Combined endovascular-surgical management of the internal carotid artery in complex tympanojugular paragangliomas

[Application of internal carotid artery stent in glomus jugular paraganglioma surgery]

Objective:To summarize the application of internal carotid artery stent in glomus jugular paraganglioma surgery, and to provide an effective strategy for reducing the risk of internal carotid artery injury. Methods:This article reviewed the surgical cases of internal carotid artery stent implanting from 2018.06 to 2022.12, and discussed the stent placement method, treatment protocols, and perioperative management strategies. Results:A total of 5 patients underwent a comprehensive evaluation of the degree of internal carotid artery invasion using imaging techniques such as MRI, carotid CT angiography （CTA）, and digital silhouette angiography （DSA）. All patients were found to have varying degrees of internal carotid artery involvement. Stenting of the internal carotid artery was performed in all patients before surgery, and the stenting process went smoothly without any internal carotid artery injury. Three months after stenting, tumor resection or subtotal resection surgery was performed to avoid internal carotid artery injury during the surgery, and the surgical process was successfully completed. Postoperative follow-up from 4 months to 2 years showed that the internal carotid artery was patent after stent placement, with great endothelialization process and no stent-related complications. Conclusion:In patients with glomus jugular paraganglioma, when preoperative imaging shows internal carotid artery involvement, preoperative stenting is a safe and effective therapeutic strategy to reinforce the arterial wall structure, protect and maintain the integrity of the artery, and reduce the risk of vascular injury during the surgery. This article summarizes the experience of internal carotid artery stent in glomus jugular paraganglioma surgery, which provides an important reference for clinical practice.

[Review and prospect of the diagnosis and treatment of head and neck paragangliomas]

ead and neck paraganglioma（HNPGL） often originates from the parasympathetic ganglia and is a highly invasive benign tumor. The diagnosis and treatment of this disease with strong heterogeneity is still a challenge. In the future, deep exploration is needed in genetic typing, grading diagnosis and treatment decisions, protection of cranial nerves and new drug treatments to better treat this disease.

[Reconstruction of internal carotid artery in the resection of paraganglioma of head and neck]

Objective:This study aims to discuss the necessity，surgical method and effect of reconstruction of internal carotid artery （ICA） in the resection of paraganglioma of head and neck. Methods:We retrospectively analyzed the data of the patients who underwent head and neck paraganglioma resection and ICA reconstruction in Peking Union Medical College Hospital from May 2015 to August 2023. The demographic characteristics, preoperative examinations, diagnoses, surgical techniques, and follow-up information were collected. Results:Six patients were enrolled, including four females and two males, with an average age of（39.8±13.0） years. All the patients presented mainly complaining local masses with or without pain. Four cases underwent surgery through Fisch infratemporal fossa approach type A+B, and one through approach type A and one through transcervical approach. Five patients had vascular reconstruction using the great saphenous vein while one patient used an artificial vessel. The average follow-up period was（43.8±31.6） months. One patient had tumor recurrence after 3 years and underwent second surgery to remove the residual tumor, and the other 5 patients had no tumor recurrence. One patient had acute bridging vessel embolism, and the other was found to have occlusion of the bridging vessel at follow-up. Conclusion:Carotid revascularization during resection of paraganglioma of head and neck is an important technique to completely remove the tumor, cure the disease, ensure intracranial blood supply, and reduce cerebrovascular complications. The "pre-reconstruction technique " is an effective method to minimize the duration of brain blood flow interruption, compared to traditional carotid revascularization. Close observation is necessary, along with regular radiological examinations to assess the patency of transplanted vessels, and the residual or recurrent tumors.

