Efficiency and Safety of Preoperative Embolization of Paragangliomas of The Head and Neck

Efficiency and Safety of Preoperative Embolization of Paragangliomas of The Head and Neck | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Efficiency and Safety of Preoperative Embolization of Paragangliomas of The Head and Neck Maged Abdelgwad, Mohammed Salim, Mohammed Saad, Farouk Hassan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6951468/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Paragangliomas of the head and neck, also known as glomus tumors or chemodectomas, are rare neoplasms that account for less than 5% of all head and neck tumors, with an incidence rate ranging from 1 in 30,000 to 1 in 100,000. They can cause local compressive symptoms, leading to varied clinical presentations, or may show biochemical activity. Regardless of their location, paragangliomas are highly vascular and generally benign; however, they can be locally infiltrative, potentially lethal, and challenging to treat. The estimated malignant potential ranges from 2–8% of cases. Histologic examination of the tumor does not provide a definitive diagnosis of its malignant potential. The presence of tumor cells in lymph nodes or systemic metastases is the only accepted criterion for malignancy. Because these tumors can be locally destructive or exhibit malignant tendencies, surgical resection is usually necessary. However, their high vascularity can lead to significant bleeding during surgery, which may impede the complete surgical removal of the lesion. Thus, pre-surgical embolization is an intervention that has been shown to reduce surgical time and blood loss, thereby decreasing morbidity and mortality. The most commonly used method for embolizing these lesions is the transarterial approach, although the direct puncture technique has also been described in some cases. Results: Between January 2021 and March 2023, twenty-five patients with head and neck paraganglioma were referred to our department for preoperative embolization. All cases showed no post-embolic complications. The average intra-operative blood loss was approximately (384 ± 150.5) mL, and only one case required an intra-operative blood transfusion due to injury to the internal jugular vein during the surgical procedure. Two cases, representing 8% of the study group, could not be completely excised, with residual tumor volume that was less than 25% in both cases; one was a recurrent jugulotympanicum lesion, and the other was associated with injury to the internal jugular vein during surgical resection. Conclusion: Preoperative embolization of paragangliomas is a safe technique that can significantly enhance the surgical approach, especially when a targeted strategy is employed using the most appropriate methods and materials for each specific case. Head and neck Paragangliomas Chemodectomas Glomus Carotid body Preoperative embolization Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Background The paraganglia are clusters of highly vascularized neuroendocrine cells dispersed throughout the body and closely related to the autonomic nervous system. Tumors arising from the paraganglia are referred to as paragangliomas [ 1 , 2 ]. Paragangliomas of the head and neck, also known as glomus tumors or chemodectomas, are rare neoplasms accounting for less than 0.5% of all head and neck tumors, with incidence range of 1:30,000 to 1:100,000, and the average age at diagnosis is variable in different literatures it was reported to be from 34.5 to 55 years old [ 3 , 4 ]. Head and neck paragangliomas are often asymptomatic, but some may cause local compressive symptoms, leading to varied clinical presentations based on their location. A painless neck mass is the most common symptom in patients with carotid body tumors, while tinnitus is frequently observed in jugular paragangliomas. Other symptoms can include hearing loss, otalgia, or cranial neuropathy. Cranial neuropathy may result in dysphagia, facial weakness, and vocal fold paresis. A small percentage may also exhibit biochemical activity similar to pheochromocytomas, resulting in symptoms such as diarrhea, hypertension, and flushing [ 5 ]. As these tumors can be locally destructive or exhibit malignant tendencies, surgical resection is usually necessary. However, their high vascularity can lead to significant bleeding during surgery, which may impede the complete surgical removal of the lesion. Thus, pre-surgical embolization is an intervention that has been shown to reduce surgical time and blood loss, thereby decreasing morbidity and mortality. The most commonly used method for embolization of these lesions is transarterial. It involves super-selective catheterization of the arterial feeders of the glomus and embolizing the lesion. However, the transarterial pathway is contingent upon the vascular anatomy of the afferent arteries, their tortuosity, atherosclerotic disease, or the possibility of inducing vasospasm during embolization. In addition, special care must always be taken with dangerous anastomoses between the branches of the external carotid artery and the internal carotid, vertebral, and ophthalmic arteries, especially if embolic particles are used. As a result, in some cases, the direct puncture technique was described [ 6 ]. This study aimed to assess the safety and effectiveness of preoperative embolization of head and neck paragangliomas in simplifying the surgical procedure and facilitating the complete removal of the tumor. Methods Patients: Between January 2021 and March 2023, twenty-five patients presenting clinically and radiologically with paraganglioma of the head and neck were referred from the general surgery or otolaryngology departments to our radiology department for preoperative embolization. The local ethical committee approved this prospective study, and written informed consent was taken. Inclusion criteria: Patients with head and/or neck paragangliomas. Patients referred for interventional procedures based on their preferences or in combination with the general surgery or otolaryngology departments regarding the preferred modality of treatment Patients who consent. Exclusion criteria: Patients whose operation was postponed for any reason. General contraindications and chronic debilitating diseases, e.g., allergy to contrast media, severe renal failure, severe respiratory insufficiency, severe anemia, congestive heart failure, and chronic liver insufficiency. Bleeding and coagulation disorders and anticoagulant users. Patient with a vascular abnormality preventing the endovascular pathway, and the lesion is not accessible via direct embolization. Declined consent. Pre-procedural preparation All patients underwent the following procedures: Complete history taking, general and local clinical examination, and laboratory investigations. The patient’s enhanced cross-sectional imaging studies of the head and neck (contrast-enhanced CT “Computed tomography” and/or MRI “Magnetic resonance imaging”) were carefully reviewed. Procedure Anesthesia and preparation The patients were adequately placed on the angiography table, ensuring adequate exposure of the groin area. They were connected to Electrocardiography leads, a pulse oximeter, and an automated blood pressure monitor. General anesthesia was administered, the hair in the groin area was shaved, and the skin was cleaned with povidone iodine before a sterile gown was applied. Femoral access The right common femoral artery serves as the target for vascular access in all procedures. All catheters, sheaths, and guidewires are flushed with sterile saline in vitro before endovascular use. Local infiltration anesthesia using 1% Lidocaine is injected into the skin, subcutaneous tissue, and around the femoral artery. Aspiration is performed before each injection to ensure the needle is not intravascular. The access needle is introduced between the index and middle fingers, with a pulse felt at its base. A 0.035-inch guidewire is advanced coaxially through the access needle under fluoroscopic guidance to reach the common iliac artery. The needle is withdrawn slowly over the wire, and a 6-French vascular sheath is placed into the common femoral artery. A Y-connector is attached to the tip of the vascular sheath, and a continuous pressurized saline flush is connected at a pressure of 300 mmHg. Catheter insertion The guiding catheter was advanced through the aortic arch to evaluate its vascular anatomy and origins. Angiography was performed to rule out variations or anomalies. The catheter and guidewire were then maneuvered to selectively catheterize the common carotid, external carotid, internal carotid, and vertebral arteries. Identification of the feeding vessels Selective angiography via digital subtraction angiography of each external and internal carotid artery, along with the vertebral artery, was performed at a frame rate of 3 frames per second to detect tumor blush. The tumor blush was examined on the images, and the supplying vessels were identified. The involvement of the external and internal carotid arteries was noted separately. Special attention was given to reviewing the arterial anatomy and detecting any anatomical variations, including the origin of the ophthalmic artery from the middle meningeal artery and the potentially dangerous anastomosis between the internal carotid artery (ICA) and external carotid artery (ECA), before initiating the embolization process. Embolization techniques : Endovascular route : A microcatheter (either Progreat® or Renegade®) with a microwire inside was advanced to super-selectively catheterize the tumor's feeding vessels. Embolic material was prepared by mixing Polyvinyl Alcohol (PVA) powder with a contrast solution and aspirating it into the embolization syringe. The syringe was labeled and utilized for injecting the embolic material. The material was injected in short pulses, synchronized with heartbeats to avoid reflux. It was introduced in small, medium, and large particles. After achieving near stagnation of flow, saline was injected to clear the catheter's dead space. Post-embolization angiography was performed, and residual tumor blush was assessed and compared to the pre-embolization blush. The endpoint of embolization was defined as the disappearance of tumor blush on post-embolization angiography. The procedure was repeated for all vessels supplying the tumor. Post-embolization angiography for the common carotid artery was also conducted and reviewed for any significant residual tumor blush. Direct needle puncture route : If trans-arterial embolization can’t completely devascularize the tumor bed due to the presence of complex angioarchitecture, such as multiple small feeding branches that cannot be directly catheterized, and possible vasospasm. A 22-gauge coaxial introducer puncture needle is utilized under fluoroscopic guidance to access the lesion. Contrast material is injected for parenchymography to confirm arterial reflux and vascular compartment filling. An endovascular non-detachable balloon is placed in the high cervical segment of the internal carotid artery and inflated during the glue injection. The liquid embolic agent, a 1:3 mixture of Histoacryl and Lipiodol, is administered under continuous fluoroscopic monitoring. The procedure is halted when there is a high risk of arterial reflux. The ICA balloon is deflated after each injection to facilitate blood flow into the cerebral arteries. Post-procedure care The anesthesiologist ensured the patient's recovery from anesthesia and spontaneous breathing before discharge from the angiography suite. The patient was instructed to complete bed rest for 12 hours, and their