FIGURE 1.
Flowchart summarizing the cellular origin, localization, and phenotype of pheochromocytomas and paragangliomas (PPGLs).3,5–8
FIGURE 2.
Graphical illustration of sympathetic and parasympathetic paragangliomas’ most frequent locations.
Table 1
Advantages and limitations of temporary and permanent embolization agents20 and the properties and compositions of different non-adhesive liquid embolization agents.21
Temporary | Advantages | Limitations | ||
|---|---|---|---|---|
Microsphere | Deep microvasculature penetration Minimal clumping | Radiolucent Fragile | ||
Gelfoam | Medium to large vessel occlusion Inexpensive Easy to use | Temporary | ||
Permanent | Advantages | Limitations | ||
|---|---|---|---|---|
PVA (polyvinyl alcohol) | Microvascular penetration Easy to use | Radiolucent Irregular shape may allow recanalization | ||
Coils | Precise deployment Useful in high-flow vessels | Possible dislogment and embolization | ||
Glues (nBCA) | Rapid solidification and occlusion Can flow into complex angioarchitecture | Catheter retainment | ||
Copolymers (SQUID, ONYX, PHIL, and Easyx) | Usually slower solidification Can flow into complex angioarchitecture | Catheter retainment | ||
Copolymers | ONYX | SQUID | PHIL | Easyx |
|---|---|---|---|---|
Molecule | EVOH copolymer | EVOH copolymer | Hydroxethyl methacrylate copolymer | lodinized Polyvinyl Alcohol Polymer Ether |
Preparation | 20-minute shaking | 20-minute shaking | No needed | Ready to use (vial) |
Radiopacity visibility | Excellent | Excellent | Good | Good |
Radiopaque agent | Tantalum | Tantalum | lodine | lodine |
Embolization power | Excellent | Excellent | Excellent | Excellent |
Different viscosity | Yes | Yes | Yes | No |
Texture | Chewy | Chewy | Chalky | Chewy |
Injection time | Minutes (0.016 mL/min) | Minutes | Minutes | Minutes (0.025 mL/min) |
CT-scan artifacts | Yes | Yes | No | No |
Solidification process | Copolymerization | Copolymerization | Copolymerization | Copolymerization |
Solvent needed | DMSO | DMSO | DMSO | DMSO |
Staining | Yes (black) | Yes (black) | No (opaque-white color) | No (pearl-white color) |
Table 2
Laboratory findings and vital parameters at the emergency room.
Vital Parameters | Normal Range | |
|---|---|---|
Heart rate | 78 | 60–100 |
Respiratory rate | 18 | 10–18 |
Glasgow Coma Scale | 15 | 15 |
Blood Pressure | 118/78 mmHg | 120/100 to 60/80 mmHg |
Pulse | Rhythmic | — |
SpO2% | 98% | >95% |
Temperature | 36 | <37.3°C |
Chemistry | Normal Values | |
|---|---|---|
Sodium | 140 | 136–146 mmol/L |
Potassium | 4.2 | 3.5–5.3 mmol/L |
Creatine kinase | 213 | 15–145 U/L |
Lipase | 27 | 1–67 IU/L |
Urea | 28 | 17–43 mg/dL |
Creatinine | 0.66 | 0.7–1.5 mg/dL |
Glucose | 86 | 70–110 mg/dL |
Total calcium | 2.33 | 2.20–2.65 mmol/L |
LDH | 230 | 110–295 IU/L |
CRP | 0.16 | 0.01–0.50 mg/dL |
Hemoglobin | 13.4 | 14–17 gr/dL |
Hematocrit | 39.6 | 40–54% |
Mean cell volume | 86.8 | 85–95 FL |
Erythrocytes | 4.56 | 3.90–5.20 (106 /mm3) |
Leucocytes | 8.16 | 4.00–10.00 (106 /mm3) |
PT | 10.70 | — |
INR (PT) | 0.97 | 0.9–1.18 s |
a-PTT | 32.50 | — |
INR (a-PTT) | 1.08 | 0.81–1.20 s |
FIGURE 3.
Patient axial brain computerized tomography (A) and axial bone window CT scan of the petrosal part of the right temporal bone with bone erosion (B). CT, computerized tomography.
FIGURE 4.
Patient axial brain MRI with T2-weighted (A) and T1-weighted with contrast (B) sequences.
FIGURE 5.
Frontal (A) and lateral (B) cerebral angiography views demonstrate an intense vascular blush originating from a right-sided expansive intra-extracranial lesion. This was observed following selective injections into the hypertrophied posterior branch of the right ascending pharyngeal artery, supplying the lesion.
FIGURE 6.
Frontal (A) and lateral (B) cerebral angiography projections of our patient demonstrate super-selective navigation using a double-lumen microcatheter, with a 6–9 mm Eclipse balloon positioned within the primary vessel supplying the lesion.
FIGURE 7.
Frontal (A) and lateral (B,C) cerebral angiography projections. During occlusive balloon inflation (‘pressure cook’ technique), approximately 4 ml of SQUID-12 non-adhesive embolizing material was injected.
FIGURE 8.
Frontal cerebral angiography projection without (A) and with subtraction (C) and lateral cerebral angiography projection without (B) and with subtraction (D) after complete deafferentation of the lesion.
FIGURE 9.
Upper pre-embolization (A) and post-embolization (B) axial brain MR T2-weighted sequences and lower pre-embolization (A) and post-embolization (B) coronal MR T1 sequences of our patient showing around a reduction of the size lesion of approximately 25–30% 1 month after endovascular embolization.