头颈部副神经节瘤影像学诊断

目的:探讨头颈部副神经节瘤的影像学特征。方法:回顾性分析19例头颈部副神经节瘤的CT、MRI和DSA表现,其中颈静脉球瘤3例,鼓室球瘤2例,颈动脉体瘤12例,迷走体瘤2例。结果:颈静脉球瘤的CT特征为颈静脉孔扩大和虫蚀骨质破坏,1例双侧因肿瘤为1cm首次平扫漏诊;鼓室球瘤均较小,发生于鼓岬区,临床特征为搏动性耳鸣和鼓膜充血;颈动脉体瘤位于颈总动脉分叉处,特征为颈内、外动脉分离和动脉镶嵌于肿瘤边缘或肿瘤内;迷走体瘤与颈动脉体瘤的区别在于颈内、外动脉受压后均向前移位。增强后肿瘤均见明显强化,MRA图像有助于确认肿瘤内的滋养血管,术前栓塞是治疗的有效方法,能减少约50%~70%肿瘤供血。结论:头颈部副神经节瘤具有特定的解剖学位置和影像学表现,对临床诊断和治疗有重要价值。     

Imaging and management of head and neck paragangliomas

Paragangliomas of the head and neck are highly vascular lesions originating from paraganglionic tissue located at the carotid bifurcation (carotid body tumors), along the vagus nerve (vagal paragangliomas), and in the jugular fossa and tympanic cavity (jugulotympanic paragangliomas). Diagnostic imaging can be considered in two clinical situations: (1) patients who present with clinical symptoms suggestive of a paraganglioma, and (2) individuals from families with hereditary paragangliomas. It is not only necessary to detect and characterize the lesion, but also to study the presence of multiplicity. For these purposes, MR imaging, and especially 3D TOF MRA, is the modality of choice. CT scanning is especially useful to show destruction of the temporal bone. Angiography in combination with embolization will mainly be used prior to surgical resection, but can also be used for diagnostic purposes when the diagnosis is not yet clear. Many parameters play a role in the decision to treat of which multifocality and impairment of cranial nerves are the most important. The primary therapeutic option for paragangliomas is complete excision of tumor with preservation of vital neurovascular structures. Resection however, should be balanced against a more conservative wait and scan policy or palliative treatments such as radiotherapy.     

Devascularization of Head and Neck Paragangliomas by Direct Percutaneous Embolization

Preoperative transarterial embolization of head and neck paragangliomas using particulate agents has proven beneficial for decreasing intraoperative blood loss. However, the procedure is often incomplete owing to extensive vascular structure and arteriovenous shunts. We report our experience with embolization of these lesions by means of direct puncture and intratumoral injection of n-butyl cyanoacrylate (NBCA) or Onyx. Ten patients aged 32–82 years who were referred for preoperative embolization of seven carotid body tumors and three jugular paragangliomas were retrospectively analyzed. Intratumoral injections were primarily performed in four cases with multiple small-caliber arterial feeders and adjunctive to transarterial embolization in six cases with incomplete devascularization. Punctures were performed under ultrasound and injections were performed under roadmap fluoroscopic guidance. Detailed angiographies were performed before and after embolization procedures. Control angiograms showed complete or near-complete devascularization in all tumors. Three tumors with multiple small-caliber arterial feeders were treated with primary NBCA injections. One tumor necessitated transarterial embolization after primary injection of Onyx. Six tumors showed regional vascularization from the vasa vasorum or small-caliber branches of the external carotid artery following the transarterial approach. These regions were embolized with NBCA injections. No technical or clinical complications related to embolization procedures occurred. All except one of the tumors were surgically removed following embolization. In conclusion, preoperative devascularization with percutaneous direct injection of NBCA or Onyx is feasible, safe, and effective in head and neck paragangliomas with multiple small-caliber arterial feeders and in cases of incomplete devascularization following transarterial embolization.     

