Malignant glioma arising at the site of an excised cerebellar hemangioblastoma after irradiation in a von Hippel-Lindau disease patient

We describe herein a malignant glioma arising at the site of the resected hemangioblastoma after irradiation in a patient with von Hippel-Lindau disease (VHL). The patient was a 25 year-old male with multiple hemangioblastomas at the cerebellum and spinal cord, multiple pancreatic cysts and a renal cell carcinoma; he was diagnosed as having VHL disease. The largest hemangioblastoma at the right cerebellar hemisphere was completely removed, and he received high-dose irradiation postoperatively. The tumor recurred at the same site 7 years later, which was a malignant glioma with no evidence of hemangioblastoma. The malignant glioma showed molecular genetic profiles of radiation-induced tumors because of its diffuse p53 immunostaining and the loss of p16 immunoreactivity. The genetic study to find the loss of heterozygosity (LOH) of VHL gene revealed that only the cerebellar hemangioblastoma showed allelic losses for the gene. To the best of our knowledge, this report is the first to show a malignant glioma that developed in a patient with VHL disease after radiation therapy at the site of an excised hemangioblastoma. This report also suggests that radiation therapy should be performed very carefully in VHL patients with hemangioblastomas.

Disseminated hemangioblastomatosis of the central nervous system without von Hippel-Lindau disease: a case report

We report a very rare case of hemangioblastomatosis that developed after surgical removal of a solitary cerebellar hemangioblastoma (HB). A 51-yr-old man presented with back pain 10 yr after undergoing surgery for cerebellar HB. Magnetic resonance imaging showed numerous mass lesions along the entire neuraxis accompanied by prominent leptomeningeal enhancement. Genomic DNA analysis showed no mutation in the von Hippel-Lindau (VHL) genes. A surgical specimen obtained from a lesion in the cauda equina showed pathological findings identical to those of the cerebellar HB that had been resected 10 yr earlier. External beam radiation therapy and radiosurgery were subsequently performed; however, the patient succumbed one year after receiving the diagnosis of hemangioblastomatosis. The reduction of tumor cell spillage during surgery and regular long-term follow-up are recommended for patients with HBs.

Haemangioblastoma: a rare cause of a cerebellar mass in the elderly

In the elderly, cerebellar lesions are commonly metastatic tumours with poor prognosis. We describe two octogenarians who presented with obstructive hydrocephalus, secondary to posterior fossa tumours that, on computed tomography, were thought to be cerebellar metastases. Both lesions were excised and the histology proved them to be cerebellar haemangioblastomas, primary benign tumours of the posterior fossa, which are rare in the elderly.

[Cystic hemangioblastoma of the junction of the medulla and upper spinal cord associated to von Hippel-Lindau disease. Two case reports and a review of the literature]

INTRODUCTION

Hemangioblastomas are very highly vascularised benign tumours that can present either sporadically or in association with von Hippel-Lindau syndrome in 20% of cases. Only 5-20% of hemangioblastomas are located in the brainstem, and those that occur at the junction of the medulla and upper spinal cord are the ones that are less commonly diagnosed.

CASE REPORTS

Two young patients were diagnosed with von Hippel-Lindau disease after beginning with a cystic hemangioblastoma at the junction of the medulla and upper spinal cord as the first pathological manifestation. Both of them underwent a suboccipital craniotomy and the two lesions were completely removed without any kind of post-operative neurological deficits. One of the patients required a reintervention some years later due to a new recurrence of a symptomatic hemangioblastoma in the dorsal medulla. The genetic study conducted in both patients confirmed the presence of a mutation in the VHL gene, which is responsible for the syndrome they were suffering from.

CONCLUSIONS

The presence of cystic hemangioblastomas of the junction of the medulla and upper spinal cord associated to von Hippel-Lindau disease is very rare. Despite the technical difficulties involved in removing them, the incorporation of the latest neuroimaging and microsurgery techniques has made it possible to significantly reduce the morbidity and mortality rate associated to the surgical treatment of such patients.

Incidental hemangioblastoma of the filum terminale

Filum terminale hemangioblastoma is an extremely rare tumour with only a few case reports in the literature. The natural history is unknown but benign as well as more aggressive presentations have been reported. The authors present the first such lesion discovered incidentally and discuss the available literature.

