Dural Venous Sinus Thrombosis after Vestibular Schwannoma Surgery: The Anticoagulation Dilemma.

Introduction Dural venous sinus thrombosis (DVST) is a relatively understudied complication of vestibular schwannoma (VS) surgery. Several studies have examined this topic; however, there is limited data on the incidence, clinical progression, and proper management of this patient population. Methods A retrospective review was performed for patients undergoing surgery for VS at a single institution. All postoperative imaging was reviewed for incidence of DVST. Demographic data were collected including tumor and surgical characteristics along with postoperative course. Results A total of 63 patients underwent resection of their VS. The incidence of DVST was 34.9%. The operative time was greater in the dural venous sinus thrombosis (DSVT) group, at an average of 6.69 hours versus 4.87 in the no DSVT cohort ( p = 0.04). Tumor size was correlationally significant ( p = 0.051) at 2.75 versus 2.12 cm greatest diameter. The translabyrinthine approach was most prevalent (68.2%). The side of the thrombosis was ipsilateral to the tumor and surgery in all patients. The sigmoid sinus was most commonly involved (95.5%). Of them, 85% patients had a codominant or thrombus contralateral to the dominant sinus. All patients were asymptomatic. No patients were treated with anticoagulation. Resolution of thrombus was seen in five (22.7%) of the patients on last follow-up imaging. There were no hemorrhagic complications. Conclusion The overall incidence of DVST was (34.9%) of 63 patients who underwent VS surgery. All patients were asymptomatic and none were treated with anticoagulation. In our study, continuing to observe asymptomatic patients did not lead to any adverse events.

Combined Transarterial and Transvenous Onyx Embolization of Jugular Foramen Paragangliomas.

OBJECTIVE: Jugular foramen paragangliomas are highly vascular tumors known to have significant venous hemorrhage during resection even after conventional transarterial embolization. The authors report a novel technique to the endovascular embolization of jugular foramen paragangliomas using a combined transarterial and transvenous access for better intraoperative control of blood loss and visualization. METHODS: This is a retrospective data collection of 2 patients diagnosed with jugular foramen paragangliomas with novel embolization technique and surgical resection. RESULTS: Two patients underwent embolization of jugular foramen paragangliomas through combined transarterial and transvenous routes using 2 double-lumen balloon microcatheters. In both cases, single arterial vessel embolization was performed through the occipital artery in Case 1 and the tympanic branch of the ascending pharyngeal artery in Case 2. Simultaneously, balloon microcatheter occlusion in the sigmoid sinus and single venous outflow vessel embolization was performed. Near-complete occlusion was established, with angiographic disappearance of tumor blush. Surgical resection was performed in both cases. Estimated blood loss BL was 600 mL in Case 1 and 200 mL in Case 2. No blood transfusions were required, intraoperatively or postoperatively. There were no cranial nerve deficits post embolization. One patient had a persistent House Brackman 2 facial nerve palsy after resection. CONCLUSIONS: The initial experience with simultaneous transvenous and transarterial paraganglioma embolization demonstrated the safety of the technique and superior embolic agent penetration. This was supported by our observations during embolization and intraoperatively during tumor resection. Additional patients need to be treated with this technique for better assessment of long-term efficacy and incidence of embolization-related cranial neuropathies.

Light Chain Amyloidosis Presenting as Bilateral External Auditory Canal Obstructing Masses.

: A morbidly-obese 57-year-old diabetic and hypertensive man with chronic kidney disease, diastolic heart failure, and bilateral hearing loss was found to have soft tissue masses/densities in the lateral aspect of both auditory canals on local examination and on imaging. He underwent biopsies of both ear canal masses and histologic examination revealed amyloid deposits in the dermis. These deposits were confirmed as AL (amyloid light chain) kappa-type amyloid by laser mass spectrometry. A systemic work-up showed plasma cell dyscrasia with 9% kappa light chain restricted plasma cells in the bone marrow as well as amyloid deposits on a kidney biopsy.Involvement of the external auditory canals is a rare manifestation of systemic amyloidosis with only 13 cases reported so far, of which four cases had bilateral external auditory canal involvement, associated with multiple myeloma. Interpretation of small biopsies can be challenging especially with early, scant amyloid deposits, but a sufficient biopsy to type amyloid by immunohistochemistry or laser mass spectrometry is imperative for further management. Early diagnosis and treatment of systemic light chain amyloidosis translates to better patient outcomes, while delay in management could lead to dismal prognosis.