Nasopharyngeal angiofibromas: hazards of embolization

A systematic approach to the diagnosis and treatment of angiofibromas is presented. The distinction between true and false internal carotid supply to these tumors as well as identification of vascular anatomical variants that may represent potential hazards of embolization are emphasized. Areterial supply to the cranial nerves, prevention of neurologic complications, and the use of inappropriate embolization materials are also discussed.     

Bilateral carotid body tumor case: A novel preoperative management

Paragangliomas are rare neuroendocrine neoplasms. The most common form of these tumors in head and neck are non-functional carotid body tumors. These neoplasms may present an extensive growth and compromise vital neurovascular structures in the neck, such as carotid vessels. Carotid body tumors usually present clinically as painless neck masses and occur most frequently in adults averaging 45 to 50 years, being the majority of these tumors unilateral and only 5% of all cases bilateral. The main treatment for carotid body paragangliomas is surgical resection, which can be extremely challenging due to tumor hypervascularity and significant blood loss.We present a bilateral carotid body tumor case in a 61-year-old woman who presented due to a pulsatile and painless mass in the right carotid region of the neck of 1-year of evolution. The tumor was found encasing the external carotid artery and classified as Shamblin II. A novel approach for preoperative management was performed, placing a covered graft-stent in the right common and proximal (C1) internal carotid arteries in order to splint and provide structural protection for carotid vessels during surgical resection and temporarily reduce blood flow of the carotid body tumor.     

Intratumoral injection of cyanoacrylate glue in head and neck paragangliomas

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.     

Angiographic observations on chemodectomas of the head and neck.

Angiographic experience with chemodectomas in 21 patients is reviewed. Arterial supply was identified from the vertebral artery, the internal carotid artery, and branches of the external carotid artery. A striated cephalad extension from a cervical chemodectoma (five patients) is believed to represent arterial supply to tumor in vein. In two patients, internal and external carotid arteriograms did not opacify important arteries originating near the carotid bifurcation. Retrograde filling of sigmoid sinus (four patients), tumor mass in jugular vein (two patients), and arteriovenous shunting (nine patients) were observed during the venous phase. Thorough angiogra phy is essential for evaluation of chemodectomas of the head and neck.     

Interventional radiology of the extracranial head and neck

The topic of interventional radiology of the extracranial head and neck is reviewed. Knowledge of functional vascular anatomy and recognition of the “dangerous anastomoses” between the external carotid artery and the intracranial circulation are stressed. Technical aspects of embolization are surveyed. The authors' approach to some of the more common lesions such as paragangliomas, congenital vascular lesions, epistaxis, juvenile angiofibromas, and arteriovenous fistulas are described. Illustrative cases are presented. Proper training and experience are needed in order to safely and effectively perform embolization procedures of the head and neck.     

Preoperative embolization of intracranial meningiomas

The goal of preoperative embolization of intracranial meningiomas is to facilitate their surgical removal by reducing tumor vascularity and decreasing blood loss during surgery. This study is based on personal experience with about 100 embolized meningiomas and on the experience of others. Embolization is performed during the same session as diagnostic angiography. The appropriate embolic materials (absorbable or nonabsorbable) are chosen according to the location of the tumor, the size of the feeding arteries, the blood flow, and the presence of any potentially dangerous vessels (dangerous anastomoses between external carotid artery and internal carotid or vertebral arteries, arteries supplying the cranial nerves). Preoperative embolization appeared to be very useful in large tumors with pure or predominant external carotid artery supply (convexity meningiomas), in skull-base meningiomas, and in middle fossa and paracavernous meningiomas. It was also useful in falx and parasagittal meningiomas receiving blood supply from the opposite side and in posterior fossa meningiomas. CT low densities demonstrated after embolization did not always correlate with necrosis on microscopic examination, and large areas of infarction could be found despite normal CT. Embolic material was found on pathologic examination in 10%-30% of cases; fresh or recent ischemic and/or hemorrhagic necrosis consistent with technically successful embolization was demonstrated in 40%-60% of cases. With careful technique complications are rare.     