Gruppo Otologico's Experience in Managing the So-Called Inoperable Tympanojugular Paraganglioma

Objective: to identify advanced or "so-called inoperable" cases of tympanojugular paragangliomas (PGLs) and analyze how each case is surgically managed and followed afterward. Study Design: a retrospective case series study. Methods: Out of 262 type C and D TJPs and more than 10 cases of advanced or so-called inoperable cases, files of 6 patients with a diagnosis of advanced tympanojugular PGLs who were referred to an otology and skull-base center between 1996 and 2021 were reviewed to analyze management and surgical outcomes. The criteria for choosing these cases involve having one or more of the following features: (1) a large-sized tumor; (2) a single ipsilateral internal carotid artery (ICA); (3) involvement of the vertebral artery; (4) a considerable involvement of the ICA; (5) an extension to the clivus, foramen magnum, and cavernous sinus; (6) large intradural involvement (IDE); and (7) bilateral or multiple PGLs. Results: The age range at presentation was 25-43 years old, with a mean of 40.5 years: two females and four males. The presenting symptoms were glossal atrophy, hearing loss, pulsatile tinnitus, dysphonia, shoulder weakness, and diplopia. The modified Infratemporal Fossa Approach (ITFA) with a transcondylar-transtubercular extension is the principal approach in most cases, with additional approaches being used accordingly. Conclusions: The contemporary introduction of carotid artery stenting with the direct and indirect embolization of PGLs has made it possible to operate on many cases, which was otherwise considered impossible to treat surgically. Generally, the key is to stage the removal of the tumor in multiple stages during the management of complex PGLs to decrease surgical morbidities. A crucial aspect is to centralize the treatment of PGLs in referral centers with experienced surgeons who are trained to plan the stages and manage possible surgical complications.

The Role of Internal Carotid Artery Stent in the Management of Skull Base Paragangliomas

Background: After two decades from its introduction in the lateral skull base paraganglioma surgery, the indications and results of preoperative internal carotid artery stenting should be critically assessed. Materials and Methods: Monocentric retrospective study on 26 patients affected by head and neck paragangliomas (19 tympanojugular paragangliomas, 4 carotid body paragangliomas, 3 vagal paragangliomas) preoperatively treated with internal carotid artery stents between 2008 and 2023. The preoperative findings, the intraoperative complications and the final surgical results were analyzed. Results: The stent complication rate was less than 3.1%. Self-expanding highly flexible intracranial nitinol stents were applied. In all cases, it was possible to completely mobilize the internal carotid artery and perform a vascular dissection of the tumor. Gross total tumor resection was possible in 85% of cases. The median follow up was 7.83 y (SD +/- 3.93 y). No local recurrence was observed. Conclusions: The preoperative vascular stent facilitates tumor dissection from the internal carotid artery without risk of vascular damage, helping the surgeon to achieve surgical radicality. The vascular stent is indicated in the case of revision surgeries, circumferential involvement of the vessel and in cases with non-insufficient intracerebral crossflow. Procedural complications, temporary antiplatelet therapy and delay of surgery are the limitations of the procedure.

Lateral Skull Base Lesions: Our Experience of 15 Years

To analyse and report various aspects of lateral skull base surgery by describing the incidence and demographic variables, diagnostic and management challenges, surgical choices along with complications and their management and the long term morbidity and survival outcomes in our experience of 15 years. Retrospective review of complete records of all cases operated for lateral skull base tumors at a tertiary care teaching institution in India between timespan of 15 years from 2003 to 2018 was undertaken. 53 cases were selected and analysed. Those having follow up of less than 6 months were excluded. Outcomes were assessed in terms of incidence of types of tumors, benign or malignant, age and sex variation of the patients, staging status at presentation, status of facial and other lower cranial nerves pre-operatively, surgical techniques with complications if any, recurrences and survival. Of 35 benign tumors, tympanojugular paragangliomas were most common. Average age for these was 53 years with 19 females and 14 males. All were non-functional. Tinnitus and hearing loss were most common presentations. Class B2 and C1 tumors were most commonly encountered and the ITF A approach was most commonly used. Hearing loss and Facial palsy were commonest complication post-operatively. There were 2 recurrences. 18 malignancies were observed. Most were stage IV at presentation. Otorrhea and otalgia were most common presenting symptoms followed by hearing loss. 5 year survival was 55%. Successful treatment of lateral skull base lesions requires a multimodality therapy with team approach. Surgical resection is the primary management choice with variable approaches. ICA status related to the tumor is the most important consideration. Malignancies require more aggressive treatment for obtaining clear margins along with pre/post-op chemoradiation. Good results with acceptable complications can be obtained even with advanced tumors.

