Case Report: Preoperative embolization for a large intracranial pheochromocytoma metastasis: a novel approach to minimize intraoperative risk.

Intracranial metastasis from pheochromocytoma is exceedingly rare, with fewer than 100 cases reported in the literature. While preoperative embolization is established for extracranial pheochromocytoma metastases, no prior reports describe its use in the intracranial setting. We present a 65-year-old woman with known metastatic pheochromocytoma who developed progressive right hemiparesis and dysarthria from a 7.8 × 6.0 cm hypervascular left parietal mass with multi-compartmental involvement and calvarial erosion, representing one of the largest and most anatomically complex intracranial pheochromocytoma metastases reported. Markedly elevated plasma metanephrines confirmed functional disease, and multidisciplinary planning identified dual risks of catastrophic hemorrhage and catecholamine-mediated hemodynamic instability. We therefore performed superselective transarterial embolization prior to resection, the first reported use of this technique for an intracranial pheochromocytoma metastasis, achieving near-complete devascularization. Gross total resection was accomplished without hypertensive crisis, with postoperative normalization of catecholamines and significant neurological improvement. This case demonstrates that preoperative embolization offers a dual benefit, reducing intraoperative hemorrhage and attenuating catecholamine release, and should be considered for all functional intracranial pheochromocytoma metastases regardless of tumor size or degree of vascularity.