Vascularization of head and neck paragangliomas: comparison of three MR angiographic techniques with digital subtraction angiography

BACKGROUND AND PURPOSE: MR angiography of the head and neck region has been studied widely, but few studies have been performed concerning the efficacy of MR angiography for the identification of the specific vascular supply of the highly vascular head and neck paragangliomas. In this study, we compared three MR angiography techniques with respect to visualization of branch arteries in the neck and identification of tumor feeders in patients with paragangliomas. METHODS: Fourteen patients with 29 paragangliomas were examined at 1.5 T using 3D phase-contrast (PC), 2D time-of-flight (2D TOF), and multi-slab 3D TOF MR angiography. In the first part of the study, two radiologists independently evaluated the visibility of first-, second-, and third-order branch arteries in the neck. In the second part of the study, the number of feeding arteries for every paraganglioma was determined and compared with digital subtraction angiography (DSA), the standard of reference in this study. RESULTS: Three-dimensional TOF angiography was superior to the other MR angiography techniques studied (P < .05) for depicting branch arteries of the external carotid artery in the neck, but only first- and second-order vessels were reliably shown. DSA showed a total of 78 feeding arteries in the group of patients with 29 paragangliomas, which was superior to what was revealed by all MR angiography techniques studied. More tumor feeders were identified with 3D TOF and 2D TOF angiography than with 3D PC MR angiography (P < .05), with a sensitivity/specificity of 61%/98%, 54%/95%, and 31%/95%, respectively. Sensitivity was lowest for carotid body tumors. CONCLUSION: Compared with intra-arterial DSA, the 3D TOF MR angiography technique was superior to 3D PC and 2D TOF MR angiography for identifying the first- and second-order vessels in the neck. With 3D TOF angiography, more tumor feeders were identified than with the other MR angiography techniques studied. The sensitivity of MR angiography, however, is not high enough to reveal important vascularization. The sensitivity of MR angiography is too low to replace DSA, especially in the presence of carotid body tumors.     

Lidocaine injection into external carotid branches: provocative test to preserve cranial nerve function in therapeutic embolization

Endovascular obliteration of hypervascular lesions of the head and neck has become clinically accepted, but it may cause stroke and peripheral cranial nerve palsy. By using a flow-controlled technique to deliver the materials and by knowing the vascular anatomy of the cranial nerves, these problems are less likely to occur. Occasionally, though, vascular anatomy is distorted by the lesion or is anomalous in its distribution. A provocative test of lidocaine injected into the appropriate artery seems to offer a functional test of whether the capillary bed will tolerate small-particle or liquid plastic occlusion. Twenty-six patients had various branches of their external carotid arteries challenged with lidocaine. Three developed transient palsies, and their treatments were modified. None of the 26 patients developed a complication of embolization.     

头颈部副神经节瘤的术前栓塞治疗

目的：分析头颈部副神经节瘤的ＤＳＡ表现及评价术前栓塞的作用。材料与方法，８例患者均行双侧颈总动脉及椎动脉ＤＳＡ检查，而后行患侧超选择性插管，以明胶海绵颗粒或真丝段作为栓塞材料。结果：５例颈静脉球瘤，２例颈动脉体瘤及１例迷走神经体瘤的动脉期均显示主要由颈外动脉的分支供血，如咽升动脉，耳后动脉，枕动脉等，颈静球瘤如侵犯后颅凹，颈内动脉或椎动脉的分支也可参与供血，实质期，肿瘤呈分叶状，不均匀染色，静脉期     

The ascending pharyngeal artery: branches,anastomoses, and clinical significance

Neuroradiologists generally do not fully appreciate the importance of the territory of the ascending pharyngeal artery. The ascending pharyngeal artery is a small but important artery that supplies multiple cranial nerves and anastomotic channels to the anterior and posterior cerebral circulations. Several disease processes in the head and neck involve the ascending pharyngeal artery. To evaluate and treat such diseases, it is necessary for neuroradiologists not only to know selective angiography and embolization techniques, but also the territory of the ascending pharyngeal artery, anastomoses, and vascular supply to the vasa nervorum of lower cranial nerves. Herein, the normal angiographic anatomy of the ascending pharyngeal artery, its relationship with neighboring territories, its importance in clinical situations, and research models are reviewed.     

