Paragangliomas of the jugular bulb and carotid body: MR imaging with short sequences and Gd-DTPA enhancement

Diffuse subarachnoid hemorrhage following ventriculo-peritoneal shunt insertion for acute obstructive hydrocephalus from large glomus jugulare tumor: case report

Background

Glomus jugulare tumors (GJTs) are rare intra-cranial tumors. Commonly, these lesions present with cranial nerve palsies, headaches, and hydrocephalus. Rarely, GJTs present with spontaneous subarachnoid hemorrhage. However, there has never been a report of diffuse subarachnoid hemorrhage following ventriculoperitoneal shunt insertion in a patient who developed hydrocephalus secondary to any brain tumor in general or glomus jugulare tumors in particular.

Observation

The authors presented an extremely rare complication of diffuse subarachnoid hemorrhage following the insertion of a ventriculoperitoneal shunt (VPS) in a 61-year-old female patient who was diagnosed to have both clinical and radiologic features of acute obstructive hydrocephalus secondary to a highly vascular huge glomus jugulare tumor.

Conclusion

Subarachnoid hemorrhage following ventriculoperitoneal shunt insertion for hydrocephalus caused by a mass lesion is an extremely rare complication. Preoperative CT angiography should be strongly considered to look for the associated vascular malformations in extremely vascularized mass lesions. Given the not ubiquitous availability of all therapeutic options for GJTs, especially in low and middle income settings contributes for the poor outcome of GJTs and it fosters a global neurosurgery agenda.

Neurosurgical Causes of Pulsatile Tinnitus: Contemporary Update

Traditionally in the domain of the otolaryngologist, pulsatile tinnitus (PT) has become increasingly relevant to neurosurgeons. PT may prove to be a harbinger of life-threatening pathology; however, often, it is a marker of a more benign process. Irrespectively, the neurosurgeon should be familiar with the many potential etiologies of this unique and challenging patient population. In this review, we discuss the myriad causes of PT, categorized by pulse-phase rhythmicity.

Stereotactic radiosurgery for hypervascular intracranial tumors

OBJECTIVE

To evaluate the safety and efficacy of SRS treatment of central neurocytomas (CNCs), cavernous sinus hemangiomas (CSHs), and glomus tumors (GTs); and to compare upfront stereotactic radiosurgery (SRS) and adjuvant SRS in the treatment of these hypervascular tumors.

METHODS

This was a retrospective review of consecutive CNCs, CSHs, and GTs treated with SRS between 1993 and 2017. Tumor response was categorized based on volumetric analysis on magnetic resonance imaging: (1) tumor regression [> 10% decrease in tumor volume (TV)]; (2) stable tumor (≤ 10% change in TV); or (3) tumor progression (> 10% increase in TV).

RESULTS

Sixty hypervascular tumors (CNC: 28; CSH: 16; GT: 16) underwent SRS between 1993 and 2017. Margin doses were 13 Gy, 12 Gy, and 14 Gy for CNCs, CSHs, and GTs, respectively. Tumor regression was observed in 54 tumors (90%) with initial SRS after a median follow-up of 82 months. Relative reductions in TVs for CNCs were 38%, 52%, and 73% at 12, 24, and 48 months, respectively. Relative reductions in TVs for CSHs were 51%, 68%, and 88% at 12, 24, and 48 months, respectively. Relative reductions in TVs for GTs were 22%, 31%, and 47% at 12, 24, and 48 months, respectively. Upfront SRS was performed in 26 patients (43%). No difference in relative TV reductions were found between upfront and adjuvant SRS. Adverse radiation effects were observed in five patients. No mortality was encountered.

CONCLUSION

SRS for hypervascular tumors is associated with high rates of tumor regression with low risk of complications. No significant difference in rates of relative TV reduction were found between upfront and adjuvant SRS. Hence, upfront SRS may be considered in select patients.

