VIII

Table of Contents

1 Introduction 1

■ Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 ■ Genetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
■ Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Mutation Types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
■ Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Clinical Presentation of Familial Paraganglioma Syndromes . . . 4
■ Pathophysiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Summary and Management Recommendations. . . . . . . . . . . . . 5
Biological Behavior. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 ■ Historical Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Metastatic Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

2 Surgical Anatomy 12

■ The Jugular Foramen: An Overview . . . . . . . . . . . . . . . . . . . . . 12 Hypoglossal Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Bony Margins of the Jugular Foramen . . . . . . . . . . . . . . . . . . . . . 12 Posterior Inferior Cerebellar Artery. . . . . . . . . . . . . . . . . . . . . . . . 21
Internal Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Anterior Inferior Cerebellar Artery . . . . . . . . . . . . . . . . . . . . . . . . 21
Lateral Relationships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Facial and Cochleovestibular Nerves . . . . . . . . . . . . . . . . . . . . . . 21
Superior Relationships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 ■ Brainstem Arrangement and Jugular Fossa Arrangement
Anterior Relationships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 of the Lower Cranial Nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Medial Relationships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 ■ Anatomy of the Vertebral Artery . . . . . . . . . . . . . . . . . . . . . . . 22
Inferior Relationships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Extradural Segments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Posterior Relationships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Intradural Segment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
■ The Temporal Bone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 ■ The Anterolateral Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Significant Structures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Neurovascular Anatomy Pertaining to Carotid Body Tumors . . . 24
■ Intradural Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Vagus and Hypoglossal Nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Lower Cranial Nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

3 Radiological Anatomy 29

■ CT and MRI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 ■ Angiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Axial CT, Bone Windows . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 External Carotid Artery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Coronal CT, Bone Windows. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Internal Carotid Artery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Axial Heavily Weighted T2 MRI . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Radiological Anatomy of the Vertebral Artery. . . . . . . . . . . . . . . 55
Axial T1 Gadolinium-enhanced MRI . . . . . . . . . . . . . . . . . . . . . . . 39 Radiological Anatomy of the Circle of Willis . . . . . . . . . . . . . . . . 62
T1 MRI Coronal View . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 The Craniocervical Venous System. . . . . . . . . . . . . . . . . . . . . . . . 63

4 Clinical Presentations and Diagnostic Work-up 73

■ Tympanojugular Paragangliomas . . . . . . . . . . . . . . . . . . . . . . . 73 ■ Cervicocarotid Paragangliomas. . . . . . . . . . . . . . . . . . . . . . . . . 90

Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Diagnostic Work-up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Diagnostic Work-up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

5 Treatment Options and Decision Making 98

■ Solitary Lesions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 ■ Postoperative Follow-up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106

Tympanic and Tympanomastoid Paragangliomas . . . . . . . . . . . . 98 ■ Management of Recurrence . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Tympanojugular Paragangliomas . . . . . . . . . . . . . . . . . . . . . . . . . 99 ■ Unresectable Tumors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Vagal Paragangliomas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 ■ Subtotal versus Total Removal. . . . . . . . . . . . . . . . . . . . . . . . . . 106
Carotid Body Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 ■ Indications for Radiotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
■ Multiple Lesions, Paraganglioma Syndromes, and ■ Wait and Scan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Confirmed Genetic Defect. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 ■ Summary of Major Surgical Considerations in
■ Management of Metastatic Disease . . . . . . . . . . . . . . . . . . . . . 105 Tympanojugular Paraganglioma . . . . . . . . . . . . . . . . . . . . . . . . 107
aus: Sanna u. a., Microsurgery of Skull Base Paragangliomas (ISBN 9783131486110) © 2013 Georg Thieme Verlag KG
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6 Interventional Neuroradiology 111

■ Embolization of Paragangliomas. . . . . . . . . . . . . . . . . . . . . . . . 111 ■ Interventional Neuroradiological Management of the