超选择性颈外动脉分支栓塞术在头颈部疾病中的应用

目的探讨超选择性颈外动脉分支栓塞术在头颈部疾病中的应用。方法对41例头颈部疾病患者进行DSA检查,行超选择性颈外动脉分支栓塞治疗。结果12例鼻出血栓塞后即刻无活动性出血,随访6～12个月未再复发;7例鼻咽纤维血管瘤栓塞后手术出血量明显减少;1例外伤动脉出血栓塞后即刻止血,无复发;14例血管畸形栓塞后随访6～12个月,明显好转3例,好转6例,无变化5例;7例头颈部恶性肿瘤姑息性治疗后存活时间2年以上者3例。结论超选择性颈外动脉栓塞术治疗头颈部疾病安全、有效。     

Internal carotid aneurysms presenting with mass effect symptoms of cranial nerve dysfunction: efficacy and imitations of endosaccular embolization with GDC

OBJECTIVE: The authors report a retrospective analysis of their experience in the endosaccular embolization of internal carotid aneurysms which caused mass effect symptoms of cranial nerves (CN) and review the efficacy and limitations of this technique. METHODS: Between April 1997 and August 2002, 12 internal carotid aneurysms that caused mass effect symptoms of CN were treated by endosaccular GDC embolization with parent artery preservation. The locations were the cavernous internal carotid artery (CV) in six patients, carotid-ophthalmic artery (CO) in two patients, and posterior communicating artery (PCo) in four patients. The angiographical size of the aneurysms ranged from 6 to 20 mm, with a mean of 13.3 mm. Duration of symptoms ranged from 0.5 to 120 months, with a mean of 13.7 months. All aneurysms were treated by endosaccular guglielmi detachable coil (GDC) embolization with preservation of the internal carotid artery. RESULTS: Five patients (42%) had complete resolution of symptoms, four (33%) had significant improvement of symptoms, and three (25%) were unchanged. Immediate posttreatment angiographic studies revealed neck remnant (NR) in nine patients and dome filling (DF) in three patients. In one patient (case 10), the resolved symptoms became worse 29 months later. Follow-up angiograms were obtained in 10 patients, and recanalization was observed in four of them (40%). Transient thrombotic complication occurred in only one patient. The group with resolution or improvement of symptoms demonstrated a shorter duration of symptoms before GDC treatment (< or = 12 months). CONCLUSION: Even subtotal endosaccular embolization of aneurysms may reduce mass effect symptoms of cranial nerves. However, careful follow-up is needed because subtotal occlusion carries a future risk of growth.     

脑膜瘤的DSA及术前栓塞治疗

目的探讨脑膜瘤血管造影表现及手术前栓塞治疗的应用。方法36例经病理确诊的脑膜瘤,术前全部行全脑血管DSA造影,将其中主要由颈外动脉供血的22例患者用PVA栓塞,栓塞治疗后3～10d行手术切除。结果36例患者中,单纯由颈外动脉供血的9例,颈外动脉和颈内动脉供血的25例,颈内动脉供血2例。22例行肿瘤供血动脉栓塞的患者中,栓塞后肿瘤血管染色完全消失16例,染色明显减轻6例。栓塞后行手术切除的22例脑膜瘤患者,病灶被全部切除,术中平均出血150～500ml。结论脑膜瘤可由颈内、颈外动脉单独或混合供血,脑膜瘤的术前颈外动脉栓塞有利于减少术中出血及肿瘤的完整切除。     

Temporal bone trauma and the role of multidetector CT in the emergency department

