affected, and the incidence of the choroid plexus

Publisher’s Note: MDPI stays neutral carcinoma (CPC) is 20%–40% of CPT in patients under 18 months of age [1–3]. Choroid with regard to jurisdictional claims in plexus papilloma (CPP) is the benign form of these tumors—total resection is curative published maps and institutional affil- without adjuvant chemotherapy—confirmed by a 5-year overall survival of 100% [2]. In iations. contrast, the complete resection of CPC is often hindered by the hypervascularity of the lesion and the usual invasion of the contiguous brain parenchyma, leading to a high rate of subtotal resection and recurrences with a 5-year overall survival of 27%, despite adjuvant treatments [1,4,5]. The mortality rate is predominantly due to intraoperative significant blood loss in children with limited circulating volume, and it has been reported to be as Copyright: © 2021 by the authors. high as 13.3% [4,6]. Licensee MDPI, Basel, Switzerland. This article is an open access article The use of neoadjuvant chemotherapy in CPC has been reported as an approach distributed under the terms and that leads to a decrease in blood loss in patients undergoing surgery [7]. Preoperative conditions of the Creative Commons embolization, albeit limited to a small number of patients, has been attempted since the end Attribution (CC BY) license (https:// of the 90s, with encouraging results in terms of reducing blood loss, which, in turn, reduces creativecommons.org/licenses/by/ morbidity and mortality and increases the likelihood of total resection (Supplementary 4.0/). Table S1) [4,8–15]. However, the small and tortuous vasculature of small children, and the

Brain Sci. 2021, 11, 540. https://doi.org/10.3390/brainsci11050540 https://www.mdpi.com/journal/brainsci BrainBrain Sci. Sci.2021 2021, 11,, 11 540, x FOR PEER REVIEW 2 of 28 of 8

typicalTable S1) involvement [4,8–15]. However, of eloquent the small arteries, and representtortuous vasculature a significant of small hindrance. children, In thisand the paper, wetypical describe involvement the case ofof aeloquent 10-month-old arteries, patient repres withent a asignificant right lateral hindrance. ventricle In choroid this paper, plexus we describe the case of a 10-month-old patient with a right lateral ventricle choroid plexus carcinoma who underwent successful preoperative embolization. In addition, the relevant carcinoma who underwent successful preoperative embolization. In addition, the relevant literature is reviewed and discussed. literature is reviewed and discussed. 2. Case Description 2. Case Description A 10-month-old female with regular neurological development and no previous A 10-month-old female with regular neurological development and no previous medical history was admitted to our hospital for an acute onset of vomiting, followed medical history was admitted to our hospital for an acute onset of vomiting, followed by by a progressive deterioration of her neurological status, requiring tracheal intubation. a progressive deterioration of her neurological status, requiring tracheal intubation. The The computed tomography scan showed a large right intraventricular mass with recent computed tomography scan showed a large right intraventricular mass with recent bleed- bleeding associated with moderate midline shift. Magnetic resonance imaging (MRI) with ing associated with moderate midline shift. Magnetic resonance imaging (MRI) with con- contrast media and time-of-flight magnetic resonance angiography (ToF MRA) confirmed trast media and time-of-flight magnetic resonance angiography (ToF MRA) confirmed the the presence of a large, hemorrhagic, intensely enhancing intraventricular mass, centered in presence of a large, hemorrhagic, intensely enhancing intraventricular mass, centered in thethe atrium atrium of of the the right right lateral lateral ventricle, ventricle, without without invasion invasion of of the the adjacent adjacent brain brain parenchyma, paren- fedchyma, by a fed moderately by a moderately enlarged enlarged anterior anterior choroidal choroidal artery artery (Figure (Figure1). Whole1). Whole spine spine MRI excludedMRI excluded signs signs of cerebrospinal of cerebrospinal fluid fluid seeding. seeding. The patientThe patient was was scheduled scheduled for for the the following fol- daylowing to perform day to perform endovascular endovascular embolization embolization and surgical and surgical excision. excision.

