Incidence of cranial nerve palsy after preoperative embolization of glomus jugulare tumors using Onyx

Abstract

Object The resection of glomus jugulare tumors can be challenging because of their inherent vascularity. Preoperative embolization has been advocated as a means of reducing operative times, blood loss, and surgical complications. However, the incidence of cranial neuropathy associated with the embolization of these tumors has not been established. The authors of this study describe their experience with cranial neuropathy following transarterial embolization of glomus jugulare tumors using ethylene vinyl alcohol (Onyx, eV3 Inc.). Methods The authors retrospectively reviewed all cases of glomus jugulare tumors that had been treated with preoperative embolization using Onyx at their institution in the period from 2006 to 2012. Patient demographics, clinical presentation, grade and amount of Onyx used, degree of angiographic devascularization, and procedural complications were recorded. Results Over a 6-year period, 11 patients with glomus jugulare tumors underwent preoperative embolization with Onyx. All embolization procedures were completed in one session. The overall mean percent of tumor devascularization was 90.7%. No evidence of nontarget embolization was seen on postembolization angiograms. There were 2 cases (18%) of permanent cranial neuropathy attributed to the embolization procedures (facial nerve paralysis and lower cranial nerve dysfunction). Conclusions Embolizing glomus jugulare tumors with Onyx can produce a dramatic reduction in tumor vascularity. However, the intimate anatomical relationship and overlapping blood supply between these tumors and cranial nerves may contribute to a high incidence of cranial neuropathy following Onyx embolization.

Initial experience with dual-lumen balloon catheter injection for preoperative Onyx embolization of skull base paragangliomas

“…From previous experiences with transarterial Onyx embolization of these tumors, Gaynor et al 6 reported a mean fluoroscopy time of 83 minutes, which might be longer than that in our series (40 minutes per procedure or 72 minutes per patient); however, we are unable to determine if this difference is statistically significant. Radiation exposure during neurointervention is a concern, particularly for patients who receive multiple staged procedures.…”

“…In each case, near-complete tumor devascularization was achieved. In 2014, in the largest series of transarterial Onyx embolization for paraganglioma to date, despite a mean tumor devascularization rate of 90.7%, Gaynor et al 6 reported that 2 (18%) of 11 patients developed new, permanent cranial neuropathies after embolization. These authors attributed those cranial neuropathies to the intimate relationship between tumor vessels and the vasa nervorum of cranial nerves.…”

“…1,3,5,6,17,20,25 Its cohesive properties enable the core of the embolic material to propel forward into the tumor vasculature. Compared with earlier embolic materials, Onyx precipitates gradually and has a lower viscosity, which may enable longer, more controlled injections into the tumor nidus.…”

“…4,7 Given its flow characteristics, Onyx (Covidien) has seen increasing use in the preoperative embolization of tumors, including paragangliomas. 1,3,5,6,17,20,25 Direct percutaneous puncture is currently the most reported route for Onyx embolization of these tumors, although it is unclear whether that reflects a publication bias or if this modality is actually more common than using transarterial routes of embolization. 3,17,20,25 Problems with conventional transfemoral artery access, such as tortuosity, atherosclerosis, vasospasm, and small-caliber arterial feeders, may impede complete embolization of these tumors, and dangerabbreviatioNs EBL = estimated blood loss; ECA = external carotid artery; ICA = internal carotid artery; PVA = polyvinyl alcohol.…”

“…20 When transarterial embolization has been attempted, cranial neuropathies are a known complication. 5,6 Innovations in catheter design may augment transarterial paraganglioma embolization. The Scepter catheter (MicroVention, Inc.), a dual-lumen balloon catheter, was used recently in tumor and arteriovenous malformation embolization procedures.…”