Thoracic Castleman disease: computed tomography and clinical findings

AIM

The objective of this study was to evaluate the clinicoradiological findings of thoracic Castleman disease.

METHODS

The study included 34 patients (22 male and 12 female patients; mean age, 32 [SD, 18.1] years) with thoracic Castleman disease. Clinicoradiological findings of the 34 patients were analyzed. Regarding computed tomography findings, lesion number, location, degree of enhancement (moderate, >20 Hounsfield units than back muscle enhancement; high, >40 Hounsfield units), and associated findings were recorded.

RESULTS

Of 34 patients, hyaline-vascular type (HVT) was found in 27 patients (79%), plasma cell type (PCT) in 5 patients (15%), and mixed type (6%) in 2 patients. In HVTs (n = 27), lesions were found, in decreasing order, in the lower neck (n = 9, 33%), pulmonary hilum (n = 6, 22%), and the upper paratracheal area (n = 4, 15%). Ten (37%) of 27 HVT patients had symptoms, whereas all (100%) with PCT had generalized symptoms. In 26 (96%) of 27 HVT patients, disease was unicentric, whereas it was multicentric in all PCT patients. Moderate to high degree of lesion enhancement was seen in 22 (92%) of 24 HVT patients and 4 (80%) of 5 PCT patients. Feeding vessels or draining veins were identified in 12 (44%) of 27 HVT patients and 2 (40%) of 5 PCT patients. The diseases were cured with surgical removal in HVT, whereas they showed variable prognosis in PCT.

CONCLUSIONS

Irrespective of subtypes, Castleman disease is characterized radiologically by unicentric or multicentric enhancing lymph node enlargement; in HVT, they show good prognosis after surgical treatment, but in PCT, they show variable prognosis.

Laryngeal paraganglioma: a rare clinical entity managed by supraselective embolization and lateral pharygotomy

Laryngeal paragangliomas are benign slow growing tumors with symptoms resembling squamous cell carcinoma. Hoarseness or dysphasia are the commonest presenting symptoms and usually it presents as an submucosal mass on laryngoscopy. Ninety percentage of these tumors occur in the supraglottic larynx and the rest in the glottis and the subglottic region. Functional activity is seen in a few (2.9 %), none are associated with paraneoplastic syndromes. A 35-year-old male presented to us with hoarseness of voice since 4 months duration. Contrast arteriography demonstrated that the left superior thyroid artery supplied >80 % of the blood supply to the laryngeal mass. Supraselective embolization was done from the right femorals under local anaesthesia and sedation which was uneventfull. The tumor was excised from lateral pharyngotomy approach with an partial laryngectomy procedure. Microscopy and immune-histochemistry confirmed it to be paraganglioma. Complete surgical resection or partial laryngectomy with meticulous dissection of surrounding tissues and preservation of neurovascular structures gives an excellent prognosis as far as oncological clearance is concerned. Malignant paragangliomas of the larynx are rare and an major meta-analysis is necessary to provide a true biological behaviour of this tumor.

Role of duplex ultrasound in the diagnosis and assessment of carotid body tumour: A literature review

Carotid body tumour is a rare disease, a slow growing highly vascular tumour of the carotid body tissue and the most common type of the paraganglioma. This article reviews the pathological, clinical and ultrasound features of carotid body tumours and discusses the role of duplex ultrasound in the diagnosis and assessment of this condition. The initial presentation of carotid body tumour is usually a painless palpable neck mass. Some patients may experience local pressure symptoms as well as symptoms from vagal, hypoglossal and cervical sympathetic nerve impingement. Percutaneous needle aspiration or incisional biopsy is contraindicated for the diagnosis of carotid body tumours. Duplex ultrasound, computed tomography scan, magnetic resonance scan and angiography are commonly used diagnostic tools for this condition. Complete surgical excision of carotid body tumour is the treatment of choice as radiation therapy and chemotherapy are unsatisfactory. Based on vascularity and location, duplex ultrasound scan is able to diagnose carotid body tumour and differentiate it from many other masses in the neck. This non-invasive, inexpensive and readily available diagnostic tool can be used as a first-line imaging modality for the diagnosis and assessment of carotid body tumours.