Gamma knife radiosurgery for other primary intra-axial tumors

We report the usefulness of gamma knife radiosurgery for hemangioblastomas, hemangiopericytomas, germ cell tumors and pineal parenchymal tumors, and primary central nervous system lymphoma (PCNSL). In hemangioblastomas, small solid tumors can be treated very effectively. Hemangiopericytomas are still difficult to control due to their aggressiveness and metastasis to other organs. However, radiosurgery is a useful alternative to repeat craniotomy for recurrence. Radiosurgery is a reasonable option to control residual and recurrent germ cell tumors and pineoblastomas. Although the prognosis is poor for PCNSL patients, gamma knife radiosurgery, even with a relatively low tumor margin dose, is an effective treatment for controlling PCNSL.

Central alveolar hypoventilation syndrome due to surgical resection for bulbar hemangioblastoma

A 29-year-old man with a history of resected bulbar hemangioblastoma was admitted to hospital with nighttime breathing disturbance, but with apparently normal breathing while awake. After diagnostic work-up, including polysomnographic testing, he was diagnosed as having central alveolar hypoventilation syndrome due to surgical resection for bulbar hemangioblastoma. Non-invasive positive pressure ventilation (NIPPV) via oronasal facemask was given for nocturnal ventilatory support. Two months after leaving our hospital, he was readmitted because of aspiration pneumonia. The pneumonia was successfully treated with antibiotics, but the desaturation during sleep worsened despite non-invasive ventilatory support. Higher bi-level positive pressure using a full facemask successfully alleviated sleep hypoventilation and apnea. To the best of our knowledge, this is the first case report of central alveolar hypoventilation syndrome due to surgical resection for bulbar hemangioblastoma.

Neurologic manifestations of von Hippel-Lindau disease

von Hippel-Lindau disease (VHL) is an autosomal-dominant neoplasia syndrome that is the result of a germline mutation of the VHL tumor suppressor gene on the short arm of chromosome 3. Patients with VHL are predisposed to develop lesions of the central nervous system and viscera. Central nervous system lesions include hemangioblastomas (the most common tumor in VHL) and endolymphatic sac tumors (ELSTs). Visceral manifestations include renal carcinomas and cysts, pancreatic neuroendocrine tumors and cysts, pheochromocytomas, and cystadenomas of the reproductive adnexal organs. Despite their benign pathology, hemangioblastomas and ELSTs are a frequent cause of morbidity and mortality in patients with VHL. Recent molecular biologic investigations into these VHL-associated central nervous system lesions provide new insight into their origin and development. Emerging data from serial imaging and clinical surveillance protocols provide insight into the natural history of these lesions. Because of the dissimilar pathobiology and clinical course between hemangioblastomas and ELSTs, the optimal management strategies for these neurologic manifestations of VHL are very different.

Neurosurgical treatment of von Hippel-Lindau-associated hemangioblastomas: benefits, risks and outcome

AIM

Von Hippel-Lindau (VHL) disease is a genetic syndrome predisposing to central nervous system (CNS) hemangioblastomas and several lesions in many organs. The cases of all VHL individuals operated on in the Neurosurgical Unit of Padua Hospital since year 2000 were reviewed in order to define which features lead to surgical treatment and to examine surgical outcome during postoperative follow-up.

METHODS

The authors evaluated 20 VHL subjects (7 males and 13 females, age at surgery 32+/-10 years) who underwent 28 operations in order to remove 48 CNS hemangioblastomas and 1 endolymphatic sac tumor. Among the 49 resected lesions, 21 (42%) were cerebellar, 9 (18%) at brainstem, 19 (38%) spinal (7 cervical, 6 dorsal, 6 at cone-cauda level), and 1 (2%) endolymphatic sac tumor in the petrous bone. Patients were graduated according to Karnofsky Performance Status (KPS) at admission, at discharge and during the last follow up visit. Genetic testing revealing the presence of a VHL disease-causing mutation was a prerequisite for inclusion in the study.

RESULTS

Nineteen individuals (95%) were symptomatic. Symptomatic hemangioblastomas were associated with a cyst or a syrinx in 22/27 circumstances (81%). Total removal, as confirmed by postoperative magnetic resonance imaging (MRI), was achieved in all but one lesion. Following surgery, at follow-up (38+/-20 months), patients improved their neurological status in 75% of cases, 20% remained stable and 5% worsened; 16 patients (80%) are able to carry on normal activity with or without minor symptoms, 3 patients require some grade of assistance, 1 patient died because of bronchopneumonia.