FigureFigure 1. (1.A ()A Gradient-echo) Gradient-echo image image shows shows intralesional, intralesional, perilesional perilesional and and intraventricular intraventricular hemorrhagichemorrhagic components.components. (B,C)) T2 axialT2 (axialB) and (B) Volume and Volume Rendering Rendering of ToF of MRAToF MRA (C) show(C) show the coursethe course of the of the anterior anterior choroidal choroidal artery. artery. The The shifted shifted white white line line represents, schematically, the course of the artery; dashed arrows indicate the exact location of the highlighted vessel. represents, schematically, the course of the artery; dashed arrows indicate the exact location of the highlighted vessel. Segment 1 is the cisternal portion of the artery which courses across the carotid, crural and ambient cysterns, up to the Segmentchoroidal 1 is fissure, the cisternal where it portion enters the of thevent arteryricle; the which asterisk courses * corresponds across the to carotid,the plexal crural point and that ambientmarks the cysterns, entrance upin the to the choroidalventricle, fissure, and segment where it2 is enters the intraventricular the ventricle; the segment. asterisk Segme * correspondsnt 3 is the tumoral to the plexal segment point of the that artery marks running the entrance along the in the ventricle,surface andof the segment tumor (see 2 is theFigure intraventricular 4 for the complete segment. anatom Segmentical description). 3 is the tumoral segment of the artery running along the surface of the tumor (see Figure 4 for the complete anatomical description). A preoperative three vessel angiography (bilateral internal carotid artery and domi- nantA vertebral preoperative artery) three confirmed vessel angiographythe presence of (bilateral a slightly internal enlarged carotid right artery anterior and cho- domi- nantroidal vertebral artery feeding artery) the confirmed tumoral the blush. presence No feeders of a slightly were observed enlarged from right the anterior posterior choroidal cir- arteryculation; feeding embolization the tumoral was blush. obtained No feederswith n-butyl were cyanoacrylate observed from (NBCA) the posterior superselective circulation; embolizationinjection (0.4 mL) was via obtained a microcatheter with n-butyl (Magic cyanoacrylate 1.2F-Balt, Montmorency, (NBCA) superselective France; aided injection by a (0.4microguidewire mL) via a microcatheter Hybrid 0.008-Balt, (Magic Montmore 1.2F-Balt,ncy, Montmorency, France) navigated France; near aided the tumor by a microgu- ped- idewireicle, distally, Hybrid to 0.008-Balt,the plexal point Montmorency, of the anteri France)or choroidal navigated artery near (Figure the tumor 2). The pedicle, positioning distally, toof the the plexal microcatheter point of distally, the anterior in the choroidal anterior arterychoroidal (Figure artery,2). Thedetermined, positioning as expected, of the micro- a catheterrectification distally, of the in artery, the anterior and a choroidalpanoramic artery, injection determined, (guiding catheter as expected, Envoy a 5F-Codman rectification of theNeuro, artery, Raynham, and a panoramic MA-positioned injection in the (guiding internal catheter carotid Envoyartery) 5F-Codmanrevealed an Neuro,absence Rayn-of ham, MA-positioned in the internal carotid artery) revealed an absence of flow within the anterior choroidal artery. The total time that elapsed between micro-catheterization, glue injection and retrieval of the microcatheter was 6 min. The subsequent control angiography Brain Sci. 2021, 11, x FOR PEER REVIEW 3 of 8

Brain Sci. 2021, 11, 540 3 of 8

flow within the anterior choroidal artery. The total time that elapsed between micro-catheterization, glue injection and retrieval of the microcatheter was 6 min. The subsequent revealedcontrol angiography the exclusion revealed of the tumor the exclusion blush and of a the re-opening tumor blush of the and anterior a re-opening choroidal of artery. the Totalanterior contrast choroidal media artery. of 30 Tota mL (300l contrast mgI/mL), media ﬂuoroscopy of 30 mL (300 time mgI/mL), was 11 min, fluoroscopy total series time of 9, andwas cumulative11 min, total DAP series 20 of 710 9, and mGycm2. cumulative DAP 20 710 mGycm2.