Early Multicenter Experience With the Neuroform Atlas Stent: Feasibility, Safety, and Efficacy

BACKGROUND

The Neuroform Atlas stent™ (by Stryker, Fremont, California) represents the most recent widely available upgrade to intracranial stenting, providing a laser cut open cell stent with a diameter of 3.0 to 4.5 mm that is delivered through an 0.017-inch microcatheter.

OBJECTIVE

To report our initial multicenter experience of the safety, efficacy, and feasibility of the Atlas stent used for treating aneurysms, as well as one case of intracranial stenosis and one carotid artery dissection as well as other pathologies.

METHODS

A retrospective multicenter study of subjects treated with Atlas stent during the period 2018 to 2019.

RESULTS

The total number of patients included in our analysis was 71 patients. The stent was utilized to treat 69 aneurysm cases. Of the aneurysms, 36% presented with acute rupture and 56% of the ruptured aneurysms were high grade. Mean aneurysm dimension was 7 mm with an average neck width of 4.1 mm. Around 30% had received prior treatment. Telescoping or Y-stent was used in 16% of cases. We did not observe any symptomatic major complications in our series. Asymptomatic major complications were seen in 7 patients (10.1%); technical complications occurred in 4.3%. Immediate modified Raymond-Roy-occlusion-outcome class I/II was observed in 87%, and this increased to 97.7% at latest follow-up, which was at 4 mo; 91.8% of patients achieved favorable clinical outcome, and mortality rate was 1.4%.

CONCLUSION

Our series demonstrates the safety, feasibility, and efficacy of the Atlas stent. The low complication rate and the high obliteration rate managing complex aneurysms, even in an acute ruptured setting, are notable.

Surgery of the lateral skull base: a 50-year endeavour

Disregarding the widely used division of skull base into anterior and lateral, since the skull base should be conceived as a single anatomic structure, it was to our convenience to group all those approaches that run from the antero-lateral, pure lateral and postero-lateral side of the skull base as “Surgery of the lateral skull base”. “50 years of endeavour” points to the great effort which has been made over the last decades, when more and more difficult surgeries were performed by reducing morbidity. The principle of lateral skull base surgery, “remove skull base bone to approach the base itself and the adjacent sites of the endo-esocranium”, was then combined with function preservation and with tailoring surgery to the pathology. The concept that histology dictates the extent of resection, balancing the intrinsic morbidity of each approach was the object of the first section of the present report. The main surgical approaches were described in the second section and were conceived not as a step-by-step description of technique, but as the highlighthening of the surgical principles. The third section was centered on open issues related to the tumor and its treatment. The topic of vestibular schwannoma was investigated with the current debate on observation, hearing preservation surgery, hearing rehabilitation, radiotherapy and the recent efforts to detect biological markers able to predict tumor growth. Jugular foramen paragangliomas were treated in the frame of radical or partial surgery, radiotherapy, partial “tailored” surgery and observation. Surgery on meningioma was debated from the point of view of the neurosurgeon and of the otologist. Endolymphatic sac tumors and malignant tumors of the external auditory canal were also treated, as well as chordomas, chondrosarcomas and petrous bone cholesteatomas. Finally, the fourth section focused on free-choice topics which were assigned to aknowledged experts. The aim of this work was attempting to report the state of the art of the lateral skull base surgery after 50 years of hard work and, above all, to raise questions on those issues which still need an answer, as to allow progress in knowledge through sharing of various experiences. At the end of the reading, if more doubts remain rather than certainties, the aim of this work will probably be achieved.

