Hemorrhagic Complication in Surgical Resection for Massive Plexiform Neurofibroma in Body Trunk: The Flow‐Void Sign as a Predictor and Preoperative Embolization as Prevention

BACKGROUND: Plexiform neurofibromas (PNs) are highly vascularized and potentially malignant tumors. Surgical resection of a PN can be complicated by perioperative hemorrhagic events (PHE), including excessive intraoperative blood loss and postoperative hematoma at the surgical site. This study aimed to evaluate the predictive factors of PHE and the usefulness of preoperative embolization for PN. MATERIALS AND METHODS: Consecutive surgical resections of 24 massive PNs in the body trunk with a maximum diameter > 5 cm in 22 patients between January 2015 and December 2020 were reviewed. Patient demographics, laboratory analyses, MRI findings, preoperative transcatheter arterial embolization (TAE), and pathological findings were evaluated between PNs with and without PHE, which consists of intraoperative blood loss over 15% of their estimated total blood volume and/or postoperative hematoma requiring surgical intervention or blood transfusion. RESULTS: PHE was observed in 7 out of 24 PNs (29.2%), with 5 events of excessive intraoperative bleeding and 2 postoperative hematomas. The PHE group (n = 7) showed a significantly higher flow-void effect inside the tumor on preoperative MRI than the non-PHE group (n = 17) (P = 0.0186). Preoperative TAE was not associated with PHE occurrence for the 24 PNs; however, it significantly reduced the PHE risk by 12 PNs with a flow-void sign (P = 0.00126). Other characteristics showed no significant differences between groups. CONCLUSION: The flow-void sign on MRI can be the only predictive factor of PHE in surgical resection for massive PNs in the body trunk. Preoperative TAE can reduce the PHE risk for PNs with a flow-void sign.