General Principles of Embolization in Paragangliomas . . . . . . . . 111 Internal Carotid Artery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Embolization of Tympanic, Tympanomastoid, and Preoperative Neuroradiological Assessment . . . . . . . . . . . . . . . . 120
Tympanojugular Paragangliomas . . . . . . . . . . . . . . . . . . . . . . . . . 112 Permanent Occlusion of the Internal Carotid Artery. . . . . . . . . . 125
Embolization of Carotid Body Tumors . . . . . . . . . . . . . . . . . . . . . 113 Preoperative Stenting of the Carotid Artery . . . . . . . . . . . . . . . . 132
Embolization of Vagal Paragangliomas . . . . . . . . . . . . . . . . . . . . 113 ■ Interventional Neuroradiological Management of the
The Role of Direct Puncture in Embolization of Vertebral Artery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
Paragangliomas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Preoperative Neuroradiological Evaluation . . . . . . . . . . . . . . . . . 138
Preoperative Permanent Endovascular Occlusion of the
Vertebral Artery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141

7 Preoperative Preparation, Patient Care, and Nerve Monitoring 146

■ Anesthetic Techniques in Neuro-otologic Surgery . . . . . . . . . 146 ■ Lower Cranial Nerve and Facial Nerve Monitoring. . . . . . . . . 154
■ Blood Component Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 Lower Cranial Nerve Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . 154
■ Operating Room Setup, Instruments, and Patient Care . . . . 146 Facial Nerve Monitoring. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
Operating Room Setup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 Instrumentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Postoperative Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152

8 Surgical Management of Class A and B Tumors 160

■ Preoperative Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 Case 8.2: Class A2 Paraganglioma (left ear). . . . . . . . . . . . . . . . . 174
■ Surgical Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 Case 8.3: Class B1 Paraganglioma (right ear). . . . . . . . . . . . . . . . 183
Class A1 Tumors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 Case 8.4: Class B2 Paraganglioma (left ear) . . . . . . . . . . . . . . . . . 192
Class A2 Tumors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164 Case 8.5: Class B2 Paraganglioma with Poor Hearing
Class B1 and B2 Tumors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 (left ear) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196
Class B3 Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168 Case 8.6: Class B3 Paraganglioma (right ear). . . . . . . . . . . . . . . . 205
■ Clinical Cases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170 Case 8.7: Class B3 Paraganglioma (right ear). . . . . . . . . . . . . . . . 211
Case 8.1: Class A1 Paraganglioma (right ear) . . . . . . . . . . . . . . . 170 Case 8.8: Class B3 Glomus Tumor (right ear). . . . . . . . . . . . . . . . 216

9 Surgical Management of Class C1–C4 Tumors 226

■ Principles of the Approach to the Jugular Foramen . . . . . . . . 226 Case 9.3: Multiple Paragangliomas. . . . . . . . . . . . . . . . . . . . . . . . 290
Arguments against “Conservative” Approaches to the Case 9.4: Single-stage Removal of Tumor with Small
Jugular Foramen. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226 Intradural Extension (C2Di1). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301
■ The Gruppo Otologico Approach to Tympanojugular Case 9.5: Staged Removal in a Complex Case with a
Paragangliomas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227 Class C3Di2 Tympanojugular Paraganglioma, Stage I Vagal
Infratemporal Fossa Approach Type A . . . . . . . . . . . . . . . . . . . . . 228 Paraganglioma, and Sacrifice of the Internal Carotid Artery . . . 316
Extensions of the Infratemporal Fossa Approach Type A . . . . . . 234 Case 9.6: ITFA with Transcondylar Extension . . . . . . . . . . . . . . . . 336
■ Clinical Cases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254 ■ Summary of Surgical Management of Tympanojugular
Case 9.1: Class C1 Tumor, Fallopion Bridge Technique . . . . . . . . 254 Paraganglioma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343
Case 9.2: ITFA with Transcondylar Extension . . . . . . . . . . . . . . . . 261

