PMC6579522_01
(A) 3D angiotomography reconstruction showing occlusion of the right carotid artery and vicarious vertebral artery; (B) 3D angiotomography reconstruction showing glomus tumor at the left carotid bifurcation; (C) Doppler ultrasonography showing a hypervascularized nodule between the left internal and external carotids; (D) Axial angiotomography slice showing hypervascularized glomus tumor on the left and carotid occlusion on the right.
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Figure 1 A) identified a hypervascularized glomus tumor with a maximum diameter of 5 cm, located posterior to the left carotid bifurcation and primarily fed by the ascending pharyngeal artery, in addition to occlusion of the right carotid artery ( Figures 1 11D). Furthermore, a 4 mm saccular aneurysm was observed involving the left ophthalmic artery.
(A) Pre-embolization angiography showing the hypervascularized tumor and a left carotid lyre sign; (B) Superselective catheterization of the glomus tumor and "pressure cooker" embolization; (C) Direct external puncture of the glomus tumor and embolization.
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 The "pressure cooker" technique ( Figures 2 B and 3 ) was employed via a femoral artery puncture, with selective catheterization of the left common carotid artery ( Figure 2 A). It was used to inject Onyx  until arterial reflux was identified on fluoroscopy ( Figure 2 B). Since the hypervascularized tumor had not been completely filled ( Figure 3 C) by endovascular embolization, the unfilled part of the glomus tumor was directly punctured, percutaneously with a 22G needle, guided by the roadmap and fluoroscopy, and percutaneous polymer embolization was used to fill the remaining space ( Figures 2 C, 4 , and 3 D). 
"Pressure cooker" embolization technique: (A) Advancing two microcatheters, one with a detachable tip, up to the artery feeding the tumor, and release of glue via the more distal catheter to secure the tip of the proximal catheter to the lesion, creating a "cork" effect; (B) Embolization of the vascularized tumor with Onyx  via the catheter proximal of the lesion; (C) Withdrawal of both catheters. The tip of the more proximal catheter has been detached and glued where it remains inside the vessel; (D) Percutaneous puncture of the glomus tumor to fill the remaining area with polymer.
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 The "pressure cooker" technique ( Figures 2 B and 3 ) was employed via a femoral artery puncture, with selective catheterization of the left common carotid artery ( Figure 2 A). Once the ascending pharyngeal artery had been obstructed, infusion of copolymer was resumed via the Marathon  catheter, to progress in the anterograde direction and fill the hypervascularized lesion ( Figures 3 33C). Since the hypervascularized tumor had not been completely filled ( Figure 3 C) by endovascular embolization, the unfilled part of the glomus tumor was directly punctured, percutaneously with a 22G needle, guided by the roadmap and fluoroscopy, and percutaneous polymer embolization was used to fill the remaining space ( Figures 2 C, 4 , and 3 D). 
Arteriography showing the glomus tumor punctured percutaneously, soon after embolization with polymer. The arteriographic image is used to guide safe puncture of the tumor.
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Since the hypervascularized tumor had not been completely filled ( Figure 3 C) by endovascular embolization, the unfilled part of the glomus tumor was directly punctured, percutaneously with a 22G needle, guided by the roadmap and fluoroscopy, and percutaneous polymer embolization was used to fill the remaining space ( Figures 2 C, 4 , and 3 D). 
(A) Intraoperative image showing the glomus tumor adhering between the internal and external carotids; (B) Image after excision of the glomus tumor.
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After identification and isolation of arteries and nerves, a tumor with approximate dimensions of 3 cm x 2 cm was dissected without major bleeding or arterial damage, the dissection planes were identified, and rigorous hemostasis was achieved by ligation of the tumoral vessels and the ascending pharyngeal artery ( Figure 5 ).
(A) Control angiography showing the final result of embolization; (B) Late 3D angiotomography reconstruction, 3 years after the surgical procedure.
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Imaging exams conducted as part of a reevaluation 3 years after the procedure did not show any sign of relapse whatsoever ( Figure 6 ).
(A) Imagem intraoperatoria mostrando tumor glomico aderido entre carotida interna e externa; (B) Imagem apos exerese de tumor glomico.
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Figure 1 A) identified a hypervascularized glomus tumor with a maximum diameter of 5 cm, located posterior to the left carotid bifurcation and primarily fed by the ascending pharyngeal artery, in addition to occlusion of the right carotid artery ( Figures 1 11D). Furthermore, a 4 mm saccular aneurysm was observed involving the left ophthalmic artery.