Update in the classification and the role of intra-arterial stenting in the management of carotid body paragangliomas

BACKGROUND

To review the Shamblin classification of carotid body paragangliomas (CBPs) and the role of intra-arterial stenting in their surgical management.

METHODS

Retrospective case series of 20 patients with 28 CBPs that were surgically resected at our center. Intra-arterial stenting was performed in Shamblin II and II classes.

RESULTS

The mean follow-up was 47.8 months. Five (17.9%) tumors were Shamblin class I, 15 (53.6%) were class II, and 8 (28.6%) were class III. Thirteen (68.4%) CBPs were associated with other paragangliomas. The internal carotid artery (ICA) was stented preoperatively in eight (28.6%) cases and occluded in four (14.3%) cases. The tumor extended to the jugular foramen in six cases (21.4%). Intraoperatively, there was an ICA injury in one case of Shamblin II CBP in the present era.

CONCLUSIONS

The proposed classification enables the clinician to plan the management of the ICA and the right approach. Stenting of the ICA gives a chance for complete tumor removal with arterial preservation.

Contemporary management of primary parapharyngeal space tumors

The parapharyngeal space is a complex anatomical area. Primary parapharyngeal tumors are rare tumors and 80% of them are benign. A variety of tumor types can develop in this location; most common are salivary gland neoplasm and neurogenic tumors. The management of these tumors has improved greatly owing to the developments in imaging techniques, surgery, and radiotherapy. Most tumors can be removed with a low rate of complications and recurrence. The transcervical approach is the most frequently used. In some cases, minimally invasive approaches may be used alone or in combination with a limited transcervical route, allowing large tumors to be removed by reducing morbidity of expanded approaches. An adequate knowledge of the anatomy and a careful surgical plan is essential to tailor management according to the patient and the tumor. The purpose of the present review was to update current aspects of knowledge related to this more challenging area of tumor occurrence.

Management of the cervico-petrous internal carotid artery in class C tympanojugular paragangliomas

BACKGROUND

Management of the cervical and petrous internal carotid artery (ICA) is frequently required in Fisch class C tympanojugular paragangliomas (TJPs). The purpose of this study was to discuss the perioperative intervention of the ICA in patients who underwent surgical resection of a TJP.

METHODS

A retrospective study of 237 patients surgically treated for Fisch class C TJPs was done to identify cases that required ICA management.

RESULTS

Management of the ICA was required in 176 patients (74.2%). Forty-two patients required just an ICA decompression, 88 underwent a subperiosteal dissection, 19 underwent subadventitial dissection without intraluminal stenting, 17 underwent subadventitial dissection with intraluminal stenting, and 12 underwent arterial resection after permanent balloon occlusion. There were no complications associated with the endovascular procedures. Gross total tumor resection was achieved in 91.5% of the cases.

CONCLUSION

Preoperative endovascular intervention, in selected cases, facilitates gross total tumor removal and significantly reduces the risk of an intraoperative ICA injury. © 2015 Wiley Periodicals, Inc. Head Neck 38: 899-905, 2016.

Strategies and long-term outcomes in the surgical management of tympanojugular paragangliomas

BACKGROUND

The purpose of this study was to share our review of surgical strategies and long-term outcomes in the management of tympanojugular paragangliomas.

METHODS

This was a retrospective study with a literature review. The records of 184 patients with 185 tympanojugular paragangliomas were analyzed for tumor class, surgical procedure, preoperative vascular management, and perioperative sequelae.

RESULTS

Of class C1, C2, C3, and C4 tumors, we found 46 (24.9%), 95 (51.3%), 41 (22.2%), and 3 (1.6%), respectively. One hundred four (56.2%) tumors had intracranial extensions and 8 (4.3%) involved the vertebral artery. A single-stage procedure was adopted in 158 (85.4%) tumors. The infratemporal fossa type A approach was used in all cases. In 17 patients (9.7%), an intra-arterial stenting of the internal carotid artery was performed. Gross-total tumor removal was achieved in 166 cases (89.7%) and 4 (2.4%) among them developed a recurrence.