10 Surgical Management of Vagal Paragangliomas 347

■ Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347 Case 10.1: Bilateral Vagal Paragangliomas (Fisch Stage Im)
■ Pathophysiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347 with Transcervical Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 352
■ Diagnostic Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347 Case 10.2: Left Vagal Paraganglioma (Fisch Stage II)+ Left
■ Decision Making. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 348 Carotid Body Tumor (Shamblin Stage I) with ITFA. . . . . . . . . . . . 360
Indications for Radiotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349 Case 10.3: Vagal Paraganglioma (Fisch Stage I) with Internal
Degree of Extension at Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . 349 Carotid Artery Stenting and Transcervical Approach . . . . . . . . . 368
■ Preoperative Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . 351 Case 10.4: Follow-up Case (Right Vagal Paraganglioma
■ The Surgical Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351 Fisch Stage I and Left Tympanojugular Paraganglioma
Gruppo Otologico Approaches to the Upper Parapharyngeal Class C2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375
Space . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351 Case 10.5: Atypical Vagal Paraganglioma . . . . . . . . . . . . . . . . . . 379
Other Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351
■ Postoperative Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . 352
■ Clinical Cases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 352
aus: Sanna u. a., Microsurgery of Skull Base Paragangliomas (ISBN 9783131486110) © 2013 Georg Thieme Verlag KG
X Table of Contents

11 Management of Complex Tympanojugular Paragangliomas 397

■ Perioperative Complicating Factors in Complex ■ Clinical Cases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 404

Tympanojugular Paragangliomas . . . . . . . . . . . . . . . . . . . . . . . 397 Case 11.1: Two Staged Removals (ITFA, MTCA) after Permanent
Large Size . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397 Balloon Occlusion with Class C3Di2vi Tympanojugular
Large Intradural Extension. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397 Paraganglioma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 404
Extension to the Cavernous Sinus, Clivus, or Foramen Case 11.2: Two Staged Removals (ITFA with Transcondylar
Magnum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 398 Transtubercular Extension, MTCA) after Permanent Balloon
Involvement of the Internal Carotid Artery . . . . . . . . . . . . . . . . . 399 Occlusion with Class C3Di2 Tympanojugular Paraganglioma. . . 414
A Single Internal Carotid Artery on the Lesion Side. . . . . . . . . . . 400 Case 11.3: Two Staged Removals with Class C3De2Di1 TJP
Involvement of the Vertebral Artery . . . . . . . . . . . . . . . . . . . . . . 401 after PBO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 429
Dominant or Unilateral Sigmoid Sinus on the Lesion Side . . . . . 401 Case 11.4: Four Staged Tumor Removals with Class C4Di2Vi
Bilateral or Multiple Paragangliomas . . . . . . . . . . . . . . . . . . . . . . 402 after Stenting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437
Recurrence after Previous Surgery, Radiotherapy, or
Stereotactic Radiosurgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 402

12 Surgical Management of Carotid Body Tumors 455

■ Anatomy and Physiology of the Carotid Body . . . . . . . . . . . . 455 Managing Carotid Artery Injury and Grafting Techniques . . . . . 462
■ Clinical Features and Pathology of Carotid Body Tumors . . . 455 ■ Surgical Results and Assessments . . . . . . . . . . . . . . . . . . . . . . . 462
■ Diagnosis and Classification of Carotid Body Tumors . . . . . . 456 ■ Postoperative Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . 463
Multiple Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 458 ■ Alternative Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 463
Malignancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 458 Conservative or Wait and Scan . . . . . . . . . . . . . . . . . . . . . . . . . . . 463
■ Preoperative Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 458 Radiotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 463
■ Surgical Management (Surgical Steps of CBT Resection) . . . 459 ■ Clinical Cases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 464
Transcervical Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 459 Case 12.1: With Shamblin I CBT . . . . . . . . . . . . . . . . . . . . . . . . . . 464
Retroauricular–Transmastoid–Transcervical Approach Case 12.2: With Shamblin II CBT. . . . . . . . . . . . . . . . . . . . . . . . . . 466
(Modified Fisch Infratemporal Fossa Approach) . . . . . . . . . . . . . 460 Case 12.3: With Bilateral Shamblin type III CBTs. Staged
Tumor Dissection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 462 Removal of Bilateral Tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 469