The temporal bone anatomy is complex, with many critical structures in close association with one another. The temporal bone region comprises cranial nerves V, VI, VII, and VIII; vascular structures such as the internal carotid and middle meningeal arteries; sigmoid sinus; jugular bulb; and sensorineural and membranous structures of the inner ear. Most temporal bone fractures are a result of high-energy blunt head trauma. Multidetector computed tomography (CT) plays a fundamental role in the initial evaluation of patients with polytrauma in the emergency department. Multidetector CT may help identify important structural injuries that may have devastating complications such as sensorineural hearing loss, conductive hearing loss, dizziness and balance dysfunction, perilymphatic fistulas, cerebrospinal fluid leaks, facial nerve paralysis, and vascular injury. Although classifying temporal bone fractures helps physicians understand and predict trauma-associated complications and guide treatment, identifying injury to critical structures is more important for guiding management and determining prognosis than is simply classifying temporal bone fractures into a general category. Many temporal bone fractures and complications may be readily identified and characterized at routine cervical, maxillofacial, and head multidetector CT performed in patients with polytrauma, without the need for dedicated temporal bone multidetector CT. Dedicated temporal bone multidetector CT should be considered when there is a high degree of suspicion for temporal bone fractures and no fractures are identified at head, cervical, or maxillofacial CT.     

可解脱球囊在神经介入手术治疗中的应用和地位

目的 评价可解脱球囊在当今神经介入治疗中的应用价值。方法 38例颅颈部血管性疾病患者（颈内动脉海绵窦瘘26例,海绵窦段颈内动脉巨大动脉瘤3例,梭形动脉瘤1例,颅颈部AVF8例）应用可解脱球囊闭塞瘘口或闭塞一例颈内动脉。结果 38例中,获解剖治愈21例,通过颈内动脉闭塞达到疾病治愈17例,无并发症和后遗症。结论 可解脱球囊在部份颅颈部血管性疾病的介入治疗中,仍然是首选材料。     

介入放射学在颈静脉球瘤术前应用的价值

目的:评价介入放射学在颈静脉球瘤术前应用的价值.方法:本组9例颈静脉瘤患者均经手术病理证实,所有患者于术前行双侧颈内、外动脉和椎动脉造影检查,对其中7例患者行术前供血动脉栓塞及患侧颈内动脉球囊阻断试验以了解Willis'环功能.结果:9例颈静脉球瘤患者术前造影及7例供血动脉栓塞均获成功,肿瘤切除术中出血明显减少;6例通过颈内动脉球囊阻断试验,术中施行颈内动脉结扎术,术后随访均未出现神经系统症状或体征.结论:颈静脉球瘤术前供血动脉栓塞及颈内动脉球囊阻断试验是安全可靠的,可作为常规术前检查.     

Preoperative embolization of hypervascular head and neck tumours

The embolization of vascular tumours of the head and neck has become an important adjunct to the surgical treatment of these tumours. A vascular tumour in the head and neck region in a surgically treatable patient may be a candidate for embolization. Palliative embolization may be the sole treatment for high risk patients. Reducing intraoperative bleeding may shorten surgery time thus decreasing morbidity and mortality. The purpose of this study is to assess the efficacy of embolization as an adjunct to surgery or as a curative measure in the management of hypervascular head and neck tumours. We retrospectively reviewed the records of 46 consecutive patients (27 men and 16 women; mean age, 37.8 years) with 48 hypervascular head and neck tumours that had undergone preoperative transarterial, direct puncture or combined mode of embolization. Diagnosis of tumours was made on the basis of findings of imaging studies. The 46 patients underwent embolization either through transarterial route, by direct puncture technique or both direct puncture and arterial route. The devascularization reached 90-95% with the use of NBCA. The amount of devascularization reached by transarterial particle embolization is a little lesser. One patient (carotid body tumour) developed mild unilateral seventh, ninth and 10th cranial nerve palsy after transarterial embolization, transient hemiparesis was seen in another patient (nasopharyngeal angiofibroma). Both patients improved completely with steroids and had no deficit on follow up. One patient developed delayed glue migration into the middle cerebral artery territory 6 h after the procedure with no reported increase in size of the lesion in the following 5 years. Preoperative embolization of hypervascular tumour of head and neck region appears to be safe and improves the chance of complete removal during surgery with minimal blood loss.