Differential diagnosis of jugular foramen lesions

The anatomy of the jugular foramen is complex. It contains the lower cranial nerves and major vascular structures. Tumors that develop within it, or extend into it, provide significant diagnostic and surgical challenges. In this article, we describe the anatomy of the jugular foramen and outline an imaging protocol that can differentiate between lesions, thereby aiding diagnosis and facilitating management.

Carotid body tumors: objective criteria to predict the Shamblin group on MR imaging

BACKGROUND AND PURPOSE

MR imaging is an established method for diagnosis and surgical planning of carotid body tumors (CBTs). However no studies have elaborated preoperative objective criteria to predict the Shamblin (surgical) classification of CBTs, an important predictor of vascular morbidity. The purpose of this study was to establish criteria to accurately predict the Shamblin group on preoperative MR imaging for a uniform reporting system.

MATERIALS AND METHODS

MR images of 9 CBTs in 8 consecutive patients who underwent surgery between 2004 and 2007 were reviewed at a tertiary cancer hospital. The surgical records were blinded to the radiologists. A radiologic classification into 3 types (I, II, and III) based on the maximum degree of circumferential contact of the tumor with the internal carotid artery (ICA) was attempted and correlated with the Shamblin group in surgical records.

RESULTS

There were 5 type III, 3 type II, and 1 type I tumors. The type I tumor had an ICA maximum circumference of contact less than or equal to 180 degrees , type II tumors had more than 180 degrees and less than 270 degrees , and type III tumors had a maximum circumference of contact of 270 degrees of more. MR imaging accurately predicted the Shamblin group in 8 (100%) of 8 operated tumors. Tumor size and Shamblin group did not have a uniformly predictable relation.

CONCLUSIONS

Shamblin group can be predicted preoperatively on MR imaging, and the maximum degree of circumferential contact of the CBT with the ICA on axial images is the criterion to predict the Shamblin group.

Imaging and management of head and neck paragangliomas

Paragangliomas of the head and neck are highly vascular lesions originating from paraganglionic tissue located at the carotid bifurcation (carotid body tumors), along the vagus nerve (vagal paragangliomas), and in the jugular fossa and tympanic cavity (jugulotympanic paragangliomas). Diagnostic imaging can be considered in two clinical situations: (1) patients who present with clinical symptoms suggestive of a paraganglioma, and (2) individuals from families with hereditary paragangliomas. It is not only necessary to detect and characterize the lesion, but also to study the presence of multiplicity. For these purposes, MR imaging, and especially 3D TOF MRA, is the modality of choice. CT scanning is especially useful to show destruction of the temporal bone. Angiography in combination with embolization will mainly be used prior to surgical resection, but can also be used for diagnostic purposes when the diagnosis is not yet clear. Many parameters play a role in the decision to treat of which multifocality and impairment of cranial nerves are the most important. The primary therapeutic option for paragangliomas is complete excision of tumor with preservation of vital neurovascular structures. Resection however, should be balanced against a more conservative "wait and scan" policy or palliative treatments such as radiotherapy.