13 Facial Nerve Management in Paraganglioma Surgery 489

■ Identification of the Facial Nerve: Key Anatomical Points . . 490 Case 13.4 Anterior Rerouting of the Facial Nerve for
Intratemporal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 490 Class C2 Tumor Engulfing it. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 511
Extratemporal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 490 Management of the Involved Facial Nerve. . . . . . . . . . . . . . . . . . 515
■ Facial Nerve Management Based on the Case 13.5: Transection of the Involved Segment of the
Fisch Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 491 Facial Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 516
Facial Nerve Management in Classes A1 and A2 Tumors . . . . . . 491 Grafting of the Facial Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 518
Facial Nerve Management in Class B1 Tumor . . . . . . . . . . . . . . . 491 Case 13.6: Facial Nerve Grafting with the Sural Nerve for
Facial Nerve Management in Class B2 Tumor . . . . . . . . . . . . . . . 491 Class C1 Tumor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 521
Facial Nerve Management in Class B3 Tumor . . . . . . . . . . . . . . . 492 Case 13.7: Facial Nerve Grafting with the Sural Nerve for
Facial Nerve Management in Class C1–C4 Tumors . . . . . . . . . . . 492 Malignant TTP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 528
■ Facial Nerve Management Based on the Degree of Case 13.8: Facial Nerve Grafting with the Sural Nerve for
Tumor Involvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 492 Class C2 Tumor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 532
Fallopian Bridge Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 493 Case 13.9: Facial Nerve Grafting with a Sural Nerve for
Mobilization of the Facial Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . 495 Class C2De1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 536
■ Clinical Cases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 497 Case 13.10: Facial Nerve Grafting with a Sural Nerve for
Case 13.1: Fallopian Bridge Technique for Class C1 Tumor. . . . . 497 Class B3 Tumor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 539
Case 13.2: Anterior Rerouting of the Facial Nerve in Facial–Hypoglossal Anastomosis . . . . . . . . . . . . . . . . . . . . . . . . . 550
Infratemporal Fossa Approach Type A for Class C2 Tumor . . . . . 502
Case 13.3: Anterior Rerouting of the Facial Nerve in
Infratemporal Fossa Approach Type A for Class C2 Tumor . . . . . 507

14 Management of the Internal Carotid Artery 555

■ Surgical Anatomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 555 Permanent Balloon Occlusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . 564

■ Angiographic Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 564 Intra-arterial Stenting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 566
■ Preoperative Assessment and Management of the ■ Arterial Control / Exposure of the Internal Carotid Artery . . 567
Internal Carotid Artery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 564 Arterial Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 567
Indications for Presurgical Management of the Internal Carotid Exposure of the Internal Carotid Artery . . . . . . . . . . . . . . . . . . . . 567
Artery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 564

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■ Management of Tumor Involvement of the Internal Subadventitial Dissection after Reinforcement with Stent . . . . . 580
Carotid Artery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 570 Case 14.4: Subadventitial Dissection of the Internal
Decompression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 571 Carotid Artery for Class C3 Tumor . . . . . . . . . . . . . . . . . . . . . . . . 581
Decompression with Partial Mobilization. . . . . . . . . . . . . . . . . . . 571 Case 14.5: Subadventitial Dissection of the Internal
Subperiosteal/Subadventitial Dissection and Anterior Carotid Artery after Stent Insertion for Class C3Di2 Tumor . . . . 587
Mobilization without Stent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 571 Case 14.6: Subadventitial Dissection of the Internal
■ Clinical Cases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 572 Carotid Artery after Stent Insertion for Class C4Di2Vi Tumor . . 592
Case 14.1: Subperiosteal Dissection of the Internal Case 14.7: Subadventitial Dissection of the Internal
Carotid Artery for Class C2 Tumor . . . . . . . . . . . . . . . . . . . . . . . . 572 Carotid Artery after Stent Insertion for Class C3Di2Vi Tumor . . 598
Case 14.2: Subadventitial Dissection of the Internal Dissection and Resection after Permanent Balloon Occlusion . . 606
Carotid Artery for Class C2 Tumor . . . . . . . . . . . . . . . . . . . . . . . . 575 Case 14.8: Resection of the Internal Carotid Artery after
Case 14.3: Subadventitial Dissection of the Internal Permanent Balloon Occlusion for Class C3Di2 TJP and
Carotid Artery for Class C3 Tumor . . . . . . . . . . . . . . . . . . . . . . . . 577 Stage I VP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 608
■ Intraoperative Internal Carotid Artery Injury . . . . . . . . . . . . . 615