puncture site was compressed and inspected every 2 hours to prevent hematoma formation. They were advised to avoid flexing or standing on the puncture site for 6 hours to prevent rebleeding. Analgesics were prescribed for persistent pain, and antibiotics were provided as a routine preoperative measure for tumor excision. Evaluation of tumor devascularization The pre- and post-embolization angiographies were compared. The percentage of tumor devascularization and residual blush was assessed subjectively by three observers. The remaining feeding vessels of the blush were also identified and recorded. Evaluation of surgical outcome The amount of intraoperative blood loss was quantitatively documented by the surgeon on the surgical sheet and extracted for each patient. It is estimated from the suction tubes and soaked dressings. The operative approach for resection was recorded, and the blood transfusion units were also obtained from the surgical sheet. Statistical Analysis Methods: Statistical analysis of the collected data was conducted using Statistical Package for Social Sciences (SPSS) software version 22 on Windows 7 (SPSS Inc., Chicago, IL, USA). The following formulae were applied: range, mean value, and standard deviation (SD), along with a T-test for comparing the means. The correlation between the parameters was assessed using Spearman’s rank correlation and Pearson’s correlation. A P-value < 0.05 was deemed statistically significant. Language and editorial assistance This manuscript was reviewed using Grammarly (Grammarly Inc., 2024) for grammar and language clarity. Additionally, ChatGPT (OpenAI, 2024), a large language model, was utilized to assist in rephrasing and refining the text's structure. All AI-generated suggestions were critically evaluated and edited by the authors to ensure scientific accuracy and integrity. Results Between January 2021 and March 2023, twenty-five patients presenting clinically and radiologically with paraganglioma of the head and neck were referred from the general surgery or otolaryngology departments to our radiology department for preoperative embolization. The age of the patients ranged from 27 to 72 years, with the mean age of the study group being about (51.2 ± 12.1) years old; 8 of the patients were males (32%) versus 17 female patients (68%). Table 1 Description of demographic characteristics among the study group. Variables Number (n = 25) Age (years) Mean ± SD 51.2 ± 12.1 Range 27–72 Sex Male 8 32% Female 17 68% In this study, the PVA particles were the most commonly used embolic agent in 96% of cases, while Histoacryl was used in one case. Preoperative embolization occurred within 48 hours before surgery in 56% of cases. In 64% of cases, complete embolization of the HNPs was achieved, with no residual tumor blush detected in the control angiogram. All cases showed no post-embolic complications. (Table 2 ) Table 2 Frequency of different embolization data among the study group. Variables (n = 25) Frequency Number % Route of preoperative embolization: • Endovascular approach. 24 96% • Direct puncture approach. 1 4% Embolic agent • PVA 23 92% • PVA & Gelfoam 1 4% • Histoacryl 1 4% Timing of embolization prior to surgical resection : • 24 hrs. 8 32% • 48 hrs. 14 56% • 72 hrs. 3 12% Residual tumor blush after embolization : • No residual tumoral blush 16 64% • Low residual tumoral blush (1–9%) 2 8% • Moderate residual tumoral blush (10–19%) 7 28% Post embolization complication : • No complications occurred. 25 100% • Minor complications (e.g., puncture site hematoma) 0 0% • Major complication (e.g., stoke or cranial nerve palsy) 0 0% All cases were supplied from the ipsilateral arterial side and received blood supply from the external carotid artery; however, in 16% of cases, an additional supply from the internal carotid artery and/or the vertebrobasilar system was detected. The ascending pharyngeal artery supplied 88% of the cases in the study group. In comparison, the posterior auricular artery contributed to the blood supply in 68% of the cases, and the occipital artery provided blood supply for 52% of the study group cases. (Table 3 ). Table 3 Frequency of different arterial feeders among the study group. Variables (n = 25) Frequency Number % Main arterial supply • ECA 21 84% • ECA & ICA 1 4% • ECA & vertebral arteries 1 4% • ECA, ICA & vertebral arteries 1 4% • ECA, ICA & basilar arteries 1 4% Detailed arterial supply a) ICA branches • Parasitic branches from the ICA 3 12% b) Vertebral artery branches • Posterior inferior cerebellar artery 2 8% c) Basilar artery branches • Anterior inferior cerebellar artery 1 4% d) External carotid artery branches • Ascending pharyngeal artery 22 88% • Posterior auricular 17 68% • Occipital artery 13 52% • Internal maxillary artery 4 16% • Superior thyroid artery 7 28% • Superficial temporal artery 1 4% • Facial artery 1 4% • Lingual artery 4 16% The mean amount of intraoperative blood loss was approximately (384 ± 150.5) mL, and only one case required an intraoperative blood transfusion due to internal jugular vein injury. Two cases, representing 8% of the study group, could not be completely surgically excised, with residual tumor volumes of less than 25% in both instances. One was a recurrent jugulotympanicum lesion, while the other was associated with internal jugular vein injury during surgical resection. (Table 4 ) Table 4 Frequency of intra-operative data among the study group. Variables Number (n = 25) Amount of intra operative blood loss (mL) • Mean ± SD 384 ± 150.5 • Range 150–750 Intra-operative blood transfusion • No 24 96% • Yes 1 4% Complete surgical removal of the lesion • No significant residual tumor tissue 23 92% • Residual tumor tissue (< 25%) 2 8% During the statistical analysis of the amount of intraoperative blood loss and the need for intraoperative blood transfusion, as well as their impact on complete surgical removal among the study group cases, a significantly higher amount of intraoperative blood loss was observed among cases that received blood transfusions. Additionally, increased blood loss was linked to incomplete tumor excision, resulting in residual tumor tissue (< 25%) following surgery, with p-values of 0.01 and 0.002, respectively. (Table 5 ). Table 5 Comparisons of the amount of intra-operative blood loss and the need for intra-operative blood transfusion, also, their effect on complete surgical removal. Variables Amount of intra operative blood loss (mL) P-value Sig. Mean SD Intra-operative blood transfusion No 268.8 132.5 0.01 S Yes 750 0 Complete surgical removal No significant residual tumor tissue 358.7 125.8 0.002 HS Residual tumor tissue (< 25%) 675 106.1 Regarding the relationship between post-embolization residual tumor blush and the occurrence of intraoperative complications, there was a statistically significant increase in intraoperative blood loss for cases with moderate post-embolization residual tumor blush, with a p-value of 0.001. In contrast, in cases with no or low post-embolization residual tumor blush, there was no need for intraoperative blood transfusions, and complete surgical excision of the tumor was achieved, with p-values greater than 0.05. (Table 6 ) Table 6: Comparisons of intra-operative complications in relation to different residual tumor blush after embolization. Variables Residual tumor blush after embolization P-value Sig. No (n=16) Low (n=2) Moderate (n=7) Mean ±SD Mean ±SD Mean ±SD 1. Amount of intra operative blood loss (mL) 315.6±132.6 375±35.4 542.9±67.3 0.001 HS 2. Intra-operative blood transfusion No. (%) No. (%) No. (%) No 15(93.8%) 2(100%) 7(100%) 0.7 NS Yes 1(6.3%) 0(0%) 0(0%) 3. Complete surgical removal No significant residual tumor tissue 15(93.8%) 2(100%) 6(85.7%) 0.7 NS Residual tumor tissue (< 25 %) 1(6.3%) 0(0%) 1(14.3%) Case Reports Case 1: Clinical Presentation : A 62-year-old female patient, who is neither diabetic nor hypertensive, has a history of right mastoidectomy performed eight years ago. She presented with right-sided hearing loss and pulsatile tinnitus that has persisted for three years. Radiological findings: Enhanced CT and MRI revealed a well-defined mass lesion that is expanding and eroding the right jugular foramen, measuring approximately 2.5 x 1.5 cm. It displays isointense T1 and mildly hyperintense T2 signals (with a “salt and pepper” appearance), with intense post-contrast enhancement. (Fig. 1 ) Technical details: Under general anesthesia, a right femoral puncture was performed, followed by the insertion of a 6-Fr femoral sheath that was continuously flushed with saline. Selective catheterization of the right carotid artery was performed using a 6-Fr Guider softip® (SE, Boston Scientific, Natick, MA, USA) over a 0.035-inch hydrophilic guide wire (Terumo). Diagnostic angiography revealed a vascular pathological blush corresponding to the lesion supplied mainly by branches from the right occipital, right posterior auricular, and right ascending pharyngeal arteries, which arise from the right external carotid artery. Super-selective catheterization of all feeding vessels arising from the aforementioned branches of the right external carotid artery was performed using Renegade™ HI-FLO™ Microcatheter Kits with Transend™-18 Guidewires (SE, Boston Scientific, Natick, MA, USA). Super-selective embolization was performed using Contour® (SE, Boston Scientific, Natick, MA, USA) PVA particles in sizes of 150–250 µm and 250–355 µm. The control angiogram showed occlusion of the feeding vessels and successful devascularization of the lesion with no significant residual blush. (Figs. 2 and 3 ) Result: The patient made a good recovery without any minor or major post-embolization complications. Complete surgical resection of the tumor was accomplished. Intraoperative estimated blood loss was approximately 350 mL, and no blood transfusion was required. Case 2: Clinical Presentation : A 42-year-old female patient, hypertensive but not diabetic, presented with right-sided painless neck swelling for 2 years. Radiological findings: Enhanced CT & MRI showed a fairly defined mass lesion seen insinuated at the right common carotid artery bifurcation measuring about (5.0 x 2.5 cm). It displays isointense T1 and hyperintense T2 signals (with a “salt and pepper” appearance) as well as intense post-contrast enhancement. Technical details: Under general anesthesia, right femoral puncture was performed, followed by insertion of a 6-Fr femoral sheath that was continuously flushed with saline. Selective catheterization of the right common, internal, and external carotid arteries was performed via diagnostic catheter 6-Fr Guider softip® (SE, Boston Scientific, Natick, MA, USA) over 0.035-inch. hydrophilic guide wire (Terumo), and diagnostic angiography showed vascular pathological blush corresponding to the lesion supplied by the right external carotid branches, “mainly from the superior thyroid artery (about 85%) and a few small branches from the occipital and lingual arteries, representing (about 15%)”. Super selective catheterization of the superior thyroid artery was performed using Renegade™ HI-FLO™ Microcatheter Kits with Transend™-18 Guidewires (SE, Boston Scientific, Natick, MA, USA). Super-selective embolization using Contour® (SE, Boston Scientific, Natick, MA, USA) PVA particles of sizes 150–250µm & 250–355µm. The other feeder branches can’t be catheterized due to their tiny size. The control angiogram showed good devascularization of the lesion with a moderate, rather insignificant residual blush (approximately 15%). Result: Good recovery of the patient with no minor or major post-embolization complications occurred. Complete surgical resection of the tumor was