Jugular vein invasion rate in surgically operated paragangliomas: a multimodality retrospective study

Friend or Foe? Preoperative Embolization in Jugular Paraganglioma Surgery-A Systematic Review and Meta-Analysis

BACKGROUND

Jugular paragangliomas are highly vascularized tumors that can grow in challenging neurovascular compartments and are particularly challenging to resect. There is still no consensus whether preoperative embolization should be employed to minimize intraoperative morbidity.

METHODS

A systematic review and meta-analysis was conducted by searching PubMed, Web of Science, and Embase databases for key terms including "embolization," "jugular paragangliomas," and "surgery."

RESULTS

This review included 25 studies with 706 patients and 475 (67%) preoperative embolizations. Polyvinyl alcohol particles were the most common embolic agent (97.8% of all patients who underwent embolization). Complication rate of embolization was 1% (95% confidence interval [CI]: 0%, 2%). Preoperative embolization was significantly associated with less intraoperative estimated blood loss (mean difference of -7.92 dL [95% CI: -9.31 dL, -6.53 dL]), shorter operating room times (mean difference of -55.24 minutes [95% CI: -77.10 minutes, -33.39 minutes]), and less overall tumor recurrence (odds ratio = 0.23 [95% CI: 0.06, 0.91]) compared with resective surgery alone. Preoperative embolization had no impact on the development of postoperative new cranial nerve deficits not associated with embolization (odds ratio = 1.17 [95% CI: 0.47, 2.91]) and achievement of gross total resection (odds ratio = 1.92 [95% CI: 0.67, 5.53]).

CONCLUSIONS

Preoperative embolization may provide surgical efficiency with faster surgical times and less bleeding and safety with diminished overall recurrence via safe embolization with minimal risks. These results must be considered taking into account the nonrandomness of studies.

A rare case of carotid body tumor associated with near complete cerebral sinus thrombosis and idiopathic intracranial hypertension. Management strategy and review of the literature

Background

Carotid body tumors (CBTs) are rare hypervascular lesions with critical location which makes them very challenging to treat. In rare occasions, compression of the jugular vein from the tumor mass could predispose to progressive thrombosis of intracranial venous sinuses. The latter consequently leads to intracranial hypertension (pseudotumor cerebri) with the accompanying danger to the vision. Herewith, we present our management strategy for this rare presentation of CBTs.

Case Description

A 38-year-old woman, with no medical history, was admitted in the emergency unit with acute onset of headache, dizziness, and vomiting. On the diagnostic imaging studies (CT venography and MRI) a near total occlusion of all cerebral venous sinuses and a large CBT (Shambin Type II) were diagnosed. Initially, the patient was treated with anticoagulants for the thrombosis and with lumbo-peritoneal (LP) shunt for the management of pseudotumor cerebri. At a second stage, after resolution of the cerebral sinus thrombosis, the CBT was completely resected under electrophysiological monitoring, without preoperative embolization. At 1-year follow-up, the patient is neurologically intact with functioning LP shunt, patent cerebral venous sinuses, without tumor recurrence.

Conclusion

We present a rare case of CBT with intracranial complications, which was managed successfully by staged treatment. Careful study of the preoperative radiological and laboratory data, thorough preoperative planning of the tridimensional lesion anatomy, as well as meticulous microsurgical technique under intraoperative electrophysiological monitoring was essential for the successful outcome of the case.

Preoperative embolization of jugular paraganglioma tumors using particles is safe and effective

BACKGROUND

Jugular paragangliomas represent a surgical challenge due to their vascularity and proximity to vital neurovascular structures. Preoperative embolization aids in reducing intraoperative blood loss, transfusion requirements, and improves surgical visualization. Several embolization agents have been used.

OBJECTIVE

The aim of this study is to evaluate the safety and efficacy of PVA in pre-operative embolization of jugular paragangliomas.

METHODS

A retrospective review of all patients who underwent jugular paraganglioma resection with pre-operative embolization between 2000 and 2020 was performed. Pre-operative data including baseline patient and tumor characteristics were documented. Outcomes of preoperative embolization including extent of devascularization and post-embolization complications were recorded. Early and long-term postoperative outcomes were reported.

RESULTS

Twenty-nine patients met study criteria with a median age of 38 years. Average tumor size was 3.4±1.8 cm. The most commonly encountered arterial feeder was the ascending pharyngeal artery followed by the posterior auricular artery. More than 50% reduction in tumor blush was achieved in 25 patients (86.2%). None of the patients experienced new or worsening cranial neuropathy following embolization. Gross total or Near total resection was achieved in 13 patients (44.8%). A STR or NTR was chosen in these patients to preserve cranial nerve function or large vessel integrity. Average intraoperative estimated blood loss was 888 ml, 9 patients (31%) required intra-operative transfusion of blood products. Extent of resection and post-operative complications did not correlate with extent of devascularization.

CONCLUSION

Pre-operative embolization of jugular paraganglioma tumors with PVA particles is an effective strategy with a high safety profile.

Microsurgical management of primary jugular foramen meningiomas: a series of 22 cases and review of the literature

This study summarized clinical manifestations, surgical management, histological grading, and long-term outcome of jugular foramen meningiomas (JFMs). Retrospective study was performed in 22 consecutive patients with primary JFMs from January 2004 to October 2010, enrolling 10 men and 12 women with average age of 39.4 (14-57 years). The most common initial symptom is hearing disorder, followed by lower cranial nerve dysfunctions. The tumor was classified into type I (intracranial) in 1, type II (intracranial) in 15, type IV (intracranial-extracranial) in 6, and none type III (extracranial). Surgical approaches mainly included retrosigmoid in 7, far lateral in 10, and juxtacondylar in 5, with some variations. The gross total resection was achieved in 15 cases and subtotal resection in 7. Fourteen patients (63.6 %) developed new or worse neurological deficits immediately after operation, of whom 11 (78.6 %) got alleviation. Postoperatively, keeping airway patency and prevention from aspiration pneumonia is very important. Nasotracheal intubation is much more tolerated than orotracheal intubation for postoperative patient management. WHO grade 2 was found in four cases (18.2 %) and grade 3 in one. During the average time of follow-up in 83.2 months, only one (grade 3) died of tumor regrowth 20 months after surgery and radiosurgery. Five of 17 patients of grade 1 developed tumor regrowth. Radiosurgery provides a good tumor control for tumor regrowth in grade 1, or postoperative grade 2 tumor. In conclusion, JFMs has a favorable long-term overall survival; however, neurological preservation is still challenging, especially low cranial nerves.