FigureFigure 2. 2.( A(A)) Tumoral Tumoral blush blush during during superselective superselective free-flow free-flow contrast contrast injection injection in Frontal in Frontal (F) and (F) Lateraland Lateral (L) views. (L) views. (B) Forced (B) injectionForced injection of contrast of contrast media is media performed is performed to test for to thetest presence for the presence of dangerous of dangerous anastomosis. anastomosis. By comparison, By comparison, with injection with injection A, note the appearance of an additional vessel which corresponds to the course of the posterolateral choroidal A, note the appearance of an additional vessel which corresponds to the course of the posterolateral choroidal artery. artery. Unsubtracted images (small quadrants) of the final glue cast show penetration in the vascular bed of the tumor, Unsubtractedand in the right images posterolateral (small quadrants) choroidal of artery; the final penetration glue cast in show the latter penetration should inbe the anticipated, vascular bedeven of in the the tumor, absence and of in theenlarged right posterolateralposterior choroidal choroidal feeders, artery; and penetrationshould be carefully in the latter monitored should to be avoid anticipated, potential even complications. in the absence of enlarged posterior choroidal feeders, and should be carefully monitored to avoid potential complications. Immediately after the endovascular procedure, the patient underwent a surgical ex- cisionImmediately of the tumor. after Opening the endovascular of the right pa procedure,rietal craniotomy the patient and dura underwent revealed a a surgicalherni- excisionation of the of thesuperior tumor. parietal Opening lobule. of The the rightcortex parietal was incised, craniotomy leading andto the dura spontaneous revealed a herniationdrainage of of an the intralesional superior parietal haemorrhage lobule. and The the cortex identificati was incised,on of the leading neoplastic to the tissue, sponta- neouswhich drainagewas soft and of an scarcely intralesional bleeding. haemorrhage A gross total and resection the identification was easily achieved of the neoplastic and an tissue,external which drainage was was soft left and for scarcely 4 days bleeding.postoperatively A gross and total then resection removed. was Total easily blood achieved loss andwas estimated an external to drainagebe approximately was left 200 for cc, 4 daysmainly postoperatively during soft tissue and opening. then removed. Histopatho- Total bloodlogical lossanalysis was estimatedof the specimen to be approximatelywas consistent with 200 cc,WHO mainly grade during III choroid soft tissue plexus opening. carci- Histopathological analysis of the specimen was consistent with WHO grade III choroid noma (Immunophenotype S100: +; CAM 5-2: +; MNF116: +, MIB1 > 20%). The patient was plexus carcinoma (Immunophenotype S100: +; CAM 5-2: +; MNF116: +, MIB1 > 20%). The patient was discharged at 8 days with no neurological sequelae, and was planned for adjuvant chemotherapy according to CPT-SIOP 2009 recommendation (6 cycles al- Brain Sci. 2021, 11, x FOR PEER REVIEW 4 of 8

Brain Sci. 2021, 11, 540 4 of 8

discharged at 8 days with no neurological sequelae, and was planned for adjuvant chem‐ otherapy according to CPT‐SIOP 2009 recommendation (6 cycles alternating Cyclophos‐ phamideternating and Cyclophosphamide Carboplatin). Follow and Carboplatin).‐up at 3 months Follow-up revealed at regular 3 months development revealed regular of the childdevelopment and absence of the of child recurrent and absencedisease ofat MRI recurrent (Figure disease 3). at MRI (Figure3).

Figure 3. ((A)) T1 T1 post post-contrast‐contrast image image pre pre-operative‐operative shows shows a large large enhancing intraventricular intraventricular mass without invasion of the adjacent brain parenchyma. ( B) T1 post post-contrast‐contrast image at 3 3-months‐months follow-upfollow‐up shows absence of recurrence.