achieved. Intraoperative estimated blood loss was less than 450 mL, and no need for blood transfusion. Case 3: Clinical Presentation : A 47-year-old female patient, not diabetic or hypertensive, with a history of mastoidectomy 13 years ago, then she presented with right otalgia & pulsatile tinnitus for two years. Radiological findings: Enhanced MRI revealed a well-defined mass lesion in the tympanic cavity that extends to the jugular foramen, measuring approximately 3 x 2 cm. It shows isointense T1 and hyperintense T2 signals (with a “salt and pepper” appearance) as well as intense post-contrast enhancement. Technical details: Under general anesthesia, a right femoral puncture was performed, followed by the insertion of a 6-Fr femoral sheath that was continuously flushed with saline. Selective catheterization and diagnostic angiogram of the right common, internal, and external carotid arteries were conducted using a 6-Fr Fargo-Max (Balt Extrusion, Montmorency, France) guiding catheter over a 0.035-inch hydrophilic guide wire (Terumo, Medical/MicroVention, Inc., Aliso Viejo, CA). A pathological blush was observed on the right side of the skull base, corresponding to the jugulotympanicum glomus tumor. It is supplied through branches arising from the right external carotid artery, namely the pharyngeal and neuromeningeal branches of the right ascending pharyngeal artery, the stylomastoid branch of the right posterior auricular artery, and the petrous branch of the right middle meningeal artery. Selective catheterization of the right external carotid artery was performed using a guiding catheter. Super-selective catheterization of the feeding arteries was accomplished with Renegade™ HI-FLO™ Microcatheter Kits and Transend™-18 Guidewires (SE, Boston Scientific, Natick, MA, USA). Embolization was conducted using Contour® (SE, Boston Scientific, Natick, MA, USA) PVA particles in sizes of 150–250 µm and 250–355 µm. The final control angiogram demonstrated good devascularization of the lesion and occlusion of its feeding arteries. Result: The patient showed good recovery, with no minor or major complications following embolization. Approximately 85% of the tumor was surgically resected. The estimated blood loss during the procedure was around 600 mL, and only one unit of blood transfusion was required. Discussion The exact cause of head and neck paraganglioma is unknown in most cases, and it occurs randomly, or “sporadically,” in about 60–80% of instances. Approximately 10–15% of HNPs have a “familial” link to genetic syndromes. Recognizing familial HNPs is important because they present an increased lifetime risk for multiple tumors, a higher incidence of recurrence, and a possible risk of malignancy [ 3 , 7 ]. The main results of our study were as follows: All our cases underwent preoperative angiography, and the aforementioned data were collected and analyzed for better embolization planning. Regarding the blood supply, all cases in the study group were supplied by the ipsilateral external carotid artery; however, in 16% of the cases, an additional supply from the ipsilateral ICA and/or vertebrobasilar system was detected. The ascending pharyngeal artery was the most frequent arterial feeder, supplying 88% of the cases in the study group. This is consistent with published literature [ 8 , 9 ]. The timing of preoperative embolization occurred within 48 hours before surgical intervention in 56% of the study group cases. An intentional delay of 1–3 days between embolization and surgery provides sufficient time for tumor devascularization. Also, it allows soft tissue edema to resolve without permitting time for reconstitution or recruitment of feeding arteries. This aligns with published literature [ 8 , 9 ]. In 96% of the study group cases, the embolization route was accomplished through an endovascular approach, while one case (4%) utilized direct puncture embolization due to the presence of multiple tiny arterial feeders from both the internal carotid artery and external carotid artery supplying it. The most frequently utilized embolic agent was PVA particles, with particle sizes ranging from 150 µm to 500 µm, used in 96% of cases (23 cases embolized via PVA particles alone, and one case was embolized using PVA particles and Gelfoam). Meanwhile, Histoacryl was used in one case where direct needle puncture was performed. Post-embolization, 64% of the study group cases were completely embolized with no significant residual tumoral blush. In contrast, 9 cases exhibited varying degrees of residual tumoral blush (2 cases with low residual blush and 7 cases with moderate residual tumoral blush). All cases in the study group supplied by branches from the ICA or the vertebrobasilar system showed moderate residual tumoral blush. Regarding post-embolization complications, none of the patients experienced intraprocedural or neurological issues. The reduction of intraoperative blood loss is a significant finding in this study, where the mean intraoperative blood loss for all procedures was 384 ± 150.5 mL, with a range of 150–750 mL. This finding aligns with results from multiple studies that preoperatively embolized patients with HNPs at various disease sites, demonstrating a significant decrease in intraoperative blood loss. White et al. [ 8 ] reported that in their study group, the intraoperative blood loss for each tumor type was 289 mL for carotid body, 243 mL for glomus vagale, and 1018 mL for glomus jugulare. Helal et al. [ 9 ] reported that the intraoperative estimated blood loss among their study group ranged from 888 to 1,084 mL. This finding is also consistent with Persky et al. [ 10 ], who reported that among 28 patients presenting with HNPs who underwent preoperative embolization, the mean blood loss, according to tumor type, was 450 to 517 mL. Similarly, La Muraglia et al. [ 11 ] used PVA to preoperatively embolize 11 neck paragangliomas and found that intraoperative blood loss was lower in the embolized patients (372 ± 213 mL). Studies conducted on HNPs resected without preoperative tumor embolization have reported much higher blood loss. In 1997, Tikkakoski et al. [ 12 ] reported that the mean blood loss during surgery in the non-embolized group was 1374 mL (range, 100–4500 mL), whereas in the embolized group, the mean blood loss was significantly lower at 588 mL (range, 100–1800 mL). When analyzing intraoperative blood loss in relation to post-embolization residual tumor blush, a statistically significant increase in intraoperative blood loss was observed among cases with moderate post-embolization residual tumor blush, with a p-value of 0.001. On the other hand, there was no statistically significant correlation between intraoperative blood loss and the various tumor sites or the different arterial feeders. Regarding the intraoperative needs for blood transfusion, only one patient required a transfusion during surgery; this was associated with an intraoperative injury to the internal jugular vein. When analyzing the need for intraoperative blood transfusion in relation to the amount of intraoperative blood loss, there was a statistically significantly higher amount of blood loss in patients who received blood transfusions during the operation, with a p-value of 0.01. Conclusion The preoperative embolization of paragangliomas in the head and neck is a safe technique that can significantly enhance the surgical approach, especially when a targeted strategy is pursued. Preoperative embolization of head and neck paragangliomas should be tailored to the angioarchitecture of the lesion, utilizing the most suitable materials based on the specific case being treated. Abbreviations CCA Common carotid artery CT Computed tomography ECA External carotid artery ICA Internal carotidartery HNPs Head and neck paraganglioma MA Massachusetts µm Micrometer mL Milliliter mmHg Millimeters of mercury MR Magnetic resonance MRI Magnetic resonance imaging PVA Polyvinyl Alcohol SD Standard deviation SE Synchro® SPSS Statistical Package of Social Science USA United States of America. Declarations Ethics approval and consent to participate This study received approval from the Research Ethics Committee of the Faculty of Medicine (Approval number: M M600), which approved this prospective study. Written informed consent was obtained from all patients prior to inclusion in the study. All procedures were conducted in accordance with the ethical standards of the institutional research committee and the 1964 Declaration of Helsinki and its subsequent amendments. Consent for publication: Not applicable. Availability of data and materials: Data are available in the article or its supplementary materials. Competing interests The authors declare that they have no competing interests related to this work.. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The interventional procedures were performed as part of routine clinical care under national healthcare coverage, either via health insurance or government-sponsored treatment plans. References Fatima N, Pollom E, Soltys S, Chang SD, Meola A. Stereotactic radiosurgery for head and neck paragangliomas: a systematic review and meta-analysis. Neurosurg Rev. 2021;44(2):741–752. https://doi.org/10.1007/s10143-020-01292-5 .. Meli GA, Chiaramonte R, Cavallaro T, Puglisi C, Pero G. Carotid body paraganglioma. Diagnosis and treatment by angiography. Neuroradiol J. 2006;19(5):645–8. https://doi.org/10.1177/197140090601900516 . Noujaim SE, Brown KT, Walker DT, Hasbrook CD. Paragangliomas of the head and neck: a practical approach to diagnosis and review of detailed anatomy of sites of origin. Neurographics. 2020;10(4):211–22. https://doi.org/10.3174/ng.1900045 Chapman DB, Lippert D, Geer CP, Edwards HD, Russell GB, Rees CJ, et al. Histopathologic and radiographic indicators of malignancy in head and neck paragangliomas. Otolaryngol Head Neck Surg. 2010;143(4):531–7. https://doi.org/10.1016/j.otohns.2010.05.031 Faragò G, Castellani C, Ponzi S, Jankovic C, Saginario V, Berardi C, et al. Preoperative embolization of carotid chemodectoma: a technical challenge that can be customized according to angioarchitecture. Illustrative cases. Neuroradiol J. 2013;26(6):678–82. https://doi.org/10.1177/197140091302600611 . Pérez-García C, Rosati S, Serrano-Hernando FJ, López-Ibor Aliño L, Moreu M. Preoperative Squid embolization of carotid paragangliomas with direct puncture. Neuroradiol J. 2020;33(3):224–229. https://doi.org/10.1177/1971400920910409 . Neumann HP, Pawlu C, Peczkowska M, Bausch B, McWhinney SR, Muresan M, et al. European-American Paraganglioma Study Group. Distinct clinical features of paraganglioma syndromes associated with SDHB and SDHD gene mutations. JAMA. 2004;292(8):943–51. https://doi.org/10.1001/jama.292.8.943 . White JB, Link MJ, Cloft HJ. Endovascular embolization of paragangliomas: A safe adjuvant to treatment. J Vasc Interv Neurol. 2008;1(2):37–41. PMID: 22518217; PMCID: https://pmc.ncbi.nlm.nih.gov/articles/PMC3317314/ . Helal A, Vakharia K, Brinjikji W, Carlson ML, Driscoll CL, Van Gompel JJ. Preoperative embolization of jugular paraganglioma tumors using particles is safe and effective. Interv Neuroradiol. 2022;28(2):145–151. https://doi.org/10.1177/15910199211019175 . Persky MS, Setton A, Niimi Y, Hartman J, Frank D, Berenstein A. Combined endovascular and surgical treatment of head and neck paragangliomas–a team approach. Head Neck. 2002;24(5):423–31. https://doi.org/10.1002/hed.10068 . LaMuraglia GM, Fabian RL, Brewster DC, Pile-Spellman J, Darling RC, Cambria RP, et al. The current surgical management of carotid body paragangliomas. J Vasc Surg. 1992;15(6):1038–44; discussion 1044-5. https://doi.org/10.1067/mva.1992.35505 . Tikkakoski T, Luotonen J, Leinonen S, Siniluoto T, Heikkilä O, Päivänsälo M, et al. Preoperative embolization in the management of neck paragangliomas. Laryngoscope. 