Management of paragangliomas. Clinical and angiographic aspects

SUMMARY

Head and neck paragangliomas are highly vascular tumors with variable clinical behavior. The goal of this paper is to determine specific clinical and radiological findings and extract from these findings a treatment algorithm. Twenty-three patients with paragangliomas were referred from different surgical centers for angiography and pre-operative embolization. Clinical records were analyzed retrospectively, and focused on impairment of cranial nerves. Angiographic features of paragangliomas, such as arterial supply, tumor flow characteristics, and venous drainage, were evaluated to find characteristic angioarchitectural patterns. All but one patient presented with a single tumor. All eight jugular and four of five vagal paragangliomas caused a lower cranial nerve deficit. Tympanic paragangliomas presented with hearing loss and tinnitus. The ascending pharyngeal artery was the main feeder and contributed to the supply in every tumor. Jugular and vagal paragangliomas typically compromise the patency of the jugular vein with resulting antegrade or retrograde flow through collateral venous systems. Surgical resection of vagal and jugular paragangliomas was especially performed when unifocal paragangliomas were present. In all of these patients, the tumor caused a cranial nerve deficit. The supply from an enlarged ascending pharyngeal artery is typical for paragangliomas. The venous drainage pattern of jugular and vagal paragangliomas allows differentiation from other vascular lesions at the skull base.

Radiographic evaluation and assessment of paragangliomas

Radiographic imaging plays an important role in the diagnosis and treatment of paragangliomas. Diagnosis and treatment should be performed as a team effort, with all the involved disciplines working together to provide the best possible individualized work-up and treatment plan for the patient.

Sympathetic paraganglioma as an unusual cause of Horner's syndrome

BACKGROUND

Paragangliomas are rare tumors arising from paraganglionic tissue of neural crest origin. They are present in any location where autonomic ganglia are found. The most common location in the head and neck is the carotid body, followed by the jugular bulb and vagus nerve.

METHODS

A 30-year-old woman with a slowly growing left neck mass, aniscoria, and left eyelid ptosis was found to have a vascular tumor consistent with a paraganglioma arising near the left carotid bifurcation. After preoperative embolization, the patient underwent resection of the tumor.

RESULTS

The tumor was found to be arising from the left sympathetic trunk and did not involve any other surrounding structures. Histopathologic analysis revealed the typical findings of a paraganglioma.

CONCLUSIONS

Sympathetic paragangliomas are exceedingly rare tumors in the head and neck and should be considered in the differential diagnosis when clinical and radiographic evidence suggest a paraganglioma. The presentation is typically a slow-growing neck mass with the presence of an ipsilateral Horner's syndrome.

From the archives of the AFIP. Paragangliomas of the head and neck: radiologic-pathologic correlation. Armed Forces Institute of Pathology

Paragangliomas of the head and neck are ubiquitous in their distribution, originating from the paraganglia or glomus cells within the carotid body, vagal nerve, middle ear, jugular foramen, and numerous other locations. The typical patient is middle-aged and presents late in the course of the disease, with a painless slow-growing mass. Clinical manifestations include hoarseness of voice, lower cranial nerve palsies, pulsatile tinnitus, and other neuro-otologic symptoms. The overall prognosis of patients with a cervical paraganglioma is favorable, whereas its temporal bone counterpart often results in recurrence, residual tumor, and neurovascular compromise when in the advanced stage. Pathologic examination reveals a characteristic biphenotypic cell line, composed of chief cells and sustentacular cells with a peripheral fibrovascular stromal layer that are organized into a whorled pattern ("zellballen"). Imaging hallmarks of paragangliomas of the head and neck include an enhancing soft-tissue mass in the carotid space, jugular foramen, or tympanic cavity at computed tomography; a salt-and-pepper appearance at standard spin-echo magnetic resonance imaging; and an intense blush at angiography. Imaging studies depict the location and extent of tumor involvement, help determine the surgical approach, and help predict operative morbidity and mortality. Surgical treatment is definitive. Radiation treatment is included as a palliative adjunct for the exceptional paraganglioma not amenable to surgery.

Management of the internal carotid artery during carotid body tumor surgery

Patients with carotid body tumors require accurate preoperative assessment of vessel involvement and the probable impact of interrupting blood flow through the internal carotid artery. Recent developments in imaging, methods of measuring cerebral blood flow, balloon occlusion testing, and techniques to maintain vascular flow when a graft is required have improved the surgeon's ability to completely resect these tumors with reduced complications. We discuss these methods with respect to our review of 20 carotid body tumors in 18 patients. Twenty-five percent of patients were misdiagnosed, and in four patients injury to the vessel wall required appropriate surgical intervention.