CONCLUSION

VHL-associated hemangioblastomas generally affect a young adult population and can be successfully removed, either when symptomatic, or when they reach a critical volume. Microsurgery of hemangioblastomas has a favourable impact on survival and quality of life of VHL patients, although it is strongly influenced by preoperative conditions. Transient surgical complications are possible, particularly with brainstem and spinal cord hemangioblastomas.

Cerebellar lesions: is there a lateralisation effect on memory deficits?

BACKGROUND

Until recently, neurosurgeons eagerly removed cerebellar lesions without consideration of future cognitive impairment that might be caused by the resection. In children, transient cerebellar mutism after resection has lead to a diminished use of midline approaches and vermis transection, as well as reduced retraction of the cerebellar hemispheres. The role of the cerebellum in higher cognitive functions beyond coordination and motor control has recently attracted significant interest in the scientific community, and might change the neurosurgical approach to these lesions. The aim of this study was to investigate the specific effects of cerebellar lesions on memory, and to assess a possible lateralisation effect.

METHODS

We studied 16 patients diagnosed with a cerebellar lesion, from January 1997 to April 2005, in the "Centre Hospitalier Universitaire Vaudois (CHUV)", Lausanne, Switzerland. Different neuropsychological tests assessing short term and anterograde memory, verbal and visuo-spatial modalities were performed pre-operatively.

RESULTS

Severe memory deficits in at least one modality were identified in a majority (81%) of patients with cerebellar lesions. Only 1 patient (6%) had no memory deficit. In our series lateralisation of the lesion did not lead to a significant difference in verbal or visuo-spatial memory deficits.

FINDINGS

These findings are consistent with findings in the literature concerning memory deficits in isolated cerebellar lesions. These can be explained by anatomical pathways. However, the cross-lateralisation theory cannot be demonstrated in our series. The high percentage of patients with a cerebellar lesion who demonstrate memory deficits should lead us to assess memory in all patients with cerebellar lesions.

Intramedullary hemangioblastomas: timing of surgery, microsurgical technique and follow-up in 23 patients

Hemangioblastomas are highly vascularised tumors of the central nervous system and account for 1.5-2.5% of all spinal cord tumors. Because of the rarity of these tumors, surgical experience is often limited and, therefore, treatment and indications for timing of surgery are discussed controversial. The authors reviewed their data of 23 consecutive patients with respect to timing of surgery, microsurgical technique, and follow-up. Clinical records of 23 consecutive patients with intramedullary hemangioblastomas who underwent first surgery in our department between 1990 and 2005 were reviewed. In three cases the tumors were localised at the craniocervical junction; four patients had a single tumor in the cervical spine, six patients multiple tumors in the cervical and thoracic spine, eight patients in the thoracic spine only, one patient in the conus region, and one patient had multiple tumors located in the thoracic and lumbar spine. In eight patients, a von-Hippel-Lindau disease (VHL) was associated. The neurological follow-up was evaluated according to the classification of McCormick. Operation was recommended to every symptomatic patient as early as possible. In asymptomatic patients with a sporadic tumor surgery was discussed for diagnostic purposes at any time. In VHL patients, surgery was recommended if tumor growth was observed on MRI in the next practicable time. All tumors were diagnosed by magnetic resonance imaging and in all cases but one a DSA was performed. All patients were treated microsurgically through a posterior approach. The tumors in the spinal cord were removed microsurgically through a partial hemilaminectomy (n = 1), a hemilaminectomy (n = 15), or laminectomy (n = 4) and at the craniocervical junction (n = 3) through a suboccipital craniotomy. During follow-up after 6 months, 18 patients remained neurologically stable (17 in McCormick grade I and 1 in McCormick grade II) and 5 patients recovered to a better status (3 from grade III to II, 2 from grade II to I). There was one complication with a CSF fistula and one recurrence/incomplete removal. Following the above-mentioned principles of microsurgical removal of intramedullary hemangioblastomas, operation is possible with a low procedure-related morbidity and can be recommended especially in VHL patients with progressive symptoms or tumor growth during follow-up. Patients without VHL most frequently require hemangioblastoma resection for diagnostic purposes and/or because symptoms prompted an imaging work-up that lead to the discovery of the tumor.

Surgical management of spinal cord haemangioblastoma

BACKGROUND

The surgical management of spinal cord haemangioblastomas is distinct from that of other benign spinal cord tumours and optimal surgical strategy is still being determined because of the rarity of the condition. The aim of this study is to investigate factors that affect the outcome of surgical management.