1997;107(6):821–6. https://doi.org/10.1097/00005537-199706000-00018 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6951468","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":477706450,"identity":"1a9b0369-459f-4a79-98ae-3436e21b0494","order_by":0,"name":"Maged Abdelgwad","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4klEQVRIiWNgGAWjYHACxgcJFXIwDjNRWpgNHpwxJk0Lm+DDNlK06LYffsaQOM9A3uB4j+kGhgrrxAb29gt4tZidSTN7kLjNwHDDmTNmNxjOpCc28JwpwK/lQIK5QeK2P4wbbuSY3WBsO5zYIJGTgF/L+effJBLnGNhDtPwDapF/Q0ALUKVEYoNBIkRLA8gW9gMEtLwpNkg4ZpA888yxshsJx9KN23hy8OoAOix948MfNQa2fcebt934UGMt289+/AF+PTCgAHINyBNsDDwGxGmRb4Az2Ym0ZRSMglEwCkYKAABi9lHEAZl5BgAAAABJRU5ErkJggg==","orcid":"","institution":"Fayoum University","correspondingAuthor":true,"prefix":"","firstName":"Maged","middleName":"","lastName":"Abdelgwad","suffix":""},{"id":477706451,"identity":"83975ff6-f5fb-4c28-ae95-9b70911708f6","order_by":1,"name":"Mohammed Salim","email":"","orcid":"","institution":"Fayoum University","correspondingAuthor":false,"prefix":"","firstName":"Mohammed","middleName":"","lastName":"Salim","suffix":""},{"id":477706452,"identity":"019f14c8-65c1-4d72-b79a-bfc92c18d156","order_by":2,"name":"Mohammed Saad","email":"","orcid":"","institution":"Fayoum University","correspondingAuthor":false,"prefix":"","firstName":"Mohammed","middleName":"","lastName":"Saad","suffix":""},{"id":477706453,"identity":"3941e6f8-c10f-46c8-a8dd-121cded8f947","order_by":3,"name":"Farouk Hassan","email":"","orcid":"","institution":"Cairo University","correspondingAuthor":false,"prefix":"","firstName":"Farouk","middleName":"","lastName":"Hassan","suffix":""}],"badges":[],"createdAt":"2025-06-22 22:08:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6951468/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6951468/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85828438,"identity":"64f78952-2e95-40d5-b772-ef08cba17c92","added_by":"auto","created_at":"2025-07-02 07:30:13","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":974709,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e(A) An axial-enhanced CT scan of the skull base soft tissue window reveals an intensely enhancing soft tissue lesion within the right jugular foramen. (B \u0026amp; C) Axial and coronal CT bone window displays a permeative, destructive lesion in the right jugular bulb, eroding its contours. (D) An axial T2-weighted MR image shows a mass centered on the right jugular foramen, exhibiting a heterogeneous, primarily hyperintense signal with prominent vascular flow voids. (E) The axial unenhanced T1-weighted MR image reveals an isointense mass within the right jugular foramen, also with prominent vascular flow voids. (F) The axial contrast-enhanced T1-weighted MR image depicts an intensely enhancing mass within the jugular foramen.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6951468/v1/515fc8a4fc485456075fbb7f.jpeg"},{"id":85827151,"identity":"b7fc5093-b151-4e67-9dd5-238800cbc6df","added_by":"auto","created_at":"2025-07-02 07:22:13","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":757897,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eConventional angiography with multiple lateral views reveals: (A) Selective catheterization of the right common carotid artery (CCA) demonstrating intense tumoral blush corresponding to the right glomus jugular “arrow,” supplied by ECA branches primarily via the posterior auricular and occipital arteries, and to a lesser extent from the ascending pharyngeal artery. (B \u0026amp; C) Super-selective catheterization of the right posterior auricular artery resulted in successful occlusion of the supplying vessel and devascularization of the related tumoral blush in the control angiogram. (D \u0026amp; E) Super-selective catheterization of the right occipital artery led to embolization of its involved supplying branch. (F) Control angiogram of the right CCA shows residual tumoral blush supplied by the ascending pharyngeal artery. (G) Super-selective catheterization of the right ascending pharyngeal artery shows the related tumoral blush. (H) Control angiogram of the right CCA showed complete devascularization of the tumor and occlusion of the supplying blood vessels.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6951468/v1/a7e8d6cbc95169525b1d6b57.png"},{"id":85827150,"identity":"819deb1f-adef-4eb8-a84b-bfbdaf2cd427","added_by":"auto","created_at":"2025-07-02 07:22:13","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":25106,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eQR code for YouTube video demonstrating pre- and post-endovascular embolization of the right glomus jugular.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-6951468/v1/290c6c9232b5203dd804c2e5.png"},{"id":85827154,"identity":"56d45000-668f-4147-9b82-c6f73b5e8fe1","added_by":"auto","created_at":"2025-07-02 07:22:13","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1109530,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e(A) An axial enhanced CT scan of the neck reveals an intensely enhancing soft tissue lesion positioned between the ECA and ICA. (B) An axial T2-weighted MR image reveals a relatively well-defined soft tissue mass situated between the ECA anterolaterally and the ICA posteriorly, exhibiting a hyperintense signal with internal vascular flow voids.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-6951468/v1/a31f2db730ae3093280354b0.png"},{"id":85828440,"identity":"e50124bd-db1d-4304-a35d-d249f95eaa87","added_by":"auto","created_at":"2025-07-02 07:30:13","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":648156,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eConventional angiography reveals multiple lateral views. (A \u0026amp; B) Selective catheterization of the right CCA shows a tumoral blush corresponding to the right carotid body tumor, primarily supplied by ECA branches via the superior thyroid artery and, to a lesser extent, by the lingual and occipital arteries. (C) Super-selective catheterization of the right occipital artery reveals small branches contributing to the tumoral blush associated with the right carotid body tumor. (D) Super-selective catheterization of the right lingual artery shows a small branch contributing to the tumoral blush related to the right carotid body tumor. (E) Super-selective catheterization of the right superior thyroid artery is performed, resulting in embolization of its involved supplying branch. (F) The follow-up angiogram of the right CCA displays a faint residual tumoral blush.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-6951468/v1/618d7cd658969afccc20021a.png"},{"id":85827179,"identity":"2268ee15-e6a6-46fe-8524-4bda769fb21c","added_by":"auto","created_at":"2025-07-02 07:22:22","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":21408,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eQR code for YouTube video showing endovascular embolization of a right carotid body tumor\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-6951468/v1/9b6a9894f2ab9deb76421772.png"},{"id":85829669,"identity":"bde0e48e-39c9-49c4-81d2-5ecf9a55928a","added_by":"auto","created_at":"2025-07-02 07:38:13","extension":"jpeg","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":1266374,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e(A \u0026amp; B) Coronal T1 and T1 post-contrast weighted MR images show a lobulated, strongly enhancing mass lesion almost occupying the right middle ear cleft, with extension into the mastoidectomy bed. (B \u0026amp; C) Coronal and axial T2-weighted MR images show the lesion displaying a hyperintense signal with a few internal vascular flow voids.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage7.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6951468/v1/367f9b3a2056a7dabf9ee54f.jpeg"},{"id":85828442,"identity":"a30da9a9-641c-4de4-af13-7dc92102df20","added_by":"auto","created_at":"2025-07-02 07:30:13","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":121326,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eConventional angiography lateral views showing: (A) Selective catheterization of the right CCA showing tumoral blush corresponding to right glomus jugulotympanicum. (B) Selective catheterization of the right ECA shows that the tumoral blush is supplied via the pharyngeal and the neuromeningeal branches of the right ascending pharyngeal artery, the stylomastoid branch of the right posterior auricular artery, and the petrous branch of the right middle meningeal artery. (C) Super-selective catheterization of the right ascending pharyngeal artery reveals its branches contributing to the tumoral blush corresponding to the right glomus jugulotympanicum.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage8.png","url":"https://assets-eu.researchsquare.com/files/rs-6951468/v1/b41be1a1ac3ec94fc236b1b6.png"},{"id":85827161,"identity":"aff28cfe-0270-4b53-a43f-c0702457a904","added_by":"auto","created_at":"2025-07-02 07:22:14","extension":"png","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":23177,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eQR code for YouTube video showing endovascular embolization of the right glomus jugulotympanicum.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage9.png","url":"https://assets-eu.researchsquare.com/files/rs-6951468/v1/76e7d80cfd11db7489a988c3.png"},{"id":91255467,"identity":"70277984-66a2-4843-89cc-bffba890dec1","added_by":"auto","created_at":"2025-09-13 20:17:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":6557624,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6951468/v1/60e93a3b-a3d0-4de5-b9c9-f5f0080bd090.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Efficiency and Safety of Preoperative Embolization of Paragangliomas of The Head and Neck","fulltext":[{"header":"Background","content":"\u003cp\u003eThe paraganglia are clusters of highly vascularized neuroendocrine cells dispersed throughout the body and closely related to the autonomic nervous system. Tumors arising from the paraganglia are referred to as paragangliomas [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eParagangliomas of the head and neck, also known as glomus tumors or chemodectomas, are rare neoplasms accounting for less than 0.5% of all head and neck tumors, with incidence range of 1:30,000 to 1:100,000, and the average age at diagnosis is variable in different literatures it was reported to be from 34.5 to 55 years old [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHead and neck paragangliomas are often asymptomatic, but some may cause local compressive symptoms, leading to varied clinical presentations based on their location. A painless neck mass is the most common symptom in patients with carotid body tumors, while tinnitus is frequently observed in jugular paragangliomas. Other symptoms can include hearing loss, otalgia, or cranial neuropathy. Cranial neuropathy may result in dysphagia, facial weakness, and vocal fold paresis. A small percentage may also exhibit biochemical activity similar to pheochromocytomas, resulting in symptoms such as diarrhea, hypertension, and flushing [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. As these tumors can be locally destructive or exhibit malignant tendencies, surgical resection is usually necessary. However, their high vascularity can lead to significant bleeding during surgery, which may impede the complete surgical removal of the lesion. Thus, pre-surgical embolization is an intervention that has been shown to reduce surgical time and blood loss, thereby decreasing morbidity and mortality. The most commonly used method for embolization of these lesions is transarterial. It involves super-selective catheterization of the arterial feeders of the glomus and embolizing the lesion. However, the transarterial pathway is contingent upon the vascular anatomy of the afferent arteries, their tortuosity, atherosclerotic disease, or the possibility of inducing vasospasm during embolization. In addition, special care must always be taken with dangerous anastomoses between the branches of the external carotid artery and the internal carotid, vertebral, and ophthalmic arteries, especially if embolic particles are used. As a result, in some cases, the direct puncture technique was described [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study aimed to assess the safety and effectiveness of preoperative embolization of head and neck paragangliomas in simplifying the surgical procedure and facilitating the complete removal of the tumor.