Preoperative Embolization of a Glomus Vagale Tumor Resected via the Retrosigmoid Approach

Introduction: Glomus vagale and jugulare tumors are highly vascular and locally destructive lesions that often require complex skull base approaches for surgical management. These tumors often have intra- and extracranial extension and derive their blood supply from multiple sources. Preoperative endovascular embolization decreases intraoperative blood loss, allows for a controlled and organized resection, and can facilitate brainstem separation in tumors with a large intradural component. We describe a glomus vagale tumor with primarily intradural extension and pontine compression treated with preoperative embolization prior to resection via the retrosigmoid approach.

Case Description: A 64-year-old male presented with several months of dysphagia and hoarseness and was found to have complete paralysis of the left vocal cord. Magnetic resonance imaging demonstrated an avidly enhancing tumor arising in the left jugular foramen and extending into the posterior fossa with compression of the pons. No disease was present in the middle ear and mastoid air cells and the distal cervical and petrous carotid artery was not involved. Diagnostic angiography identified an intense vascular blush with blood supply derived from branches of the left posterior inferior cerebellar artery (PICA), ascending pharyngeal artery (APA), and occipital artery (OA). The left transverse and sigmoid sinuses and the left jugular vein were widely patent. Superselective catheterization and embolization of the APA and OA branches with 250–355 µm polyvinyl alcohol particles (PVAs) resulted in a dramatic reduction in the tumor blush. The following day, the patient underwent a left retrosigmoid craniotomy and resection of the intradural tumor. The feeding branch of the PICA was coagulated and sectioned prior to resection, resulting in near complete devascularization of the tumor. Resection proceeded with minimal blood loss and the tumor was easily debulked and separated from the brainstem. Pathology was consistent with a paraganglioma. The patient was discharged with baseline hoarseness and no additional deficits. Cranial nerve XI function was preserved. The residual tumor in the jugular foramen will be treated with stereotactic radiosurgery. A left vocal cord injection resulted in a dramatic improvement in voice quality.

Conclusion: Glomus jugulare and vagale tumors are highly vascular complex lesions that are best treated by a multidisciplinary team. Preoperative embolization is a key adjuvant therapy that reduces blood loss, improves the safety of the procedure, and facilitates resection. Embolization can be associated with significant neurologic complications due to occlusion of the blood supply to the lower cranial nerves. Additionally, dangerous anastomoses with the internal carotid and vertebrobasilar circulations can result in devastating neurologic injury. Cranial base surgeons also trained in endovascular intervention provide a unique perspective and allow for a tailored embolization prior to the planned resection.

No conflict of interest has been declared by the author(s).