3. Discussion 3. Discussion TheThe extent ofof resectionresection is is the the only only prognostic prognostic factor factor influencing influencing the the survival survival of patients of pa‐ tientsaffected affected by CPC by [CPC2,4,5 ].[2,4,5]. The achievement The achievement of a total of a tumortotal tumor removal removal is often is often undermined under‐ minedby their by vascular their vascular nature, responsiblenature, responsible for significant for significant perioperative perioperative morbidity morbidity and mortality and mortalitydue to important due to important blood loss blood in patients loss in patients with a with small a circulatingsmall circulating volume volume [4,6]. [4,6]. In this In thisscenario, scenario, the accomplishmentthe accomplishment of a of preoperative a preoperative reduction reduction of tumor of tumor vascularity vascularity is crucial. is cru‐ cial.The useThe of use neoadjuvant of neoadjuvant chemotherapy chemotherapy has proven has toproven be valid to forbe decreasingvalid for decreasing intraoperative in‐ traoperativeblood loss; nevertheless, blood loss; nevertheless, it requires timeit requires to be effectivetime to be (from effective 2 to (from 5 cycles). 2 to In5 cycles). fact, it Incannot fact, it be cannot used in be cases used of in patients cases of with patients CPT with and symptomsCPT and symptoms of intracranial of intracranial hypertension, hy‐ pertension,requiring urgent requiring surgical urgent treatment surgical [treatment7]. The first [7]. reports The first of reports preoperative of preoperative embolization em‐ bolizationof CPT described of CPT described very limited very success, limited success, serving serving as a deterrent as a deterrent in the in past the decade past decade [4,9]. [4,9].Nevertheless, Nevertheless, preoperative preoperative embolization embolization has proven has proven to be ato safe be procedurea safe procedure to achieve to achievetumor devascularization, tumor devascularization, resulting resulting in a significant in a significant reduction reduction of intraoperative of intraoperative blood loss bloodand improving loss and improving outcomes [outcomes8]. However, [8]. theHowever, procedure the isprocedure still considered is still considered hazardous bothhaz‐ ardousfor the both vascular for the tumor vascular features tumor and features the population and the involved.population CPT involved. are supplied CPT are by sup the‐ pliedanterior by choroidalthe anterior artery choroidal and the artery posterior and choroidal the posterior arteries, choroidal which also arteries, nourish which eloquent also nourishareas. The eloquent cisternal areas. portion The cisternal of the anterior portion choroidal of the anterior artery choroidal supplies artery the optic supplies tract, the opticlateral tract, part the of lateral the geniculate part of the body, geniculate the posterior body, the two-thirds posterior of two the‐thirds posterior of the limb posterior of the limbinternal of the capsule, internal the capsule, globus pallidus, the globus the pallidus, origin of the the origin optic radiations of the optic and radiations the middle and third the middleof the cerebral third of peduncle, the cerebral the peduncle, ventrolateral the ventrolateral thalamus, and thalamus, the mesencephalon. and the mesencephalon. The posterior Thechoroidal posterior arteries, choroidal divided arteries, into medial divided and into lateral medial groups, and supplylateral groups, the subthalamic supply the nucleus, sub‐ thalamicthe midbrain, nucleus, portions the midbrain, of the thalamus, portions including of the thalamus, the medial including geniculate the nucleus, medial geniculate the lateral nucleus,geniculate the nucleus, lateral geniculate the pulvinar nucleus, of the the thalamus, pulvinar and, of the partially, thalamus, the and, medial partially, temporal the medialstructures temporal [12,14 ].structures Moreover, [12,14]. small Moreover, children represent small children another represent important another drawback important due drawbackto their small due andto their tortuous small vessels,and tortuous increasing vessels, the increasing challenge the in challenge cannulating in cannulating the feeding thevessels feeding and vessels the risks and of the vascular risks of dissection vascular dissection and thrombosis and thrombosis [4,9]. Furthermore, [4,9]. Furthermore, despite the hypervascular nature of these tumors, their vessels present very limited dilation. In addition, the younger age of the patients and their low-weight limits the amount of Brain Sci. 2021, 11, 540 5 of 8