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients:\u003c/h2\u003e \u003cp\u003eBetween January 2021 and March 2023, twenty-five patients presenting clinically and radiologically with paraganglioma of the head and neck were referred from the general surgery or otolaryngology departments to our radiology department for preoperative embolization.\u003c/p\u003e \u003cp\u003e The local ethical committee approved this prospective study, and written informed consent was taken.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInclusion criteria:\u003c/h3\u003e\n\u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003ePatients with head and/or neck paragangliomas.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePatients referred for interventional procedures based on their preferences or in combination with the general surgery or otolaryngology departments regarding the preferred modality of treatment\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePatients who consent.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e\n\u003ch3\u003eExclusion criteria:\u003c/h3\u003e\n\u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003ePatients whose operation was postponed for any reason.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eGeneral contraindications and chronic debilitating diseases, e.g., allergy to contrast media, severe renal failure, severe respiratory insufficiency, severe anemia, congestive heart failure, and chronic liver insufficiency.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eBleeding and coagulation disorders and anticoagulant users.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePatient with a vascular abnormality preventing the endovascular pathway, and the lesion is not accessible via direct embolization.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eDeclined consent.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e\n\u003ch3\u003ePre-procedural preparation\u003c/h3\u003e\n\u003cp\u003eAll patients underwent the following procedures: Complete history taking, general and local clinical examination, and laboratory investigations. The patient\u0026rsquo;s enhanced cross-sectional imaging studies of the head and neck (contrast-enhanced CT \u0026ldquo;Computed tomography\u0026rdquo; and/or MRI \u0026ldquo;Magnetic resonance imaging\u0026rdquo;) were carefully reviewed.\u003c/p\u003e\n\u003ch3\u003eProcedure\u003c/h3\u003e\n\u003cp\u003e \u003cstrong\u003eAnesthesia and preparation\u003c/strong\u003e \u003cp\u003eThe patients were adequately placed on the angiography table, ensuring adequate exposure of the groin area. They were connected to Electrocardiography leads, a pulse oximeter, and an automated blood pressure monitor. General anesthesia was administered, the hair in the groin area was shaved, and the skin was cleaned with povidone iodine before a sterile gown was applied.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFemoral access\u003c/strong\u003e \u003cp\u003eThe right common femoral artery serves as the target for vascular access in all procedures. All catheters, sheaths, and guidewires are flushed with sterile saline in vitro before endovascular use. Local infiltration anesthesia using 1% Lidocaine is injected into the skin, subcutaneous tissue, and around the femoral artery. Aspiration is performed before each injection to ensure the needle is not intravascular. The access needle is introduced between the index and middle fingers, with a pulse felt at its base. A 0.035-inch guidewire is advanced coaxially through the access needle under fluoroscopic guidance to reach the common iliac artery. The needle is withdrawn slowly over the wire, and a 6-French vascular sheath is placed into the common femoral artery. A Y-connector is attached to the tip of the vascular sheath, and a continuous pressurized saline flush is connected at a pressure of 300 mmHg.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCatheter insertion\u003c/strong\u003e \u003cp\u003eThe guiding catheter was advanced through the aortic arch to evaluate its vascular anatomy and origins. Angiography was performed to rule out variations or anomalies. The catheter and guidewire were then maneuvered to selectively catheterize the common carotid, external carotid, internal carotid, and vertebral arteries.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eIdentification of the feeding vessels\u003c/strong\u003e \u003cp\u003eSelective angiography via digital subtraction angiography of each external and internal carotid artery, along with the vertebral artery, was performed at a frame rate of 3 frames per second to detect tumor blush. The tumor blush was examined on the images, and the supplying vessels were identified. The involvement of the external and internal carotid arteries was noted separately. Special attention was given to reviewing the arterial anatomy and detecting any anatomical variations, including the origin of the ophthalmic artery from the middle meningeal artery and the potentially dangerous anastomosis between the internal carotid artery (ICA) and external carotid artery (ECA), before initiating the embolization process.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eEmbolization techniques\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eEndovascular route\u003c/b\u003e: A microcatheter (either Progreat\u0026reg; or Renegade\u0026reg;) with a microwire inside was advanced to super-selectively catheterize the tumor's feeding vessels. Embolic material was prepared by mixing Polyvinyl Alcohol (PVA) powder with a contrast solution and aspirating it into the embolization syringe. The syringe was labeled and utilized for injecting the embolic material. The material was injected in short pulses, synchronized with heartbeats to avoid reflux. It was introduced in small, medium, and large particles. After achieving near stagnation of flow, saline was injected to clear the catheter's dead space. Post-embolization angiography was performed, and residual tumor blush was assessed and compared to the pre-embolization blush. The endpoint of embolization was defined as the disappearance of tumor blush on post-embolization angiography. The procedure was repeated for all vessels supplying the tumor. Post-embolization angiography for the common carotid artery was also conducted and reviewed for any significant residual tumor blush.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eDirect needle puncture route\u003c/b\u003e: If trans-arterial embolization can\u0026rsquo;t completely devascularize the tumor bed due to the presence of complex angioarchitecture, such as multiple small feeding branches that cannot be directly catheterized, and possible vasospasm. A 22-gauge coaxial introducer puncture needle is utilized under fluoroscopic guidance to access the lesion. Contrast material is injected for parenchymography to confirm arterial reflux and vascular compartment filling. An endovascular non-detachable balloon is placed in the high cervical segment of the internal carotid artery and inflated during the glue injection. The liquid embolic agent, a 1:3 mixture of Histoacryl and Lipiodol, is administered under continuous fluoroscopic monitoring. The procedure is halted when there is a high risk of arterial reflux. The ICA balloon is deflated after each injection to facilitate blood flow into the cerebral arteries.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePost-procedure care\u003c/strong\u003e \u003cp\u003eThe anesthesiologist ensured the patient's recovery from anesthesia and spontaneous breathing before discharge from the angiography suite. The patient was instructed to complete bed rest for 12 hours, and their puncture site was compressed and inspected every 2 hours to prevent hematoma formation. They were advised to avoid flexing or standing on the puncture site for 6 hours to prevent rebleeding. Analgesics were prescribed for persistent pain, and antibiotics were provided as a routine preoperative measure for tumor excision.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEvaluation of tumor devascularization\u003c/strong\u003e \u003cp\u003eThe pre- and post-embolization angiographies were compared. The percentage of tumor devascularization and residual blush was assessed subjectively by three observers. The remaining feeding vessels of the blush were also identified and recorded.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEvaluation of surgical outcome\u003c/strong\u003e \u003cp\u003eThe amount of intraoperative blood loss was quantitatively documented by the surgeon on the surgical sheet and extracted for each patient. It is estimated from the suction tubes and soaked dressings. The operative approach for resection was recorded, and the blood transfusion units were also obtained from the surgical sheet.\u003c/p\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis Methods:\u003c/h2\u003e \u003cp\u003eStatistical analysis of the collected data was conducted using Statistical Package for Social Sciences (SPSS) software version 22 on Windows 7 (SPSS Inc., Chicago, IL, USA). The following formulae were applied: range, mean value, and standard deviation (SD), along with a T-test for comparing the means. The correlation between the parameters was assessed using Spearman\u0026rsquo;s rank correlation and Pearson\u0026rsquo;s correlation. A P-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was deemed statistically significant.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eLanguage and editorial assistance\u003c/strong\u003e \u003cp\u003eThis manuscript was reviewed using Grammarly (Grammarly Inc., 2024) for grammar and language clarity. Additionally, ChatGPT (OpenAI, 2024), a large language model, was utilized to assist in rephrasing and refining the text's structure. All AI-generated suggestions were critically evaluated and edited by the authors to ensure scientific accuracy and integrity.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eBetween January 2021 and March 2023, twenty-five patients presenting clinically and radiologically with paraganglioma of the head and neck were referred from the general surgery or otolaryngology departments to our radiology department for preoperative embolization. The age of the patients ranged from 27 to 72 years, with the mean age of the study group being about (51.2\u0026thinsp;\u0026plusmn;\u0026thinsp;12.1) years old; 8 of the patients were males (32%) versus 17 female patients (68%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescription of demographic characteristics among the study group.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;25)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e51.2\u0026thinsp;\u0026plusmn;\u0026thinsp;12.