Glomus Jugulare tumors are notorious for their high vascularity and technical challenges required for their resection. This is a 42 year old male who presented with progressive gait difficulty and on MRI evaluation was diagnosed with a typical large Glomus Jugulare tumor characterized by this salt and pepper appearance, which is signifying the high vascularity and the flow voids within the tumor on the MRI evaluation. You can see the permeative and the erosive nature of the tumor around the area of the jugular bulb. The mass effect of this tumor led to mild hydrocephalus in this patient and you can see this tumor extends all the way to the level of the bone and therefore significant amount of bleeding from the bone during elevation of the bone flap is expected. Preoperative angiography, again, confirmed the high vascularity of the tumor and its character, the ascending pharyngeal artery, and the other extracranial vessels, were the source of feeding vessels for this tumor. In addition, the small feeding vessels directly from their vertebral artery were noted. Unfortunately, these small feeding vessels can not be embolized without placing the vertebral artery at risk. Therefore, I expect a significant amount of blood loss in this patient, and we planned on a stage approach to tackle this daunting tumor. A typical incision for a Glomus Jugulare tumor was completed extending to the level of the neck. Obviously the brainstem auditory evoked responses were monitored. You can see the neck vessels, including the carotid artery and jugular vein were exposed all the way to the level of the jugular bulb, and here's the tour of the posterior fossa, here's the transfer sinus. The initial bony opening led to actually significant amount of blood lost. We lost almost a liter of blood, and by the time I opened the dura and exposed the root of the tumor over the area of the dura of the jugular bulb, I felt it is best to close the case and return him in about a week to tackle the tumor itself. Here you can see the high vascularity of the tumor at the level of the jugular bulb. During the second stage, additional mastoidectomy was completed to further devascularize the tumor. Here you see the lower cranial nerves, I had to actually resort to using the Bovie electrocautery to devascularize the tumor from the area of the jugular bulb. Subsequently the small feeding vessels from the branches of the vertebral artery were disconnected from the tumor and the tumor was also gently mobilized from the lower cranial nerves. The portion of the dura affected by the tumor as well as a segment of the transfer sinus affected by this tumor were resected. You can see that essentially the majority of the portion of the lesion causing brain stem compression has been resected. However, a significant part of the bone at the level of the skull base around the jugular bulb was also affected by the tumor. Removal of this part of the tumor was noted to be risky and would have placed a lower cranial nerves at risk. Here's the post operative MRI, which demonstrates reasonable resection of the tumor, aggressive decompression of the brain stem, but obviously residual tumor within the Oni skull base. This patient subsequently underwent proton beam therapy and his tumor has remained stable for about four years after his procedure. His gait did significantly improve after the operation. Thank you.
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