contrast medium and poses the problem of radiation dose. Despite modest success in older series [4,9], the literature discloses encouraging results (Supplementary Table S1). The rate of partial and complete embolization in the group of patients with CPT submitted to preoperative embolization was 76.5%, enabling a gross total resection in the vast majority of the patients with limited blood loss, regardless of the degree of embolization. Endovascular procedures were complicated by hemorrhage in 9.4% of the cases [8,15] and stroke in 3.1% [8]; mortality was 0%. Embolization through the anterior choroidal artery represents a technical challenge due to its role in supplying critical motor areas, the relative lack of collaterals, and the unfavorable small caliber of vessels. Despite the abovementioned conditions depicting the anterior choroidal artery as a hostile vessel for endovascular navigation, embolization through it can be performed in safe conditions following some important key-points listed by Trivelatto et al.: (a) The anterior choroidal artery enters into the ventricle, passing the choroidal fissure, giving no more supply to the brain parenchyma. This point is identified as the plexal (or choroidal) point; (b) it is necessary to navigate the microcatheter beyond this landmark, positioning the microcatheter as close as possible to the tumor blush; and (c) it is recommended to inject the embolic agent carefully in order to avoid a potentially harmful reflux [12]. Few considerations have been made regarding other embolic agents used for this purpose, and previous authors have chosen metallic coils, gelatin sponges, cyanoacrylates and ethanol, as highlighted in Supplementary Table S1. Wang et al. reported a 28.6% occurrence of tumor bleeding related to the endovascular procedure, adopting tris-acryl gelatin microspheres. They explained these complications with two possible mechanisms: (a) rupture of some collateral vessels of the lesion, which received an increased blood flow after particles were injected from other residual feeders; and (b) rupture of residual tumor vessels due to an increased pression, originating after a continuous injection of the particles into a wedge catheter in a feeding artery. These considerations raise the concern about the use of particles in intra-axial lesion, whose feeders are more fragile than extra-axial tumor, and when the flow of the proximal feeding arteries is arrested due to a catheter wedged in small tumor feeders, with a caliber matching the size of the microcatheter, or when the tortuous tumor feeders are straightened by the microcatheter [15]. Trivelatto et al. described the first report of a successful Onyx™ embolization of choroid plexus papilloma through the anterior choroidal artery without complications. The choice of this embolic agent was attributed to the low precipitation rate, permitting a deep penetration into the small vessels of the tumor. Moreover, the injection of this material is more controlled, avoiding reflux toward the plexal point by virtue of its non-adhesive properties and good visualization under fluoroscopy. Nevertheless, it requires a prolonged injection time, as well as protracted fluoroscopy and radiation exposure, which could be not negligible in pediatric patients [12,16]. Furthermore, Onyx™ safety is not well established in children because of potential dimethyl sulfoxide toxicity [17]. NBCA is a fast-acting adhesive glue that has long been used in both the adult and pediatric populations [18]; it provides a rapid vascular bed penetration in a flow-directed fashion and, therefore, is especially suited for children. As mentioned above, we highlight a source of potential complication, which is in- sidious due to the specific pathology and populations affected. Indeed, it is otherwise infrequent for neurointerventional radiologists to navigate long segments of an eloquent artery that is only mildly enlarged by the underlying pathology (contrary to AVMs). More- over, since contrast and dose sparing are required for pediatric interventions, it is also advisable to perform only strictly necessary control angiograms. Therefore, a potential absence of flow can be easily overlooked. Our case clearly demonstrates that the rectification of the artery, even using the smallest microcatheters and in the absence of spasm, may be sufficient to completely stop the flow along the whole course of the anterior choroidal artery, even proximally to the plexal point, where eloquent perforators are located (Figure4). It is our opinion that the time from entrance to exit in the anterior choroidal artery should be Brain Sci. 2021, 11, x FOR PEER REVIEW 6 of 8

Brain Sci. 2021, 11, 540 6 of 8 even proximally to the plexal point, where eloquent perforators are located (Figure 4). It is our opinion that the time from entrance to exit in the anterior choroidal artery should be monitored and regarded as a potential ‘occlusion time’ in this specific subset of pa- monitoredtients. In fact, and it regardedmay explain as a some potential of the ‘occlusion complications time’ inreported this speciﬁc in recent subset literature of patients. and it In fact,should it may be minimized, explain some not of only the complicationsby the expertis reportede, but also in recent by the literature choice of and fast it shouldembolic be minimized,agents. not only by the expertise, but also by the choice of fast embolic agents.