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e27\u0026ndash;72\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn this study, the PVA particles were the most commonly used embolic agent in 96% of cases, while Histoacryl was used in one case. Preoperative embolization occurred within 48 hours before surgery in 56% of cases. In 64% of cases, complete embolization of the HNPs was achieved, with no residual tumor blush detected in the control angiogram. All cases showed no post-embolic complications. (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFrequency of different embolization data among the study group.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;25)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eRoute of preoperative embolization:\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Endovascular approach.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Direct puncture approach.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmbolic agent\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; PVA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e92%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; PVA \u0026amp; Gelfoam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Histoacryl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTiming of embolization prior to surgical resection\u003c/b\u003e:\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; 24 hrs.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; 48 hrs.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; 72 hrs.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResidual tumor blush after embolization\u003c/b\u003e:\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; No residual tumoral blush\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Low residual tumoral blush (1\u0026ndash;9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Moderate residual tumoral blush (10\u0026ndash;19%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePost embolization complication\u003c/b\u003e:\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; No complications occurred.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Minor complications (e.g., puncture site hematoma)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Major complication (e.g., stoke or cranial nerve palsy)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAll cases were supplied from the ipsilateral arterial side and received blood supply from the external carotid artery; however, in 16% of cases, an additional supply from the internal carotid artery and/or the vertebrobasilar system was detected. The ascending pharyngeal artery supplied 88% of the cases in the study group. In comparison, the posterior auricular artery contributed to the blood supply in 68% of the cases, and the occipital artery provided blood supply for 52% of the study group cases. (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFrequency of different arterial feeders among the study group.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;25)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eMain arterial supply\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; ECA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e84%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; ECA \u0026amp; ICA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; ECA \u0026amp; vertebral arteries\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; ECA, ICA \u0026amp; vertebral arteries\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; ECA, ICA \u0026amp; basilar arteries\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDetailed arterial supply\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003ea) \u003cb\u003eICA branches\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Parasitic branches from the ICA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eb) \u003cb\u003eVertebral artery branches\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Posterior inferior cerebellar artery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003ec) \u003cb\u003eBasilar artery branches\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Anterior inferior cerebellar artery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003ed) \u003cb\u003eExternal carotid artery branches\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Ascending pharyngeal artery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Posterior auricular\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Occipital artery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Internal maxillary artery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Superior thyroid artery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Superficial temporal artery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Facial artery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Lingual artery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe mean amount of intraoperative blood loss was approximately (384\u0026thinsp;\u0026plusmn;\u0026thinsp;150.5) mL, and only one case required an intraoperative blood transfusion due to internal jugular vein injury. Two cases, representing 8% of the study group, could not be completely surgically excised, with residual tumor volumes of less than 25% in both instances. One was a recurrent jugulotympanicum lesion, while the other was associated with internal jugular vein injury during surgical resection. (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFrequency of intra-operative data among the study group.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;25)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eAmount of intra operative blood loss (mL)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e384\u0026thinsp;\u0026plusmn;\u0026thinsp;150.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Range\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e150\u0026ndash;750\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIntra-operative blood transfusion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; No\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Yes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComplete surgical removal of the lesion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; No significant residual tumor tissue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e92%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Residual tumor tissue (\u0026lt;\u0026thinsp;25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eDuring the statistical analysis of the amount of intraoperative blood loss and the need for intraoperative blood transfusion, as well as their impact on complete surgical removal among the study group cases, a significantly higher amount of intraoperative blood loss was observed among cases that received blood transfusions. Additionally, increased blood loss was linked to incomplete tumor excision, resulting in residual tumor tissue (\u0026lt;\u0026thinsp;25%) following surgery, with p-values of 0.01 and 0.002, respectively. (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparisons of the amount of intra-operative blood loss and the need for intra-operative blood transfusion, also, their effect on complete surgical removal.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eAmount of intra operative blood loss (mL)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSig.\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eIntra-operative blood transfusion\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e268.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e132.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e750\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComplete surgical removal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo significant residual tumor tissue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e358.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e125.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eHS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResidual tumor tissue (\u0026lt;\u0026thinsp;25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e675\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e106.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRegarding the relationship between post-embolization residual tumor blush and the occurrence of intraoperative complications, there was a statistically significant increase in intraoperative blood loss for cases with moderate post-embolization residual tumor blush, with a p-value of 0.001. In contrast, in cases with no or low post-embolization residual tumor blush, there was no need for intraoperative blood transfusions, and complete surgical excision of the tumor was achieved, with p-values greater than 0.05. (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6:\u0026nbsp;\u003c/strong\u003eComparisons of intra-operative complications in relation to different residual tumor blush after embolization.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"719\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 274px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 324px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eResidual tumor blush after embolization\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSig.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;(n=16)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLow\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(n=2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eModerate\u003c/strong\u003e (n=7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean \u0026plusmn;SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean \u0026plusmn;SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean \u0026plusmn;SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 274px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1. Amount of intra operative blood loss (mL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e315.6\u0026plusmn;132.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e375\u0026plusmn;35.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\"\u003e\n \u003cp\u003e542.9\u0026plusmn;67.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 274px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2. Intra-operative blood transfusion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo. (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo. (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo. (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 274px;\"\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e15(93.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e2(100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\"\u003e\n \u003cp\u003e7(100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 54px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 274px;\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e1(6.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e0(0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\"\u003e\n \u003cp\u003e0(0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" style=\"width: 719px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3. Complete surgical removal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 274px;\"\u003e\n \u003cp\u003eNo significant residual tumor tissue\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e15(93.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e2(100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\"\u003e\n \u003cp\u003e6(85.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 54px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 274px;\"\u003e\n \u003cp\u003eResidual tumor tissue (\u0026lt; 25 %)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e1(6.