CONCLUSION

A thorough understanding of skull base techniques and a logical decision-making process in the management of tympanojugular paragangliomas can achieve a high rate of success in terms of recurrences and complications. © 2015 Wiley Periodicals, Inc. Head Neck 38: 871-885, 2016.

Endoscopic Endonasal Nasopharyngectomy in Selected Cancers

Objective

To describe the different surgical techniques for nasopharyngeal endoscopic resection (NER) and to support the efficacy of the endoscopic endonasal approach in the management of selected primary and locally recurrent nasopharyngeal tumors (NPTs).

Study Design

Case series with chart review.

Setting

Patients affected by NPTs who underwent NER from 1997 to 2011 at two Italian referral centers.

Subjects and Methods

NER was tailored to the NPT extension and classified as follows: type 1 NER, resection of the posterior nasopharyngeal wall; type 2 NER, resection superiorly extended to the sphenoid; type 3 NER, trans-pterygoid approach to the postero-lateral nasopharynx with removal of pterygoid plates and Eustachian tube, under control of parapharyngeal-petrous-cavernous segments of the internal carotid artery.

Results

Thirty-six consecutive patients with primary (9 cases) or locally recurrent (27 cases) NPTs were enrolled. The lesions were staged as follows: stage I, 16 (44.4%); stage II, 3 (8.4%); stage III, 15 (41.6%); and stage IVA, 2 (5.6%). Type 1 NER was performed in 6 cases, type 2 NER in 12, type 3 NER in 16, and bilateral-extended type 3 NER in 2. No perioperative mortality or major complications were observed. Postoperatively, 11 patients received intensity-modulated radiotherapy, with or without chemotherapy. Follow-up ranged from 2 to 173 months (mean: 38 months). Five years overall, disease-specific, and disease-free survivals were 75.1% ± 9.13%, 80.9% ± 7.79%, and 58.1% ± 14.8%, respectively.

Conclusion

NER is a feasible and minimally invasive surgical approach for the management of selected primary and locally recurrent NPTs. Our preliminary outcomes are promising, with local control rates comparable to those of conventional procedures. Larger case series and longer follow-up are needed to validate the reproducibility and efficacy of the technique.

Pediatric bypasses for aneurysms and skull base tumors: short- and long-term outcomes

OBJECT

Cerebral bypass is a useful microsurgical technique for the treatment of unclippable aneurysms and invasive skull base tumors. The authors present the largest reported series of cerebrovascular bypasses in the pediatric population. They describe the short- and long-term clinical and radiographic outcomes of extracranial-intracranial and local bypasses performed for complex cerebral aneurysms and recurrent, invasive, and malignant skull base tumors in pediatric patients.

METHODS

A consecutive series of 17 pediatric patients who underwent revascularization were analyzed retrospectively for indications, graft patency, and neurological outcomes.

RESULTS

The mean age was 12 years (median 11 years, range 4-17 years), and there were 7 boys (41%) and 10 girls (59%). A total of 18 bypasses were performed in 17 patients and included 10 aneurysm cases (55.5%) and 8 tumor cases (45%). Of these 18 bypasses, there were 11 (61.1%) extracranial-intracranial bypasses (10 saphenous vein grafts [90%] and 1 radial artery graft [10%]), 1 side-to-side anastomosis (5.5%), 2 intracranial reimplants (11.1%), and 4 interposition bypass grafts (22.2%; 2 radial artery grafts, 1 saphenous vein graft, and 1 lingual artery graft). The mean clinical follow-up was 40.5 months (median 24 months, range 3-197 months). The mean radiographic follow-up was 40 months (median 15 months, range 9-197 months). Eighty-two percent of patients (14 of 17) achieved a modified Rankin Scale score between 0 and 2; however, 2 patients died of disease progression during long-term follow-up. The short-term (0- to 3-month) graft patency rate was 100%. Two patients had graft stenosis (11.7%) and underwent graft revisions. Two patients (11.1%) with giant middle cerebral artery aneurysms (> 25 mm) had strokes postoperatively but recovered without a persistent neurological deficit. One patient observed for 197 months showed a stable dysplastic change at the end of the graft. The long-term graft patency was 100% with a mean follow-up of 40 months. There were 2 deaths in the cohort during follow-up; both patients died of malignant tumors (osteogenic sarcoma and chondrosarcoma).

