Preoperative Squid embolization of carotid paragangliomas with direct puncture

Abstract

Background and purpose: Preoperative embolization of carotid paragangliomas is a common procedure in interventional neuroradiology. Direct puncture embolization has shown less morbidity and mortality than endovascular embolization and a higher percentage of devascularization. We describe our experience using Squid® as the only embolic agent in direct puncture glomus embolization.

Methods: We retrospectively reviewed pre-embolization imaging tests, emphasizing the volume of the lesion, clinical history data, technical aspects of the procedure, as well as the approximate amount of blood lost during the surgical procedure in all patients with preoperative embolization of carotid paragangliomas performed at our tertiary care hospital.

Results: Six patients met our criteria from May 2017 to August 2018. The volume of the mass ranged from 1.4-18.5 mL and the quantity of Squid® injected varied from 1.1-15 mL. Total devascularization was achieved in almost all cases (>90%), with one puncture needed in all but one patient, who was punctured two times. No hemorrhagic complications were described in surgery, no blood transfusions were needed, and the mean decrease of hemoglobin after surgery was 1.04 g/dL.

Conclusions: Direct puncture embolization of carotid paragangliomas only using Squid® is a safe and relatively simple procedure that facilitates the subsequent surgery with minimal blood loss.

Keywords: Carotid paraganglioma; Squid; direct puncture; presurgical embolization.

Figure 1.

Patient 1 in Table 1. (a) Sagittal maximum intensity projection contrast-enhanced computed tomography (CT) scan of the neck showing a left carotid body tumor. (b) Three-dimensional (3D) volume-rendering of the aforementioned lesion. (c) Lateral left common carotid artery angiogram demonstrating a hypervascular mass splaying the carotid bifurcation. (d) Lateral single-shot showing direct needle placement into the tumor with the first Squid® injection. (e) Lateral single-shot at the end of the procedure demonstrating the distribution of the embolizing agent. (f) Lateral left common carotid artery angiogram at the end of the procedure that depicts an almost complete devascularization of the paraganglioma.

Figure 2.

Patient 2 in Table 1. (a) Anteroposterior left common carotid artery angiogram demonstrating the hypervascular mass. (b) Anteroposterior parenchymogram demonstrating direct needle placement into the tumor with contrast injection showing the neovascularity of the tumor. (c) Anteroposterior left common carotid artery angiogram halfway through the procedure showing still enhancement of the most cranial and caudal portions of the lesion. (d) Anteroposterior parenchymogram demonstrating the new placement of the needle after a second puncture with contrast injection showing the cranial portion of the glomus.