a 52-year - old male presented with a swelling of the right side of the neck of four months duration . the clinical examination was unremarkable except for the swelling . an mri of the head and neck showed features that were typical of carotid body tumor . the high vascularity of the tumor , along with features of arteriovenous shunting , was evident on the angiography ( figs . the tumor was supplied by feeders from the ipsilateral external carotid artery ( eca ) , internal carotid artery ( ica ) and vertebral artery ( va ) . bilateral common femoral punctures were performed and 7 fr vascular sheaths ( avanti+ , cordis , miami lakes , fl ) were placed . one femoral access was used for balloon occlusion of the right carotid while the second access was used for performing controlled angiography . since transarterial embolization through the right ascending pharyngeal artery failed to decrease the tumor 's vascularity and the feeders were small in size and multiple in number , a decision was made to inject glue percutaneously into the tumor . since there was a direct feeder from the right cervical ica ( fig . 1b ) , a 6 fr berman angiographic balloon catheter ( arrow international , pa ) was used to occlude the ica across the origin of the feeder ( fig . glue was injected at three separate sites and more than 90% of the tumor was finally devascularized ( figs . the intracranial circulation was intact , the same as was seen on the preprocedure angiogram ( figs . care was taken to avoid palpation of the tumor site in the postoperative period . however , approximately 12 hours after the procedure , he developed left - sided hemiparesis . a brain ct scan was performed immediately and this showed multiple small fragments of glue located intracranially with non - hemorrhagic infarction of the right cerebral hemisphere ( fig . 2c ) . digital subtraction angiography performed at this time showed partial recanalization of the tumor vascular bed . there was absence of any filling of the rolandic and parietal branches of the right middle cerebral artery ( fig . paragangliomas of the carotid bifurcation ( carotid body tumors ) are characterized by high vascularity and arteriovenous shunting ( 3 , 4 ) . preoperative embolization is often performed to reduce the vascularity of these tumors so as to avoid any significant blood loss during surgery ( 4 ) . embolization of a carotid body tumor and other hypervascular tumors of the head and neck is usually performed through the transarterial route with using particulate agents ( 1 - 3 ) . although the ascending pharyngeal artery is considered to be the main feeder to a carotid body tumor , this type of tumor often derives its blood supply from multiple feeders of the eca . each of these feeders seems to supply individual compartments of a multicompartmental vascular bed of the tumor ( 3 ) . the tortuous course and smaller caliber of some of the feeders , the proximity of the feeders to the carotid bifurcation , the tortuous carotids and the presence of carotid bifurcation atherosclerotic plaques may prevent effective transarterial embolization of carotid body tumors ( 4 , 6 ) . further recruitment of a blood supply from the internal carotid artery and vertebral artery may preclude embolization through the transarterial route ( 1 , 2 ) . direct embolization provides an easy access to a hypervascular tumor with a higher chance of achieving complete devascularization ( 1 , 2 , 4 ) . were the first to use this technique to devascularize tumors of the head and neck ( 1 ) . while percutaneous tumor embolization offers an easy , safe access in the majority of the cases , it may occasionally lead to complications , the most serious being migration of glue into the intracranial circulation ( 1 , 2 , 4 , 9 ) . migration of glue into the intracranial circulation may occur through an eca - ica communication , or it may occur in a retrograde fashion from the eca into the ica or through the branches arising from the internal carotid arteries or vertebral arteries . in a series of 65 cases of hypervascular tumors of the head and neck that were treated with glue , casasco et al . had two complications related to migration of glue into the arterial side during embolization of juvenile nasopharyngeal angiofibroma ( 9 ) . in one case , glue embolized to the middle cerebral artery and in the other it embolized to the ophthalmic artery . in both cases , migration of glue occurred towards the end of the procedure when the glue was being injected . in order to prevent this complication the authors emphasized performing an angiogram , as well as a parenchymogram , in at least two planes prior to embolization . further , they recommended using a higher concentration of glue in the range of 50% to promote faster polymerization ( 9 ) . also , a non - detachable occlusal balloon may help prevent glue migration during embolization of carotid body tumors and juvenile angiofibromas . using an occlusal balloon is recommended whenever there is a direct supply from the internal carotid artery or the vertebral artery ( 9 ) . we ensured that no glue migrated during the procedure by using 50% glue , as well as occlusal balloon , to occlude the ica across the origin of the feeder from the ica . further , the occlusal balloon was kept inflated for at least 10 minutes after injecting glue into each sector of the tumor to allow complete polymerization . controlled injection of glue ensured that no glue migrated during the procedure and consequently , we could observe filling of all the branches of the right anterior and middle cerebral arteries , as well as the ophthalmic artery . the intact neurological status of the patient for several hours after the procedure further ruled out migration of glue during the procedure . in the absence of a demonstrable glue cast in the eca branches at the base of the skull , it is unlikely that the glue migrated through a dangerous eca - ica communication in our patient . it is highly likely that a polymerized glue cast in the tumor must have got fragmented several hours later and then some of it embolized into the intracranial circulation during the patient 's postoperative period . migration of glue is presumed to happen only when the glue is in its liquid state during injection ( 1 ) . occurrence of stroke several hours later in our case illustrates that even polymerized glue may embolize into the intracranial circulation .
a 52-year - old male with right carotid body tumor underwent direct percutaneous glue ( n - butylcyanoacrylate [ nbca ] ) embolization . 
 several hours later , he developed left hemiparesis from embolization of the polymerized glue cast . 
 migration of glue during percutaneous tumor embolization is presumed to occur only in the liquid state , which may lead to stroke or cranial nerve deficits . to the best of our knowledge , 
 this is the first report of delayed glue embolization from a treated hypervascular tumor of the head and neck .