Intratumoral injection of cyanoacrylate glue in head and neck paragangliomas

Abstract

Background and purpose: Substantial intraoperative bleeding during surgical removal of head and neck paragangliomas may be a major problem in the management of these highly vascularized tumors. Traditional preoperative embolization via a transarterial approach has proved beneficial but is often limited by complex vascular anatomy and unfavorable locations. We report our experience with the preoperative devascularization of head and neck paragangliomas by using direct puncture and an intralesional injection of cyanoacrylate.

Methods: We retrospectively analyzed nine consecutive patients with head and neck paragangliomas who were referred for preoperative devascularization. Three patients were treated for carotid-body tumors; two for vagal lesions; and four, for jugular paragangliomas. Direct puncture of the lesion was performed by using roadmap fluoroscopic guidance. Acrylic glue was injected by using continuous biplane fluoroscopy. All patients underwent postembolization control angiography and immediate postoperative CT scanning.

Results: Angiograms showed that complete devascularization was achieved in all cervical glomus tumors, whereas subtotal devascularization was achieved in jugular paragangliomas. In this latter location, the injection of acrylic glue was limited by the potential risk of reflux into normal brain territory via feeders from the internal carotid or vertebral artery. The tumors were surgically removed and histologically examined. No technical or clinical complications related to the embolization procedure occurred.

Conclusion: Percutaneous puncture of paragangliomas in the head and neck region and their preoperative devascularization by intralesional injection of acrylic glue is a feasible, safe, and effective technique.

Fig 1.

Vagal glomus tumor. A, Left common carotid arteriogram, lateral view, shows the highly vascularized tumor displacing the ICA posteriorly (arrow). B, Nonsubtracted view shows the glue cast after embolization. C, Control arteriogram demonstrates complete devascularization of the vascular tumor bed at the end of the procedure. D, Macroscopic specimen of the tumor after en bloc removal.

Fig 2.

Carotid-body glomus tumor. A, Left common carotid arteriogram, lateral view, shows significant pathologic vascularization and associated mass effect of the tumor enlarging the carotid bifurcation. B, Cast after glue injection. C, Postembolization arteriogram demonstrates complete devascularization at the end of the procedure.

Fig 3.

Jugular glomus tumor. A, Left vertebral arteriogram, anteroposterior view, shows tumor blush in the left posterior fossa. The tumor is supplied by the feeders of the left posterior inferior cerebellar artery. B, Left external carotid arteriogram, lateral view, shows tumor vascularization from the posterior branch of the AsphA (short arrow) and the posterior auricular artery (long arrow). C, Glue cast after several punctures (arrows) and glue injections. D and E, Final control angiogram of the vertebrobasilar system and the left common carotid artery demonstrates complete devascularization of the tumor bed previously supplied by posterior inferior cerebellar artery feeders and subtotal devascularization of the ECA territory.