A Multidisciplinary Approach to Carotid Paragangliomas

Abstract

The surgical management of carotid paragangliomas can be problematic. A multidisciplinary approach was used to include vascular surgery, otolaryngology, and neuroradiology to treat these patients over 9 years. From January 1992 to July 2001, a multidisciplinary team evaluated patients with carotid paragangliomas. Analyzed patient data included age, gender, diagnostic evaluation, tumor size, preoperative tumor embolization, operative exposure, need for extracranial arterial sacrifice/reconstruction, postoperative morbidity including cranial nerve dysfunction, and long-term follow-up. Twenty-five carotid paragangliomas in 20 patients underwent multidisciplinary evaluation and management. Average age was 51 years (range, 28-83 years), and 52% were male. Diagnostic evaluation included computed tomography in 76%, magnetic resonance imaging/magnetic resonance angiography in 52%, catheter angiography in 60%, and duplex ultrasonography in 16%. An extended neck exposure was required in 11 cases (44%), mandibulotomy was used once (4%), and mandibular subluxation was never required. The external carotid artery (ECA) was sacrificed in 8 cases (32%). The carotid bifurcation was resected in 1 patient (4%) requiring interposition reconstruction of the internal carotid artery. Preoperative tumor embolization was performed for 13 tumors (52%). Operative blood loss for patients undergoing preoperative embolization (Group I) was comparable to the nonembolized group (group II): group I lost 365 +/-180 mL versus 360 +/- 101 mL for group II (P = .48). This occurred despite larger tumors (group I - 4.2 cm versus group II - 2.1 cm, P = .03) and a higher mean Shamblin class (group I - 2.5 versus group II - 1.45, P = .001) for group I. There were no perioperative mortalities. Transient cranial nerve dysfunction occurred in 13 CBTs (52%), 2 (8%) of which remained present after 4 months. Patients with carotid paragangliomas benefit from a multidisciplinary team approach. Neuroradiology has been used for selective preoperative embolization, which has decreased estimated blood loss during excision of larger complex tumors. A combined surgical team of otolaryngology and vascular surgery provides for exposure of the distal internal carotid artery as high as the skull base, limited permanent cranial nerve dysfunction, and selective early division and excision of the external carotid artery for complete tumor resection.

Dangerous Extracranial–Intracranial Anastomoses and Supply to the Cranial Nerves: Vessels the Neurointerventionalist Needs to Know

“…[3][4][5][6] However, because embryologic and phylogenetic development closely links the ECAs to the intracranial arteries, there are certain common anastomotic routes that have to be kept in mind while doing the embolization procedures to avoid possible major complications such as embolic stroke or cranial nerve palsies. 7 Most of these anastomotic channels follow the cranial nerves along the neural foramen.…”

Visualization of external carotid artery and its branches: Non–contrast‐enhanced MR angiography using balanced steady‐state free‐precession sequence and a time‐spatial labeling inversion pulse

“…Several less-invasive treatment approaches using catheter-directed selective angiographic techniques have been more and more applied to head and neck diseases, including selective arterial embolization (1), preoperative endovascular embolization (2,3), and selective intra-arterial infusion chemotherapy (4). Detailed preoperative anatomical information of the ECA system is especially important for these treatment approaches.…”

“…ANATOMICAL INFORMATION OF the external carotid artery (ECA) system has become more important for less-invasive treatment approaches to head and neck disorders (1)(2)(3)(4), and time-of-flight (TOF) and phasecontrast (PC) imaging have been used for non-contrastenhanced head and neck MR angiography (MRA) (5). However, saturation effects often lead to signal reduction of the ECA branches in TOF.…”

Carotid body tumors: A report of three cases and current literature review

“…According to some studies, the preoperative embolization procedure is beneficial since it lowers blood flow and decreases tumor size, thereby may facilitate complete tumor removal with less blood loss especially in large tumors [20][21][22]. On the other hand, in some other studies, the preoperative embolization was not recommended on account of not only its uselessness both also the risk of postembolization morbidity such as transient ischemic attack and even stroke by embolic particles [23,24].…”