Paragangliomas

Paragangliomas (glomus tumors, chemodectomas) are benign, vascular, slow-growing tumors arising from paraganglionic glomic tissue of neuroectodermal origin. These tumors are found in adults and have a predilection for females.3 The four most common sites are the jugular foramen (glomus jugulare), cochlear promontory of the middle ear (glomus tympanicum), carotid body, and vagus nerve (glomus vagale). Presenting clinical symptoms often include pulsatile tinnitus; other symptoms are caused by local mass effect and depend on tumor location.26 On MRI, these tumors exhibit an internal "salt-and pepper" appearance because of the abundant tumor vessels. Glomus jugulare tumors often erode the jugular foramen, a process best seen on CT scanning.31

Surgical resection of large paragangliomas may be complicated by intimate involvement of the temporal bone and posterior fossa structures. Given the extreme vascularity of

FIGURE 12-1 A 29-year-old man with a right parasagittal convexity meningioma. A, Coronal short repetition time (TR)/echo time (TE) magnetic resonance (MR) image with gadolinium contrast enhancement demonstrates a homogeneous mass consistent with this diagnosis. B, Pre-embolization right external carotid angiogram, lateral projection, shows tumor vascularity typical of a meningioma, supplied by an enlarged branch of the middle meningeal artery. C, Superselective right middle meningeal branch arteriogram, lateral projection, immediately before embolization. D, Postembolization right external carotid angiogram, lateral projection, after particulate embolization of the tumor bed and coil occlusion of the feeding artery. No residual tumor vascularity is seen. This patient is now prepared for surgical resection.

FIGURE 12-1 A 29-year-old man with a right parasagittal convexity meningioma. A, Coronal short repetition time (TR)/echo time (TE) magnetic resonance (MR) image with gadolinium contrast enhancement demonstrates a homogeneous mass consistent with this diagnosis. B, Pre-embolization right external carotid angiogram, lateral projection, shows tumor vascularity typical of a meningioma, supplied by an enlarged branch of the middle meningeal artery. C, Superselective right middle meningeal branch arteriogram, lateral projection, immediately before embolization. D, Postembolization right external carotid angiogram, lateral projection, after particulate embolization of the tumor bed and coil occlusion of the feeding artery. No residual tumor vascularity is seen. This patient is now prepared for surgical resection.

these tumors, preoperative embolization is warranted.30 Angio-graphically, paragangliomas are highly vascular, are encapsulated, exhibit arteriovenous shunting, and are supplied primarily by branches of the external carotid artery. The ascending pha-ryngeal artery nearly always supplies glomus jugulare and glomus tympanicum tumors. Careful embolization, usually with particulate agents, is undertaken in the same fashion as for meningiomas. Particular care is necessary to preserve the neuromeningeal branch of the ascending pharyngeal artery (cranial nerves IX through XI) and the stylomastoid artery (facial nerve).16

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