15 Management of the Large Intracranial and Extracranial Veins 617

■ Intraoperative Management . . . . . . . . . . . . . . . . . . . . . . . . . . . 617

■ Potential Problems with Dural Sinus and Jugular Vein
Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 622

16 Management of the Lower Cranial Nerves 623

■ Maximizing the Preservation of Lower Cranial Nerves . . . . . 624 Case 16.3: Intrabulbar Dissection. . . . . . . . . . . . . . . . . . . . . . . . . 627
■ Clinical Cases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 624 Case 16.4: Intrabulbar Dissection. . . . . . . . . . . . . . . . . . . . . . . . . 630
Case 16.1: Intrabulbar Dissection to Preserve Lower Case 16.5: Sacrifice of the Involved Intradural Lower
Cranial Nerve Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 624 Cranial Nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 631
Case 16.2: Infralabyrinthine Dissection . . . . . . . . . . . . . . . . . . . . 625

17 Management of Intradural Tumor Extension 633

■ Clinical Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 634 ■ Clinical Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 647

Case 17.1: One-Stage Procedure for Class C1Di1 Tumor . . . . . . 634 Case 17.3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 647
■ MR Image Comparison Before and After the First Skull Base Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 653
Stage Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 640 ■ The Order of Resection: Intradural or Extradural Tumor
■ Rationale for Staging. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 641 First in Single-Stage Resections or Staged Procedures . . . . . 653
■ Clinical Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 642 ■ Important Factors at Initial Surgery to Minimize
Case 17.2: Second-Stage Procedure for Class C2Di2 Tumor . . . . 642 Recurrence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 654
■ Techniques of Intradural Dissection . . . . . . . . . . . . . . . . . . . . . 647

18 Management of Tumors Involving the Vertebral Artery 656

■ Preoperative Evaluation and Treatment. . . . . . . . . . . . . . . . . . 656
■ Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 656
Surgical Technique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 658
■ Clinical Cases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 661
Case 18.1: Second-Stage Surgery after Preoperative Balloon
Occlusion of the Vertebral Artery . . . . . . . . . . . . . . . . . . . . . . . . . 661
Case 18.2: Three-Stage Surgery after Preoperative
Balloon Occlusion of the Vertebral Artery . . . . . . . . . . . . . . . . . . 665
Case 18.3: Extreme Lateral Transcondylar Approach for
Removal of the Remnant Intradural Tumor Around the
Vertebral Artery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 672
Case 18.4: Modified Transcochlear Approach Type D . . . . . . . . . 677

19 Postoperative Care and Management of Complications 681

■ Perioperative Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . 681 Lower Cranial Nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 683

Management of CSF Leakage . . . . . . . . . . . . . . . . . . . . . . . . . . . . 681 Hearing Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 684
■ Postoperative Medication and Discharge . . . . . . . . . . . . . . . . 681 ■ Long Term Follow-up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 684
■ Rehabilitation of Cranial Nerve Deficits . . . . . . . . . . . . . . . . . . 682
Facial Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 682

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20 Treatment Planning of Pharyngolaryngeal Surgery for Iatrogenic Complications following High Vagal Injury 685

■ Surgical Anatomy of the Vagus Nerve in the Skull Base ■ Clinical Assessment of Pharyngolaryngeal Disorders
and Upper Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 685 after High Vagal Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 686
■ Pharyngolaryngeal Pathophysiological Changes following ■ Therapeutic Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 687
High Vagal Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 685 ■ Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 689

Index 691

aus: Sanna u. a., Microsurgery of Skull Base Paragangliomas (ISBN 9783131486110) © 2013 Georg Thieme Verlag KG