Direct Puncture Embolization for Intracranial Glomus Jugulare Tumor: Technical Note and Literature Review

Background Direct puncture embolization is widely described for sinonasal and neck tumors. However, it has been rarely described in the literature for management of intracranial tumors. We describe a case of a recurrent jugular glomus tumor in a 42-year-old man who was treated with preoperative direct puncture embolization followed by surgical resection. The literature on direct puncture embolization of intracranial tumors is reviewed.

Methods A 42-year-old man with a history of multiple surgical resections and radiation treatment of a glomus jugulare tumor presented with worsening headaches and imbalance. MRI revealed regrowth of tumor with significant brain stem compression and hemorrhage into the fourth ventricle. Prior coiling of ECA vessels during previous treatments at an outside institution made traditional endovascular embolization difficult. The patient underwent direct puncture embolization using a 20-guage spinal needle via a postauricular retrosigmoid approach in the angiography suite. The spinal needle was guided through the titanium mesh cranioplasty and into the tumor using a combination of neuronavigation, fluoroscopy, and Dyna CT. Endovascular catheters were placed in the left vertebral and left maxillary arteries to simultaneously inject and better define the total area of tumor blush. The area of tumor blush was used during Onyx embolization to understand the territories Onyx was penetrating. Dyna CT brain was performed twice—first to confirm needle placement and at the conclusion of the procedure to confirm absence of new hemorrhage. The patient was taken to the operating room the following day for a left far lateral craniotomy for tumor resection. Literature review was performed on PubMed and Google Scholar databases by searching for studies with titles including the terms “direct,” “embolization,” and “intracranial.”

Results A total of 12.8 mL Onyx was injected over 28 minutes during preoperative direct puncture embolization. This resulted in nearly 80% reduction in vascular supply to the tumor and helped reduce operative time during surgical resection. A subtotal resection was performed, but the entirety of the posterior fossa component of the tumor was resected and the goal of reducing mass effect on the brain stem was achieved. Literature search revealed four publications of direct puncture embolization for intracranial tumors. The first case was described in 2013 for a tentorial hemangiopericytoma that could not be adequately embolized endovascularly. Subsequently, direct embolization has been reported for a cerebellopontine renal cell carcinoma metastasis, choroid plexus papilloma, meningiomas, and endolymphatic sac tumors. In some instances, embolization was performed intraoperatively, while in other instances, there was up to a 1 week delay between embolization and surgical resection. All cases reported drastically decreased vascularity and blood loss compared with prior attempted resections after unsuccessful endovascular embolization.

Conclusion For selected cases of intracranial tumors, direct puncture embolization is safe, feasible, and efficient for preoperative embolization. It provides advantages over traditional intra-arterial endovascular embolization including circumventing challenging arterial anatomy and a lower risk of stroke. Additionally, it reduces intraoperative time and blood loss during surgical resection that follows. This treatment requires a multidisciplinary approach with intricate planning.