Magnetic resonance imaging or metaiodobenzylguanidine scintigraphy for the demonstration of paragangliomas? Correlations and disparities

Paragangliomas are tumours arising from paraganglionic tissue dispersed from the base of the skull to the pelvic diaphragm. These tumours produce symptoms by secreting catecholamines (functioning tumours) or by local tumour expansion. They can be part of several hereditary disorders. The introduction of magnetic resonance (MR) imaging and metaiodobenzylguanidine (MIBG) scintigraphy has provided new insights into paragangliomas and has tremendously changed the topographic diagnosis of paragangliomas. Both techniques have proven to be adequate in localising paragangliomas. In this report, the performance of these two noninvasive imaging methods in the examination of paragangliomas is compared and the merits and deficits of the two techniques are discussed. Both techniques produce comparable results in the detection of functioning paragangliomas. MR imaging, however, also demonstrates tumours that do not take up MIBG. MR imaging does not involve the use of ionising radiation and is not hampered by medication. Moreover, MR imaging has a higher spatial resolution. Because of these merits it is concluded that for demonstration of paragangliomas, whole-body MR imaging is the preferred and initial method of investigation. MIBG scintigraphy, on the other hand, continues to be a reliable method for non-invasive detection of functioning paragangliomas. At present it is clearly faster in whole-body imaging than MRI and it is definitely patient-friendly (no claustrophobia). It could be reserved for cases where a strong suspicion of a functioning paraganglioma persists, despite normal MR imaging findings, and for cases where doubt exists about the functional activity of one or more multicentric tumours. MIBG scintigraphy must be used in the evaluation of patients referred for iodine-131 MIBG treatment.

Fine-needle aspiration of six carotid body paragangliomas

We report six carotid body paragangliomas diagnosed by fine-needle aspiration (FNA) in five patients. A total of eight aspirations were performed. The cytologic findings are characteristic: hemorrhagic background, hypo- to hypercellular smears (depending on the skill of the aspirator) with cells having delicate, ill-defined, vacuolated cytoplasm, pleomorphic nuclei with distinct nucleoli, rare intranuclear cytoplasmic inclusions, and prominent rosette formation. No complications arose in any of the eight aspirations. FNA is a safe, accurate means of diagnosing carotid body paragangliomas. It can provide essential information for treatment planning and patient management.

MRI screening of kindred at risk of developing paragangliomas: support for genomic imprinting in hereditary glomus tumours

Paragangliomas of the head and neck (glomus tumours) can occur in a hereditary pattern and may be hormonally active as well as being associated with paragangliomas elsewhere. A number of these tumours may be present without symptoms. To detect the presence of subclinical paragangliomas we screened 83 members of a family at risk of developing hereditary paragangliomas using whole body MRI and urinary catecholamine testing. In eight previously diagnosed members, eight known glomus tumours of which one functioning, and two unknown glomus tumours and one unknown pheochromocytoma were present. Six unsuspected members showed ten glomus tumours and one pheochromocytoma. It has been suggested that the manifestation of hereditary glomus tumours is determined by the sex of the transmitting parent. There were no tumours in the descendants of female gene carriers. Comparing the likelihood of inheritance with genomic imprinting versus inheritance without genomic imprinting we found an odds ratio of 23375 in favour of genomic imprinting.

Facial nerve neuromas: MR imaging. Report of four cases

Four cases of facial nerve neuroma were evaluated by computed tomographic (CT) scan and magnetic resonance imaging (MRI). The extension of the tumor in the petrous bone or the parotid gland was well defined by MRI in all cases. CT scan was useful to demonstrate bone erosions and the relation of the tumor to inner ear structures. In cases of progressive facial palsy, CT and MRI should be combined to detect a facial neuroma and to plan the surgical approach for tumor removal and nerve grafting.