CONCLUSIONS

The authors conclude that in properly selected cases, bypasses can be safely performed in patients with aneurysms and skull base tumors. The bypasses remained patent over long periods of time despite the growth of the patients.

Oncologic outcome in surgical management of jugular paraganglioma and factors influencing outcomes

BACKGROUND

The purpose of this study was to identify the factors that may influence the management outcome in patients with jugular paragangliomas.

METHODS

The surgical records of 121 cases of jugular paraganglioma (Fisch classifications C and D) were reviewed.

RESULTS

The average follow-up was 88 months. Intracranial extension (ICE; Fisch classification De and Di) constitutes 55.4% of the cases. Two cases had a malignant jugular paraganglioma. Complete tumor resection was achieved in 81.8% of the cases, and there was evidence of recurrence in 4.0% from this group. Surgical tumor control was achieved in 96% of cases. Perioperative complications consisted mainly of cerebrospinal fluid leakage in 1.6% of the cases. The lower cranial nerve (CN) was preserved in 63% of the patients mainly in the cases without ICE.

CONCLUSION

The infratemporal fossa approach type A allows for complete tumor resection with low perioperative morbidity and recurrence rates. The significant influential factors were the severity of ICE and internal carotid artery involvement.

Consensus statement and guidelines on the management of paragangliomas of the head and neck

Paragangliomas (PGLs) of the head and neck (H&N) are uncommon tumors that either arise spontaneously or as part of an inherited syndrome. Hereditary PGL is an autosomal-dominant tumor predisposition syndrome in which an affected individual has greatly increased risk of developing PGL at any or several sites in the autonomic nervous system. The mode of inheritance for some is affected by maternal imprinting. These tumors are generally very slow growing, often taking a decade to double in size. A few are or can become malignant and can metastasize widely. Because of their site of origin, patients with these tumors may develop cranial nerve deficits that have a significant impact on their quality of life. Patients may present to specialists from widely differing disciplines, and some of these may not appreciate the full implications of their patient's disease. As a result, management can become fragmented or inappropriate, and some aspects of care may even be overlooked. This article is the distillation of consensus opinion derived from current published and unpublished data in this field, with particular reference to the management of temporal bone PGLs. We propose guidelines for the management of both sporadic and hereditary PGLs. A multidisciplinary team approach to the management of this complex disorder is advocated. Progress could be made by adopting these guidelines and by widespread dissemination of standardized information. Collaborative research should be promoted with the aim of harnessing advances in molecular genetics to develop targeted therapies for patients, particularly those with hereditary PGL.

[Neuroradiologic diagnostic and interventional procedures for diseases of the skull base]

Besides image-guided biopsy techniques, the emphasis in the interdisciplinary cooperation between head and neck surgery and neuroradiology is on vessel-occluding and preserving measures. Knowledge of dangerous anastomoses between extracranial and intracranial vessels is crucial. The principles of vessel-occluding procedures including materials are presented and illustrated with case examples. Embolization of glomus tumors or epistaxis and preoperative permanent vessel occlusion techniques are demonstrated as well as vessel-preserving therapies, such as placement of covered stents for improving tumor resectability or after iatrogenic laceration of the internal carotid artery.