Carotid Body Tumors: Advantages of Contrast Ultrasound Investigation Maria F. Giannoni, MD, Luigi Irace, MD, Edoardo Vicenzini, MD, PhD, Rita Massa, MD, Bruno Gossetti, MD, Fabrizio Benedetti-Valentini, MD From the Vascular Surgery Unit, Department “Paride Stefanini,” University “La Sapienza,” Rome, Italy (MFG, LI, BG, FBV); Department of Neurological Sciences, University “La Sapienza,” Rome, Italy (EV); and Nuclear Medicine Unit, Department of Radiological Sciences, University “La Sapienza,” Rome, Italy (RM). [Correction added after online publication 14-September-2009: Received date has been corrected.] Keywords: Carotid body tumor, contrast ultrasound investigation, echo-contrast agents, Cadence CPS technique. Acceptance: Received March 14, 2008, and in revised form July 1, 2008. Ac- cepted for publication September 15, 2008. Correspondence: Address correspon- dence to Maria Fabrizia Giannoni, MD, Vascular Surgery Unit, Department “Paride Stefanini,” Policlinico Umberto I, Viale del Policlinico 155, 00161 Roma, Italia. E-mail: mariafabrizia.giannoni@ uniroma1.it. J Neuroimaging 2009;19:388-390. DOI: 10.1111/j.1552-6569.2008.00323.x ABSTRACT Carotid body tumors are rare neoplasms that have to be considered in the evaluation of all lateral neck mass. Early surgical removal has been recommended to avoid possible cranial nerve injury, the most common perioperative complication. Computed tomography (CT) and magnetic resonance imaging (MRA) angiographies are the preferred pre-operative diagnostic imaging investigations, as well as the 111 In-pentetreotide scintigraphic scan, whereas the standard ultrasound investigations have poor sensitivity in characterizing of the blood flows of the parenchimal structure of the carotid body tumors. We describe a case of a patient with a carotid body tumor assessed with contrast ultrasonography that clearly improved the quality of the standard color Duplex. This technique may represent a non-invasive method, easy to use and to repeat, and able to achieve high diagnostic accuracy. Introduction Cervical paragangliomas are slowly growing, highly vascu- larized solid tumors that originate from the extrasuprarenal paraganglionic neuroendocrine cells of the autonomic nervous system. They generally manifested as a lateral gradually enlarging pulsatile neck mass, to be considered in the evaluation of all lat- eral neck mass. They preferentially involve the carotid artery (carotid body tumors, in 85% of the cases) and, less frequently, they are located along the vagus nerve (vagal paraganglioma) or in the jugular fossa (glomus jugulare) or in the tympanic cavity (glomus tympanicum and hypotympanicum). Head and neck paragangliomas are generally benign tumors, but in about 6-10% they show a progression toward malignancy. 1 The nat- ural history of these neoplasms involves progressive growth, possibly with local compression, and invasion of the adjacent vascular, nerve, and bone structures, thus causing patients dis- comfort and increasing the surgical risk. The gold standard for diagnostic imaging procedures are computed tomography (CT)-angiography, magnetic reso- nance imaging (MRI), and conventional angiography; 111 In- pentetreotide scintigraphic scan is also a further imaging tech- nique for diagnosis confirmation and pre-operative planning for the subsequent intra-operative evaluation. These techniques are highly specific and generally adopted in late phases. Ultrasound is a common available technique in clinical practice that, with contrast agents, may also add further important functional data in an early phase. Aim of this report is to propose a new ultrasound diagnostic approach to the detection of carotid body tumors, using the Siemens-developed Cadence contrast pulse sequencing (CPS) software, specific for second-generation contrast agents. 2 Case Report Description A 76-year-old woman was admitted to our ward for the occur- rence of recurrent episodes of dizziness, hypotension, pallor, and uncertain walking, lasting from more than 24 hours. In her past medical history she had arterial hypertension and she was submitted to coronary artery angioplasty and stenting, 5 years before. Clinical and neurological examination on admission showed only slight hypotension (BP 110/60 mmHg) and uncertain gait, without other focal neurological deficit. Routine blood exams, electrocardiogram (ECG) and Holter ECG, electroencephalog- raphy (EEG), and cerebral magnetic resonance imaging were unremarkable. The standard ultrasound investigation of the carotid vessels (Sequoia Acuson, Siemens, Mountain View, CA) detected a homogeneous, slightly hyperechoic ovoidal mass, measuring 2-cm size in the maximum diameter, placed at the bifurcation, mainly posteriorly (Fig 1), suggesting the presence of a para- ganglioma. Moreover, a swollen lymph node at the base of the neck behind the jugular vein was detected. The ultrasound investigation was completed after two re- peated SonoVue 2.5-mL bolus administration in an antecubital vein (20-Gauge Venflon), each promptly followed by a 10-mL saline flush. A 15-MHz linear probe with Siemens Cadence CPS software was used to visualize the lesion and the lymph node parenchimal vascularization. CPS investigation allowed a clear identification of the richly vascularized mass. The lymph node, 388 Copyright ◦ C 2008 by the American Society of Neuroimaging