Glomus jugulare tumor presentation and management: a case study

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.

Atypical Teratoid Rhabdoid Tumor in a Teenager with Unusual Infiltration Into the Jugular Foramen

BACKGROUND

Atypical teratoid rhabdoid tumor is a rare malignant neoplasm that represents 1%-2% of all pediatric central nervous system tumors. Immunohistochemistry plays an important role in establishing the diagnosis with a loss of INI-1 staining in tumor cells. In this case report, we describe a teenager with an unusual presentation and pattern of infiltration of the tumor.

CASE DESCRIPTION

A 13-year-old boy presented with a history over several months of progressive nausea, weight loss, and hoarseness of voice associated with multiple lower cranial nerve palsies on neurologic examination. Magnetic resonance imaging revealed a large heterogeneously enhancing extra-axial neoplasm with extension and bony expansion of the jugular foramen. After near total resection, neuropathology demonstrated the absence of INI-1 expression consistent with a diagnosis of atypical teratoid rhabdoid tumor.

CONCLUSIONS

This case highlights the diverse clinical presentation and infiltrative potential of atypical teratoid rhabdoid tumors, thus expanding the differential diagnosis of extra-axial tumors invading the jugular foramen.

Clinical presentation and management of jugular foramen paraganglioma

OBJECTIVES

Jugular foramen paraganglioma is a locally invasive, benign tumor, which grow slowly and causes various symptoms such as pulsatile tinnitus and low cranial nerve palsy. Complete surgical resection is regarded as the ideal management of these tumors. The goal of this study is to identify the clinical characteristics and most effective surgical approach for jugular foramen paraganglioma.

METHODS

Retrospective analysis of 9 jugular foramen paraganglioma patients who underwent surgical resection between 1986 and 2005 was performed. Clinical records were reviewed for analysis of initial clinical symptoms and signs, audiological examinations, neurological deficits, radiological features, surgical approaches, extent of resection, treatment outcomes and complications.

RESULTS

Most common initial symptom was hoarseness, followed by pulsatile tinnitus. Seven out of 9 patients had at least one low cranial nerve palsy. Seven patients were classified as Fisch Type C tumor and remaining 2 as Fisch Type D tumor on radiologic examination. Total of 11 operations took place in 9 patients. Total resection was achieved in 6 cases, when partial resection was done in 3 cases. Two patients with partial resection received gamma knife radiosurgery (GKS), when remaining 1 case received both GKS and two times of revision operation. No mortality was encountered and there were few postoperative complications.

CONCLUSION

Neurologic examination of low cranial nerve palsy is crucial since most patients had at least one low cranial nerve palsy. All tumors were detected in advanced stage due to slow growing nature and lack of symptom. Angiography with embolization is crucial for successful tumor removal without massive bleeding. Infratemporal fossa approach can be considered as a safe, satisfactory approach for removal of jugular foramen paragangliomas. In tumors with intracranial extension, combined approach is recommended in that it provides better surgical view and can maintain the compliance of the patients.

[Preoperative mixed embolization of a paraganglioma using Onyx]

Paragangliomas, or glomus tumors, are highly vascular benign tumors of the head and neck. Clinical symptoms are essentially progressive and neurological, involving infiltration of the regional cranial nerves. The usual treatment is surgery, which itself is a challenge because of the close proximity of vital structures and the considerable blood loss. Preoperative embolization can reduce morbidity, and several techniques have been described using arterial injection of particles or of cyanoacrylate directly into the tumor. This case report is of a patient treated by surgery using a new technique-preoperative embolization involving both the arteries and veins, and injection of Onyx, resulting in complete devascularization of the tumor's arteriovenous network.

Intracranial glomus jugulare tumors: volume reduction with Gamma Knife surgery

Object

Glomus jugulare tumors (GJTs) are slow-growing benign tumors arising from paraganglion cells of the superior vagal ganglion. Involvement of cranial nerves and extensive erosion of the jugular foramen and petrous bone are typically seen in patients with GJTs. Advances in microsurgical techniques have improved patient outcomes, but tumors involving the petrous bone remain difficult to treat effectively. The aim of our study was to further evaluate the role of Gamma Knife surgery (GKS) in the management of intracranial GJTs.

Methods

Twelve consecutive patients (mean age 51.7 years) with intracranial GJTs were included in this study. The treatment strategy was either multimodal, with microsurgical tumor volume reduction followed by GKS in patients suffering from brainstem compression, or GKS as the only treatment. Follow-up examinations included thorough neurological examinations and neuroradiological quantitative volumetric tumor analysis. Five patients (41.6%) underwent microsurgery before GKS. Tumor volumes ranging from 1.6 to 24.8 cm3 were treated using prescription doses of 14 to 20 Gy (nine–28 isocenters). The achieved overall tumor control rate after GKS was 100% (33 months mean follow up) with only mild side effects observed. A tumor volume reduction (mean 41.1%; 3.2 cm3) was achieved in all patients.

Conclusions

Gamma Knife surgery is a safe and effective treatment for intracranial GJTs. The tumor volume reductions achieved are comparable to those achieved using microsurgery but with a much lower rate of side effects. More studies with longer follow-up times are necessary to confirm these very promising results.