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e0(0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\"\u003e\n \u003cp\u003e1(14.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\u003c/br\u003e\n\u003ch2\u003eCase Reports\u003c/h2\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eCase 1:\u003c/h2\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003e\u003cb\u003eClinical Presentation\u003c/b\u003e:\u003c/h2\u003e \u003cp\u003eA 62-year-old female patient, who is neither diabetic nor hypertensive, has a history of right mastoidectomy performed eight years ago. She presented with right-sided hearing loss and pulsatile tinnitus that has persisted for three years.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eRadiological findings:\u003c/h2\u003e \u003cp\u003eEnhanced CT and MRI revealed a well-defined mass lesion that is expanding and eroding the right jugular foramen, measuring approximately 2.5 x 1.5 cm. It displays isointense T1 and mildly hyperintense T2 signals (with a \u0026ldquo;salt and pepper\u0026rdquo; appearance), with intense post-contrast enhancement. (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eTechnical details:\u003c/h2\u003e \u003cp\u003eUnder general anesthesia, a right femoral puncture was performed, followed by the insertion of a 6-Fr femoral sheath that was continuously flushed with saline. Selective catheterization of the right carotid artery was performed using a 6-Fr Guider softip\u0026reg; (SE, Boston Scientific, Natick, MA, USA) over a 0.035-inch hydrophilic guide wire (Terumo). Diagnostic angiography revealed a vascular pathological blush corresponding to the lesion supplied mainly by branches from the right occipital, right posterior auricular, and right ascending pharyngeal arteries, which arise from the right external carotid artery. Super-selective catheterization of all feeding vessels arising from the aforementioned branches of the right external carotid artery was performed using Renegade\u0026trade; HI-FLO\u0026trade; Microcatheter Kits with Transend\u0026trade;-18 Guidewires (SE, Boston Scientific, Natick, MA, USA). Super-selective embolization was performed using Contour\u0026reg; (SE, Boston Scientific, Natick, MA, USA) PVA particles in sizes of 150\u0026ndash;250 \u0026micro;m and 250\u0026ndash;355 \u0026micro;m. The control angiogram showed occlusion of the feeding vessels and successful devascularization of the lesion with no significant residual blush. (Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eResult:\u003c/h2\u003e \u003cp\u003eThe patient made a good recovery without any minor or major post-embolization complications. Complete surgical resection of the tumor was accomplished. Intraoperative estimated blood loss was approximately 350 mL, and no blood transfusion was required.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eCase 2:\u003c/h2\u003e \u003cdiv id=\"Sec17\" class=\"Section3\"\u003e \u003ch2\u003e\u003cb\u003eClinical Presentation\u003c/b\u003e:\u003c/h2\u003e \u003cp\u003eA 42-year-old female patient, hypertensive but not diabetic, presented with right-sided painless neck swelling for 2 years.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eRadiological findings:\u003c/h2\u003e \u003cp\u003eEnhanced CT \u0026amp; MRI showed a fairly defined mass lesion seen insinuated at the right common carotid artery bifurcation measuring about (5.0 x 2.5 cm). It displays isointense T1 and hyperintense T2 signals (with a \u0026ldquo;salt and pepper\u0026rdquo; appearance) as well as intense post-contrast enhancement.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eTechnical details:\u003c/h2\u003e \u003cp\u003eUnder general anesthesia, right femoral puncture was performed, followed by insertion of a 6-Fr femoral sheath that was continuously flushed with saline. Selective catheterization of the right common, internal, and external carotid arteries was performed via diagnostic catheter 6-Fr Guider softip\u0026reg; (SE, Boston Scientific, Natick, MA, USA) over 0.035-inch. hydrophilic guide wire (Terumo), and diagnostic angiography showed vascular pathological blush corresponding to the lesion supplied by the right external carotid branches, \u0026ldquo;mainly from the superior thyroid artery (about 85%) and a few small branches from the occipital and lingual arteries, representing (about 15%)\u0026rdquo;. Super selective catheterization of the superior thyroid artery was performed using Renegade\u0026trade; HI-FLO\u0026trade; Microcatheter Kits with Transend\u0026trade;-18 Guidewires (SE, Boston Scientific, Natick, MA, USA). Super-selective embolization using Contour\u0026reg; (SE, Boston Scientific, Natick, MA, USA) PVA particles of sizes 150\u0026ndash;250\u0026micro;m \u0026amp; 250\u0026ndash;355\u0026micro;m. The other feeder branches can\u0026rsquo;t be catheterized due to their tiny size. The control angiogram showed good devascularization of the lesion with a moderate, rather insignificant residual blush (approximately 15%).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eResult:\u003c/h2\u003e \u003cp\u003eGood recovery of the patient with no minor or major post-embolization complications occurred. Complete surgical resection of the tumor was achieved. Intraoperative estimated blood loss was less than 450 mL, and no need for blood transfusion.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eCase 3:\u003c/h2\u003e \u003cdiv id=\"Sec22\" class=\"Section3\"\u003e \u003ch2\u003e\u003cb\u003eClinical Presentation\u003c/b\u003e:\u003c/h2\u003e \u003cp\u003eA 47-year-old female patient, not diabetic or hypertensive, with a history of mastoidectomy 13 years ago, then she presented with right otalgia \u0026amp; pulsatile tinnitus for two years.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eRadiological findings:\u003c/h2\u003e \u003cp\u003eEnhanced MRI revealed a well-defined mass lesion in the tympanic cavity that extends to the jugular foramen, measuring approximately 3 x 2 cm. It shows isointense T1 and hyperintense T2 signals (with a \u0026ldquo;salt and pepper\u0026rdquo; appearance) as well as intense post-contrast enhancement.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eTechnical details:\u003c/h2\u003e \u003cp\u003eUnder general anesthesia, a right femoral puncture was performed, followed by the insertion of a 6-Fr femoral sheath that was continuously flushed with saline. Selective catheterization and diagnostic angiogram of the right common, internal, and external carotid arteries were conducted using a 6-Fr Fargo-Max (Balt Extrusion, Montmorency, France) guiding catheter over a 0.035-inch hydrophilic guide wire (Terumo, Medical/MicroVention, Inc., Aliso Viejo, CA). A pathological blush was observed on the right side of the skull base, corresponding to the jugulotympanicum glomus tumor. It is supplied through branches arising from the right external carotid artery, namely the pharyngeal and neuromeningeal branches of the right ascending pharyngeal artery, the stylomastoid branch of the right posterior auricular artery, and the petrous branch of the right middle meningeal artery. Selective catheterization of the right external carotid artery was performed using a guiding catheter. Super-selective catheterization of the feeding arteries was accomplished with Renegade\u0026trade; HI-FLO\u0026trade; Microcatheter Kits and Transend\u0026trade;-18 Guidewires (SE, Boston Scientific, Natick, MA, USA). Embolization was conducted using Contour\u0026reg; (SE, Boston Scientific, Natick, MA, USA) PVA particles in sizes of 150\u0026ndash;250 \u0026micro;m and 250\u0026ndash;355 \u0026micro;m. The final control angiogram demonstrated good devascularization of the lesion and occlusion of its feeding arteries.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eResult:\u003c/h2\u003e \u003cp\u003eThe patient showed good recovery, with no minor or major complications following embolization. Approximately 85% of the tumor was surgically resected. The estimated blood loss during the procedure was around 600 mL, and only one unit of blood transfusion was required.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe exact cause of head and neck paraganglioma is unknown in most cases, and it occurs randomly, or \u0026ldquo;sporadically,\u0026rdquo; in about 60\u0026ndash;80% of instances. Approximately 10\u0026ndash;15% of HNPs have a \u0026ldquo;familial\u0026rdquo; link to genetic syndromes. Recognizing familial HNPs is important because they present an increased lifetime risk for multiple tumors, a higher incidence of recurrence, and a possible risk of malignancy [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe main results of our study were as follows:\u003c/p\u003e \u003cp\u003eAll our cases underwent preoperative angiography, and the aforementioned data were collected and analyzed for better embolization planning. Regarding the blood supply, all cases in the study group were supplied by the ipsilateral external carotid artery; however, in 16% of the cases, an additional supply from the ipsilateral ICA and/or vertebrobasilar system was detected. The ascending pharyngeal artery was the most frequent arterial feeder, supplying 88% of the cases in the study group. This is consistent with published literature [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe timing of preoperative embolization occurred within 48 hours before surgical intervention in 56% of the study group cases. An intentional delay of 1\u0026ndash;3 days between embolization and surgery provides sufficient time for tumor devascularization. Also, it allows soft tissue edema to resolve without permitting time for reconstitution or recruitment of feeding arteries. This aligns with published literature [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn 96% of the study group cases, the embolization route was accomplished through an endovascular approach, while one case (4%) utilized direct puncture embolization due to the presence of multiple tiny arterial feeders from both the internal carotid artery and external carotid artery supplying it.\u003c/p\u003e \u003cp\u003eThe most frequently utilized embolic agent was PVA particles, with particle sizes ranging from 150 \u0026micro;m to 500 \u0026micro;m, used in 96% of cases (23 cases embolized via PVA particles alone, and one case was embolized using PVA particles and Gelfoam). Meanwhile, Histoacryl was used in one case where direct needle puncture was performed.\u003c/p\u003e \u003cp\u003ePost-embolization, 64% of the study group cases were completely embolized with no significant residual tumoral blush. In contrast, 9 cases exhibited varying degrees of residual tumoral blush (2 cases with low residual blush and 7 cases with moderate residual tumoral blush). All cases in the study group supplied by branches from the ICA or the vertebrobasilar system showed moderate residual tumoral blush.\u003c/p\u003e \u003cp\u003eRegarding post-embolization complications, none of the patients experienced intraprocedural or neurological issues.\u003c/p\u003e \u003cp\u003eThe reduction of intraoperative blood loss is a significant finding in this study, where the mean intraoperative blood loss for all procedures was 384\u0026thinsp;\u0026plusmn;\u0026thinsp;150.5 mL, with\u003c/p\u003e \u003cp\u003ea range of 150\u0026ndash;750 mL. This finding aligns with results from multiple studies that preoperatively embolized patients with HNPs at various disease sites, demonstrating a significant decrease in intraoperative blood loss.