title: Management of complex tympanojugular paragangliomas including endovascular intervention.
abstract: OBJECTIVE
  To identify complex cases of tympanojugular paraganglioma (TJP) and to analyze their management and surgical outcome. To present strategy and guidelines on how to deal with the perioperative complicating factors.
  
  
  METHODS
  Retrospective analysis.
  
  
  METHODS
  We retrospectively studied 212 TJP patients to identify the complex cases and analyzed their management and surgical outcome. The criteria for complex TJP are: 1) very large size; 2) large intradural extension (IDE); 3) extension to the cavernous sinus, foramen magnum, and clivus; 4) significant involvement of the internal carotid artery (ICA); 5) a solitary ICA on the lesion side; 6) involvement of the vertebral artery; 7) dominant or unilateral sigmoid sinus on the lesion side; 8) bilateral or multiple paragangliomas; and 9) recurrence.
  
  
  RESULTS
  Sixty patients were classified as complex. Forty-five patients had tumors with IDE. Twenty patients with tumor involving ICA underwent preoperative endovascular intervention. Two patients had a solitary ICA and two others unilateral sigmoid sinus on the lesion side. Thirteen patients had multicentric tumors, and three patients had bilateral ones. The main procedure was the infratemporal fossa approach type A. Total removal was achieved in 46 patients, and five of them experienced recurrence.
  
  
  CONCLUSIONS
  It is essential to carefully investigate the hemodynamics of the brain in planning surgery. A proper preoperative endovascular intervention facilitates gross total tumor removal. In bilateral paragangliomas, lower cranial nerves' function should be preserved at least unilaterally. Staged removal is recommended for a tumor with a large intradural component.
authors.affiliation: Gruppo Otologico, Piacenza, Italy.
authors.forename: Mario
authors.initials: M
authors.lastname: Sanna
authors.forename: Seung-Ho
authors.initials: SH
authors.lastname: Shin
authors.forename: Giuseppe
authors.initials: G
authors.lastname: De Donato
authors.forename: Shailendra
authors.initials: S
authors.lastname: Sivalingam
authors.forename: Lorenzo
authors.initials: L
authors.lastname: Lauda
authors.forename: Francesca
authors.initials: F
authors.lastname: Vitullo
authors.forename: Paolo
authors.initials: P
authors.lastname: Piazza
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000792:Angiography / Q000379:methods; D017130:Angioplasty / Q000379:methods; D015331:Cohort Studies; D003131:Combined Modality Therapy; D005260:Female; D005500:Follow-Up Studies; D005682:Gadolinium; D005925:Glomus Jugulare Tumor / Q000175:diagnosis / Q000473:pathology* / Q000601:surgery*; D043604:Glomus Tympanicum Tumor / Q000175:diagnosis / Q000473:pathology* / Q000601:surgery*; D006801:Humans; D007430:Intraoperative Care / Q000379:methods; D008279:Magnetic Resonance Imaging / Q000379:methods; D008297:Male; D008875:Middle Aged; D009361:Neoplasm Invasiveness / Q000473:pathology; D009367:Neoplasm Staging; D010236:Paraganglioma, Extra-Adrenal / Q000175:diagnosis / Q000473:pathology / Q000601:surgery; D011183:Postoperative Complications / Q000401:mortality / Q000503:physiopathology; D011856:Radiographic Image Enhancement; D012189:Retrospective Studies; D018570:Risk Assessment; D015996:Survival Rate; D014057:Tomography, X-Ray Computed / Q000379:methods; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000379:methods; D055815:Young Adult
chemical_list: D005682:Gadolinium