A Novel Hybrid Endovascular Technique for Tympanojugular Paraganglioma: Flow Diversion Followed by Direct Transauricular Squid Embolization

Skull-base paragangliomas with persistent internal carotid artery (ICA) supply can be challenging to devascularize safely. We report a 17-yearold male with an Succinate Dehydrogenase Complex Iron Sulfur Subunit B (SDHB)-associated tympanojugular paraganglioma treated using a staged hybrid endovascular strategy after subtotal resection. Persistent supply from a short ICA feeder and circumferential involvement of the petrous ICA precluded safe conventional transarterial embolization. A Surpass Elite flow-diverting stent was deployed across the feeder after dual antiplatelet therapy to preserve parent-vessel patency, reduce tumour inflow, and reinforce the arterial wall. Four months later, protected direct transauricular and transcervical puncture embolization with Squid 12 was performed under intermittent ICA balloon occlusion. Marked tumor devascularization was achieved without embolic or thromboembolic complication, and definitive resection was completed without new neurological or cranial nerve deficit. This staged approach may provide a useful adjunct for selected skull-base paragangliomas with persistent ICA supply when conventional embolization carries unacceptable risk.