All patients with paragangliomas presented jugular foramen invasion with extensions to the ear in 78 cases (90 %), to the cervical region in 75 cases (87 %) and in 56 patients (65 %) there was some grade of intradural invasion . The internal carotid artery was involved in 22 cases and eight patients showed radiological or intraoperative signs of invasion of the internal carotid artery walls. In three cases with invasion of the ICA walls a stent was initially inserted to protect the vessel during tumor dissection. The patients received aspirin during 3 months to avoid occlusion of the stent, and the tumors could be dissected from the involved wall of the internal carotid artery without injuring the vessel. In two cases (young patients with infiltration of the carotid artery walls) a high flow by-pass between the external carotid artery and the M2 segment of the middle cerebral artery was initially performed. The ICA in its petrous portion was occluded with a balloon. The tumors were totally removed with the infiltrated internal carotid artery . There were no ischemic deficits in these five patients with internal carotid wall invasion, treated aggressively. Four patients had familial history of paragangliomas and three of these cases presented multiple paragangliomas . Common carotid bifurcation paragangliomas were the most frequent associated tumors. Two patients presented tumors secreting catecholamines with hypertension, headache, arrhythmias, nausea, and palpitations. These cases were managed preoperatively with alpha adrenergic antagonists like phenoxybenzamine (one patient) and more selective α1 antagonists like prazosin (other patient). This therapy was initiate 1 week prior to surgery. Beta blockade is rarely used in tumors that only secrete norepinephrine and should not be used to control hypertension in these patients. Beta blockade before establishment of α blockade may result in myocardial infarction , organ ischemia, and death from unopposed α agonism. Grade of tumor resection in paragangliomas group is shown in Table 14.1.

Radical resection was possible in 67 patients (78 %). Seven patients (10 %) present tumor recurrence. Three of these cases underwent radiotherapy, two radiosurgery, and two reoperations. Subtotal resection was performed in 19 patients (22 %). Lower cranial nerves infiltration and involvement of the internal carotid artery were the factors precluding radical resection in these cases. Nine of these patients had recurrent tumors that had been operated on elsewhere and four patients had malignant paragangliomas with cervical lymph nodes invasion. All these patients received postoperatively radiation therapy.

Two patients died postoperatively (2 %). Causes of mortality were internal carotid artery thrombosis in one patient and large cervical hematoma due to bleeding from the internal jugular vein in the other. In this case the internal jugular vein was ligated without double suture-ligature and the patient presented the day after surgery a cough crises. The internal jugular vein bled and a large cervical hematoma developed. It was evacuated but the patient presented ischemic/hypoxia brain damage and died 2 months later. Double suture-ligature of the internal jugular vein is recommended to avoid this complication. Patients with radical resection of the tumors were followed with a yearly MRI. For those with subtotal removal and radiation therapy MRI control is performed every 6 months. Three patients were lost of follow-up. There is no recurrence or growth of residual tumor in this series . Long-term follow-up is, however, recommended.

There were 16 cases of jugular foramen meningiomas in this series. Meningiomas arising in other regions (cerebellopontine angle, petroclival, clival, or cranial cervical junction) invading the jugular foramen were excluded. Ten patients presented meningotheliomatous meningiomas , three anaplastic, two papillary, and one microcystic. Radical tumor resection was possible in nine cases (eight meningotheliomatous and one papillary). Invasion of cranial nerves, skull base bone, and malignant behavior were the causes of subtotal removal in this series (Table 14.2).