\u003c/p\u003e \u003cp\u003eWhite et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] reported that in their study group, the intraoperative blood loss for each tumor type was 289 mL for carotid body, 243 mL for glomus vagale, and 1018 mL for glomus jugulare.\u003c/p\u003e \u003cp\u003eHelal et al. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] reported that the intraoperative estimated blood loss among their study group ranged from 888 to 1,084 mL.\u003c/p\u003e \u003cp\u003eThis finding is also consistent with Persky et al. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], who reported that among 28 patients presenting with HNPs who underwent preoperative embolization, the mean blood loss, according to tumor type, was 450 to 517 mL.\u003c/p\u003e \u003cp\u003eSimilarly, La Muraglia et al. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] used PVA to preoperatively embolize 11 neck paragangliomas and found that intraoperative blood loss was lower in the embolized patients (372\u0026thinsp;\u0026plusmn;\u0026thinsp;213 mL).\u003c/p\u003e \u003cp\u003eStudies conducted on HNPs resected without preoperative tumor embolization have reported much higher blood loss. In 1997, Tikkakoski et al. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] reported that the mean blood loss during surgery in the non-embolized group was 1374 mL (range, 100\u0026ndash;4500 mL), whereas in the embolized group, the mean blood loss was significantly lower at 588 mL (range, 100\u0026ndash;1800 mL).\u003c/p\u003e \u003cp\u003eWhen analyzing intraoperative blood loss in relation to post-embolization residual tumor blush, a statistically significant increase in intraoperative blood loss was observed among cases with moderate post-embolization residual tumor blush, with a p-value of 0.001.\u003c/p\u003e \u003cp\u003eOn the other hand, there was no statistically significant correlation between intraoperative blood loss and the various tumor sites or the different arterial feeders.\u003c/p\u003e \u003cp\u003eRegarding the intraoperative needs for blood transfusion, only one patient required a transfusion during surgery; this was associated with an intraoperative injury to the internal jugular vein.\u003c/p\u003e \u003cp\u003eWhen analyzing the need for intraoperative blood transfusion in relation to the amount of intraoperative blood loss, there was a statistically significantly higher amount of blood loss in patients who received blood transfusions during the operation, with a p-value of 0.01.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe preoperative embolization of paragangliomas in the head and neck is a safe technique that can significantly enhance the surgical approach, especially when a targeted strategy is pursued. Preoperative embolization of head and neck paragangliomas should be tailored to the angioarchitecture of the lesion, utilizing the most suitable materials based on the specific case being treated.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCCA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCommon carotid artery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComputed tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eECA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eExternal carotid artery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eICA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInternal carotidartery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHNPs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHead and neck paraganglioma\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMassachusetts\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026micro;m\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMicrometer\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003emL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMilliliter\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003emmHg\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMillimeters of mercury\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMagnetic resonance\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMRI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMagnetic resonance imaging\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePVA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePolyvinyl Alcohol\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStandard deviation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSynchro\u0026reg;\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSPSS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStatistical Package of Social Science\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUSA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUnited States of America.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received approval from the Research Ethics Committee of the Faculty of Medicine (Approval number:\u0026nbsp;M M600), which\u0026nbsp;approved this prospective study.\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from all patients prior to inclusion in the study. All procedures were conducted in accordance with the ethical standards of the institutional research committee and the 1964 Declaration of Helsinki and its subsequent amendments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData are available in the article or its supplementary materials.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u0026nbsp;related to this work..\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The interventional procedures were performed as part of routine clinical care under national healthcare coverage, either via health insurance or government-sponsored treatment plans.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFatima N, Pollom E, Soltys S, Chang SD, Meola A. Stereotactic radiosurgery for head and neck paragangliomas: a systematic review and meta-analysis. Neurosurg Rev. 2021;44(2):741\u0026ndash;752. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10143-020-01292-5\u003c/span\u003e\u003cspan address=\"10.1007/s10143-020-01292-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e..\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeli GA, Chiaramonte R, Cavallaro T, Puglisi C, Pero G. Carotid body paraganglioma. Diagnosis and treatment by angiography. 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Endovascular embolization of paragangliomas: A safe adjuvant to treatment. J Vasc Interv Neurol. 2008;1(2):37\u0026ndash;41. PMID: 22518217; PMCID: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pmc.ncbi.nlm.nih.gov/articles/PMC3317314/\u003c/span\u003e\u003cspan address=\"https://pmc.ncbi.nlm.nih.gov/articles/PMC3317314/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHelal A, Vakharia K, Brinjikji W, Carlson ML, Driscoll CL, Van Gompel JJ. Preoperative embolization of jugular paraganglioma tumors using particles is safe and effective. Interv Neuroradiol. 2022;28(2):145\u0026ndash;151. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/15910199211019175\u003c/span\u003e\u003cspan address=\"10.1177/15910199211019175\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePersky MS, Setton A, Niimi Y, Hartman J, Frank D, Berenstein A. Combined endovascular and surgical treatment of head and neck paragangliomas\u0026ndash;a team approach. Head Neck. 2002;24(5):423\u0026ndash;31. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/hed.10068\u003c/span\u003e\u003cspan address=\"10.1002/hed.10068\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLaMuraglia GM, Fabian RL, Brewster DC, Pile-Spellman J, Darling RC, Cambria RP, et al. The current surgical management of carotid body paragangliomas. J Vasc Surg. 1992;15(6):1038\u0026ndash;44; discussion 1044-5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1067/mva.1992.35505\u003c/span\u003e\u003cspan address=\"10.1067/mva.1992.35505\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTikkakoski T, Luotonen J, Leinonen S, Siniluoto T, Heikkil\u0026auml; O, P\u0026auml;iv\u0026auml;ns\u0026auml;lo M, et al. Preoperative embolization in the management of neck paragangliomas. Laryngoscope. 1997;107(6):821\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/00005537-199706000-00018\u003c/span\u003e\u003cspan address=\"10.1097/00005537-199706000-00018\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Head and neck Paragangliomas, Chemodectomas, Glomus, Carotid body, Preoperative embolization","lastPublishedDoi":"10.21203/rs.3.rs-6951468/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6951468/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eParagangliomas of the head and neck, also known as glomus tumors or chemodectomas, are rare neoplasms that account for less than 5% of all head and neck tumors, with an incidence rate ranging from 1 in 30,000 to 1 in 100,000. They can cause local compressive symptoms, leading to varied clinical presentations, or may show biochemical activity. Regardless of their location, paragangliomas are highly vascular and generally benign; however, they can be locally infiltrative, potentially lethal, and challenging to treat. The estimated malignant potential ranges from 2\u0026ndash;8% of cases. Histologic examination of the tumor does not provide a definitive diagnosis of its malignant potential. The presence of tumor cells in lymph nodes or systemic metastases is the only accepted criterion for malignancy. Because these tumors can be locally destructive or exhibit malignant tendencies, surgical resection is usually necessary. However, their high vascularity can lead to significant bleeding during surgery, which may impede the complete surgical removal of the lesion. Thus, pre-surgical embolization is an intervention that has been shown to reduce surgical time and blood loss, thereby decreasing morbidity and mortality. The most commonly used method for embolizing these lesions is the transarterial approach, although the direct puncture technique has also been described in some cases.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eBetween January 2021 and March 2023, twenty-five patients with head and neck paraganglioma were referred to our department for preoperative embolization. All cases showed no post-embolic complications. The average intra-operative blood loss was approximately (384\u0026thinsp;\u0026plusmn;\u0026thinsp;150.5) mL, and only one case required an intra-operative blood transfusion due to injury to the internal jugular vein during the surgical procedure. Two cases, representing 8% of the study group, could not be completely excised, with residual tumor volume that was less than 25% in both cases; one was a recurrent jugulotympanicum lesion, and the other was associated with injury to the internal jugular vein during surgical resection.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion:\u003c/b\u003e\u003c/p\u003e \u003cp\u003ePreoperative embolization of paragangliomas is a safe technique that can significantly enhance the surgical approach, especially when a targeted strategy is employed using the most appropriate methods and materials for each specific case.\u003c/p\u003e","manuscriptTitle":"Efficiency and Safety of Preoperative Embolization of Paragangliomas of The Head and Neck","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-02 07:22:07","doi":"10.21203/rs.3.rs-6951468/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8ac13e70-f710-468a-b237-b32698dbee38","owner":[],"postedDate":"July 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-13T20:09:03+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-02 07:22:07","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6951468","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6951468","identity":"rs-6951468","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}