Multimodality management of large carotid-space paragangliomas: A single-center case series.

Background: Large carotid-space paragangliomas (LCSPs) are uncommon, highly vascular tumors that present significant operative challenges because of their intimate relationship to the carotid circulation, lower cranial nerves, and skull base. The central hazard in surgical management is not tumor size alone but uncertainty regarding vascular anatomy, collateral circulation, and operative conditions before incision. We describe a structured multimodality strategy to reduce this uncertainty before critical dissection. Case Description: A retrospective review was performed of eight consecutive patients treated for LCSPs using a standardized multidisciplinary workflow involving neurovascular surgery, head and neck surgery, and neurointerventional surgery. Five tumors were carotid body tumors, and three were glomus vagale tumors (GVTs). Mean age was 55 years and mean maximum tumor diameter was 6.1 cm. Multifocal disease occurred in two patients (25%); one tumor was biochemically active. All patients underwent diagnostic angiography and preoperative embolization. Balloon test occlusion was performed in seven patients; six passed. Gross total resection was achieved in six patients (75%). Intentional subtotal resection was performed in two GVTs due to skull base extension. One patient subsequently underwent stereotactic radiosurgery for residual disease. Median estimated blood loss was 100 mL (mean 122 mL; range 25-350 mL). No patient required transfusion, had perioperative stroke, carotid sacrifice, or major vascular complication. Two patients developed new postoperative vagal/recurrent laryngeal nerve dysfunction at 6-week follow-up. Median length of stay was 2 nights. Conclusion: A structured multimodality strategy emphasizing preoperative uncertainty reduction was associated with favorable outcomes in our case series. Surgical endpoints were determined by anatomy rather than dogmatic pursuit of complete resection, providing a reproducible framework for LCSP management.