Evidence-Based Treatment, Surgical Indications, Contra-indications, Preoperative Clinical Evaluation, and Preoperative Preparation for Anesthesia

and Marcos Soares Tatagiba²

(1)

Chairman of the Neurosurgical Department, Neurological Institute of Curitiba, Curitiba, Brazil

(2)

Chairman of the Neurosurgical Department, Eberhard Karls University, Tübingen, Germany

Keywords

ParagangliomasSchwannomasMeningiomasChordomasSurgeryIrradiationRadiosurgerySurgical indicationsContra-indications

Evidence-Based Treatment

Evaluation of evidence-based treatments for jugular foramen tumors should take into account various factors. The first one is to discuss with the patients their individual values, needs, and goals. Tumors of distinct histologies originate or involve the jugular foramen, and will require different modalities of treatment. Other important associated factors to decide how to manage these tumors are: patient age, clinical condition, presence of preoperative cranial nerves deficits, and grade of involvement or infiltration of the internal carotid artery . Based on relevant clinical studies the applicability and validity of the treatment modality should be decided in each case.

Paragangliomas

The proposed types of treatment are: clinical observation, surgical removal (with or previous embolization and/or radiotherapy), and irradiation therapy (all modalities) as primary treatment.

Surgical series, of benign paragangliomas, reported in the literature (Table 7.1) present a mean follow-up between 48.4 and 85.7 months. Gross total resection ranges between 51 % and 97.2 %. Grade of gross total resection depends on the size of tumor and grade of involvement of cranial nerves and the internal carotid artery. Recurrence varies from 0.7 % to 11.8 % depending on the length of follow-up period. Surgical mortality is very low and is related to tumor size and postoperative deficits of the lower cranial nerves. Postoperative morbidity is mainly related to the damage of cranial nerves and CSF fistula.

Table 7.1

Results of surgical removal of jugular foramen paragangliomas

Authors	Resection	No of cases	Follow-up	Recurrence	Clinical improvement	Complications
Li et al. [1]	Subtotal 43.1 % Gross total 51 %	51	Mean 85.7 months	11.8 %	90 %	23 (45.1 %)
Patnaik et al. [2]	Subtotal 2.8 % Gross total 97.2 %	145	Mean 48.4 months	1 (0.7 %)	VII nerve Preserved 143	0
Jackson et al. [3]	Lateral skull base resection	176	Tu. resection between 1972 and 1998	Control 85 % 9 recurrences (5.5 %)	Tinnitus 54 % Other 34.5 %	CSF leak 4.5 % New CN deficits (21–39 %) Mortality 5 (2.7 %)

Surgical removal is the only method that offers cure and long-term control. Preservation of neurologic function is a priority and less-aggressive surgical resection achieves acceptable outcomes. Most patients carry out normal life activities even with mild deficits.

Irradiation therapy is utilized as postoperative treatment after subtotal removal and as primary treatment. Control of tumor growth is high but no patient will be cured with this method. Table 7.2 shows recent results of patients treated with radiosurgery (gamma knife, LINAC, and conventional irradiation therapy).

Table 7.2

Results of jugular foramen paragangliomas treated by irradiation

Authors	Method	No of cases	Follow-up	% Tu growth control	Clinical improvement	Complications
Hafez et al. [4]	GKS	22	Mean 56 months (36–108 months)	Unchanged 12 Decrease 8 Growth 1	12	3
Liscak et al. [5]	GKS	45	Median 118 months (12–217 months)	Unchanged 9 Decrease 34 Growth 1	19	2
Gandía-González et al. [6]	GKS	75	Mean 86.4 months	Control 94,8 % Decrease 67.2 %	Tinnitus 54 % Other 34.5 %	NR
Scheick et al. [7]	LINAC	11	Median 5.3 years	81 %	NR	0 %
Gilbo et al. [8]	Fractionated RT	131	Mean 11.5 years Median 8.7 years	99 %—5 years 96 %—10 years	NR	No severe

According to these results irradiation therapy has been demonstrated to be efficient and safe. It should be considered as an alternative for elderly patients and in small tumors with proven growth.

Schwannomas

Clinical observation, surgical removal, and irradiation therapy (all modalities) are the proposed treatment for jugular foramen schwannomas. These tumors, usually benign lesions, do not infiltrate bone, vessels, and nerves. Therefore, complete surgical removal is curative in the majority of the cases. Small lesions are more favorable for surgical resection with preservation of the involved, noninfiltrated, nerves. Larger tumors compress the non-affected lower cranial nerves and surgical dissection may cause deficits (in most cases temporary). In the literature reported surgical series present favorable outcomes in the majority of cases (Table 7.3).

Table 7.3

Results of surgical removal of jugular foramen schwannomas

Authors	Resection	No of cases	Recurrence	Clinical improvement	Complications
Samii et al. [9]	Gross total 16 (100 %)	16	0 %	100 %	CSF 2 cases
Sedney et al. [10]	Gross total Subtotal	81	5.7 % 10.7 %
Sanna et al. [11]	Gross total 21 Subtotal 2	23	0 %		CSF 1 New CN deficits 50 %

Radiosurgery as primary treatment or after subtotal removal for jugular foramen schwannomas has been proposed in the literature (Table 7.4). Goals of this modality of therapy are to control tumor growth and avoid new deficits of the lower cranial nerves. Small tumors achieve better results; however, these lesions would also have better results with radical surgical resection. Elderly patients probably would have more benefit with this treatment. The reported results indicated that radiosurgery is a safe alternative to surgery in selected patients.

Table 7.4

Results of jugular foramen schwannomas treated by irradiation

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