Preoperative ONYX Embolization for Jugular Foramen Paragangliomas: The Combined Transarterial and Transvenous Technique

Objective: Jugular foramen paragangliomas are rare, histologically benign tumors that present a surgical challenge due to their high vascularity and proximity to the lower cranial nerves. A cornerstone to the treatment of these tumors is preoperative endovascular embolization followed by surgical resection. Conventional embolization of paragangliomas has included direct percutaneous puncture and conventional transarterial approaches. The authors report on a novel technique to the endovascular embolization of jugular foramen paragangliomas utilizing both a transarterial and transvenous balloon microcatheter embolization. We review our experience with two consecutive patients who underwent dual transarterial and venous Onyx embolization and subsequent surgical resection.

Methods: Retrospective data collection of two patients who presented with jugular foramen masses and underwent dual transarterial and tans venous embolization technique followed by subtotal surgical resection. Pre- and postoperative clinical and surgical data collected, with emphasis on endovascular embolization technique and surgical outcomes.

Results: Two patients underwent embolization of jugular foramen paragangliomas. All of the embolizations were performed in a single session followed by subtotal surgical resection two days after embolization. In both cases single arterial vessel embolization was performed through the tympanic branch of the ascending pharyngeal artery, while simultaneous balloon microcatheter occlusion in the sigmoid sinus and single venous outflow vessel embolization was performed. Near complete occlusion was established, with angiographic disappearance of tumor blush. Subtotal resection was performed in both. EBL was 600 mL in Case 1 and 200 mL in Case 2. No blood transfusions were required, intra or post operatively. Post embolization, Case 1 had a right House–Brackman (HB) 2 facial nerve palsy, which remained stable after surgical resection. No new cranial nerve palsy was evident post embolization in Case 2; however, a HB 3 was present in the early postoperative period. At follow-up, Case 1 has normal facial nerve function, and Case 2 has near-normal facial nerve function. Neither patient had a lower cranial nerve deficit before or after treatment.

Conclusion: Dual-transarterial and transvenous embolization of jugular foramen paragangliomas is a safe technique which yields superior embolization results in respect to more rapid tumor embolization and better parenchymal penetration. This is a limited series of two patients, further embolizations with the current technique will need to be performed to determine on long-term efficacy and incidence of cranial neuropathies.