Jugular paragangliomas are highly vascular tumors, and therefore the potential for high-volume intraoperative blood loss during tumor resection is a concern that should be discussed between the surgeon and anesthetic team prior to surgery. Excess circulating catecholamines can cause chronic vasoconstriction, leading to a smaller circulating blood volume. With tumor resection and normalization of catecholamine levels, even small amounts of hemorrhage can lead to clinically significant hypotension intraoperatively, and some anesthesiologists prefer to volume load patients prior to surgery to prevent this complication. Furthermore, all patients should receive a type and screen before surgery to ensure timely transfusion if required. Additional concerns for the surgeon include the close proximity of dural venous sinuses including the sigmoid sinus and inferior petrosal sinus. In order to reduce intraoperative blood loss, many surgeons perform preoperative embolization as some studies have shown improved resection rates and decreased intraoperative tumor bleeding [12, 13]. Embolization is not without controversy, as one small study reported a 25–50% reduction in blood flow to the tumor on arteriography, but did not show any difference in embolized patients versus non-embolized in operative time, intraoperative blood loss, or extent of resection. Additionally within this study, embolized patients had higher rates of complications, believed to be associated with embolization [14]. Other studies have also suggested a higher risk of post-embolization cranial neuropathy (facial nerve, lower cranial nerves) because of overlapping blood supply of tumor and cranial nerves [15, 16]. While less common, there have even been reports of cardiac arrest and hypertensive crisis during embolization of JP, thought to result from tumor necrosis and subsequent spillage of catecholamines [1, 17].

Elevated intracranial pressure is a rare finding in patients with JP since tumors are often extradural or have limited involvement of the posterior fossa. However, since these tumors arise from the jugular bulb, obstruction of the venous outflow tract from tumor growth or treatment may lead to elevated intracranial pressure and rarely irreversible vision loss in patients with long-standing symptoms [18]. Tumors have also been shown to masquerade as benign intracranial hypertension (pseudotumor cerebri) even in cases without significant intracranial extension [19, 20]. Preoperative head imaging, assessment for papilledema, or lumbar puncture with opening pressure should be considered in patients with symptoms concerning for hydrocephalus including headache, imbalance, vision changes, urinary incontinence, or memory impairment.

Patients with history of head and neck surgery, imaging concerning for extensive tumor involvement of cranial nerves, or symptoms suggestive of lower cranial neuropathy should be evaluated for deficits, as preoperative cranial nerve palsy and vocal fold paresis should be identified preoperatively in order for intraoperative and postoperative planning.