FigureFigure 4.4. UpperUpper quadrantsquadrants display frontal views while while lower lower quadrants quadrants display display corresponding corresponding lateral lateral views. views. Shifted Shifted lines lines areare intended,intended, asas inin FigureFigure1 1,, to to help help the the reader reader inin localizinglocalizing thethe intendedintended segments.segments. (AA) )Initial Initial angiography: angiography: segment segment 1 1is is thethe cisternal cisternal portionportion ofof thethe anterioranterior choroidal artery; the the asteri asterisksk * * corresponds corresponds to to the the plexal plexal point point that that marks marks the the entrance entrance in the ventricle; segment 2 is the intraventricular segment which, in this case, is tortuous and ventrally dislocated by the in the ventricle; segment 2 is the intraventricular segment which, in this case, is tortuous and ventrally dislocated by the tumor; segment 3 is the tumoral segment of the artery running along the surface of the tumor; segment 4 is the tumoral tumor; segment 3 is the tumoral segment of the artery running along the surface of the tumor; segment 4 is the tumoral pedicle which penetrates the mass giving rise to the tumoral blush. (B) The black solid line depicts the arterial course pediclestretched which by the penetrates microcatheter, the mass while giving the whit risee dashed to the tumoralline depicts blush. its anatomical (B) The black course. solid (C) line Panoramic depicts angiography the arterial coursewith stretchedthe microcatheter by the microcatheter, inside the anterior while thechoroi whitedal dashedartery; note line depictsthat no itsflow anatomical is seen in course. the distal (C )part Panoramic of the cisternal angiography segment with theof the microcatheter anterior choroidal inside the artery, anterior and choroidaleven the proximal artery; note part that is barely no flow visible. is seen (D in) Final the distal angiography part of the shows cisternal flow segment restored of theto the anterior cisternal choroidal and intr artery,aventricular and even segments. the proximal part is barely visible. (D) Final angiography shows flow restored to the cisternal and intraventricular segments. 4. Conclusions 4. ConclusionsPrevious medical literature remains inconclusive about the preferred embolic agent to bePrevious used in preoperative medical literature embolization remains of inconclusive pediatric CPTs, about with the preferredmodern literature embolic agentfavor- to being used liquid in embolic preoperative agents. embolization Given the rarity of pediatric of the pathology, CPTs, with it modernis unlikely literature that definitive favoring liquidevidence embolic will be agents.available Given any time the soon. rarity Neve of thertheless, pathology, our case it suggests is unlikely that that even definitive simple evidencenavigation will of the be artery available may anycause time temporary soon. Nevertheless,occlusion. Since our prolonged case suggests occlusion that of evenin- simpletracranial navigation arteries may of the cause artery infarction, may cause all temporaryefforts should occlusion. be addressed Since prolonged to reduce occlusionnaviga- oftion intracranial and embolization arteries timings, may cause thus infarction,favoring fast all embolic efforts agents, should such be addressed as NBCA. to reduce navigationAlthough and limited embolization to a single timings, observation, thus favoring temporary fast embolic arterial agents, occlusion such should as NBCA. be soughtAlthough and considered limited toa ‘red a single flag’ observation,by neurointerventionalists, temporary arterial who occlusionshould adapt should their be soughttechniques and accordingly. considered a ‘red flag’ by neurointerventionalists, who should adapt their techniques accordingly.

Supplementary Materials: The following are available online at https://www.mdpi.com/article/ 10.3390/brainsci11050540/s1, Table S1: Review of patients with choroid plexus tumors submitted to embolization. Brain Sci. 2021, 11, 540 7 of 8

Author Contributions: V.B. and J.D.G. wrote the first draft of the manuscript; G.C. and I.D. wrote sections of the manuscript. A.L., L.D. and F.C. contributed to manuscript revision, read, and approved the submitted version. All authors have read and agreed to the published version of the manuscript. Funding: No funding. Informed Consent Statement: Written informed consent has been obtained from the parents of the patient to publish this paper after anonymization of data and images. Data Availability Statement: The data presented in this study are available on request from the corresponding author. Conflicts of Interest: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Ethical Approval: The work is in accordance with the declaration of Helsinki and its later amend- ments, for as far as it was applicable.

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