Endocrine Abstracts

Cerebellopontine angle (CPA) masses are relatively common; however, paragangliomas in this region are rare. Most reported CPA paragangliomas are diagnosed postoperatively, often non-secretory and identified only on histology. Vascular, secretory CPA paragangliomas are even rarer and pose significant surgical and anaesthetic challenges due to their location, vascularity, and hormonal activity. We report a case of a large, vascular, secretory right CPA paraganglioma managed with two-stage surgical approach in a 60-year-old retired engineer. He presented with worsening headaches following six months of hearing loss, voice changes, and gait unsteadiness. Imaging revealed a tumour likely originating from the right petrous bone. Plasma normetanephrine was markedly elevated at 18,500 pmol/l (normal <1180) and 3-methoxytyramine (3-MT) at 297 pmol/l (normal <180), confirming a secretory tumour. Preoperative alpha- and beta-blockade were optimised. A multidisciplinary team planned a two-stage intervention. On Day 1, the patient underwent 11 hours of interventional radiology embolisation and surgical exploration. On Day 2, a 10-hour definitive surgical debulking was performed. Both procedures were under general anaesthesia (rocuronium, propofol, alfentanil, remifentanil). Intraoperative haemodynamic management was complex, requiring sodium nitroprusside, nicardipine, magnesium sulphate, and clonidine to maintain mean arterial pressure between 70–86 mmHg and heart rate between 50–80 bpm. Blood pressure and heart rate surges were proactively controlled. Postoperatively, rebound hypertension due to residual tumour was managed with gradual reintroduction of oral antihypertensives. Complications included mild hyponatraemia, transient ileus, and a pseudomeningocele treated with lumbar drainage. The patient was discharged on Day 20 on reduced antihypertensive therapy. Plasma normetanephrine three weeks post-surgery was 5090 pmol/l with negative 3-MT. This case highlights the perioperative complexity of secretory CPA paragangliomas and underscores the importance of tailored haemodynamic management and multidisciplinary care. It adds to the limited literature on these rare tumours and illustrates challenges from their vascularity and catecholamine secretion.