PATIENTS AND METHODS

We retrospectively analysed 24 operations for symptomatic spinal cord haemangioblastomas in 20 patients. Clinical features and surgical results were investigated by medical record review, telephone interviews, angiographic images, and magnetic resonance images (MRI). The mean follow-up period was 5.6 years (range 6 months to 13.6 years).

RESULTS

Patients with cystic components showed pre-operative motor weakness and sensory change more commonly than those without cystic components. Post-operative function scale had a positive correlation with pre-operative function (R(2) = 0.727; p < 0.001) and no correlation with the extent of the surgery. All subtotally removed tumours recurred, whereas totally removed tumours recurred in only 3 patients.

CONCLUSION

The cystic component of spinal cord haemangioblastomas is responsible for symptom generation and is helpful for dissecting tumours. Post-operative functional status is determined by pre-operative functional status. Total removal is feasible by using the correct surgical technique and is recommended to prevent recurrence.

Spontaneous regression of two putative supratentorial haemangioblastomas in one patient

Supratentorial haemangioblastomas are exceedingly rare lesions. We report a patient with spontaneous regression of two suspected supratentorial haemangioblastomas after removal of one lesion. The patient was a 61-year-old man who had a generalised seizure. Investigation with MRI revealed three supratentorial lesions situated in the trigone, occipital and frontal locations. The lesion in the occipital area was surgically removed and the histopathology was consistent with a haemangioblastoma. MRI investigations performed 6 months and one year after the operation confirmed that the two remaining lesions had totally disappeared.

Extraneural hemangioblastoma: a report of 5 cases

Hemangioblastoma is a morphologically distinctive tumor that can occur sporadically or in association with von Hippel-Lindau disease, and which involves the central nervous system in the majority of the cases. Rare occurrences of hemangioblastoma in peripheral nerves and extraneural tissues have been reported. The histogenesis of this tumor remains uncertain. Various cell lineages such as vascular, glial, neural, fibrohistiocytic, and smooth muscle/myofibroblastic have been proposed for the so-called stromal cells, which are thought to represent the neoplastic component of these lesions. We report on 5 cases of hemangioblastoma arising in extraneural tissues. Two of the tumors were located in the presacral region, and one each in the maxilla, kidney, and adrenal glands. All 5 cases were morphologically indistinguishable from central nervous system hemangioblastoma. The existence of these cases suggests that the "stromal" cells of hemangioblastoma can demonstrate a variety of mature specific lineages, such as smooth muscle/myofibroblastic, or neuroendocrine, depending on the location and possibly the microenvironment.

Internal en bloc resection and genetic analysis of retinal capillary hemangioblastoma

OBJECTIVE

To report the clinical outcomes and molecular genetics of nongermline retinal hemangioblastoma managed by surgical resection.

METHODS

Retrospective case series of 3 patients aged 16 to 46 years treated at a tertiary care referral center (Casey Eye Institute, Portland, Oregon). Tumors 7 to 9 mm in diameter were removed from 3 consecutive eyes (in 3 patients) via internal en bloc surgical resection using a bimanual technique. Samples of DNA from 2 of 3 tumors were tested for von Hippel-Lindau gene (VHL) mutations as a clue to the molecular basis for spontaneously occurring hemangioblastoma. Main outcome measures were morbidity, visual acuity, resolution of macular exudates, and presence of VHL markers.

RESULTS

Visual acuity improved or remained stable in all patients. All 3 developed cataracts, extracted in 2 instances. Histopathological findings were typical of retinal hemangioblastoma in all cases. The cells from one patient's DNA sample showed loss of heterozygosity for the VHL gene, while no genetic abnormalities were detected in the other patient's DNA sample.

CONCLUSIONS

Our patients' favorable outcomes suggest that surgical resection is an option for patients with large retinal hemangioblastomas. In addition, ours may be the first report of retinal hemangioblastoma unassociated with a VHL mutation.

Surgical treatment of intramedullary spinal cord tumors: prognosis and complications

STUDY DESIGN

Retrospective case series.

OBJECTIVE

To evaluate our recent treatment strategy for intramedullary spinal cord tumors.

SETTING

Department of Orthopaedic Surgery, Keio University, Japan.

METHODS

We reviewed 68 cases of intramedullary tumors (ependymoma, 33; astrocytoma, 23; hemangioblastoma, 12), treated surgically between 1994 and 2003. There were 42 males and 26 females whose mean age at the time of surgery was 43 years. The mean follow-up period was 6.2 years. The tumor malignancy grade according to the WHO classification was astrocytoma grade I, 3; grade II, 8 (low-grade: 11 cases); grade III, 10; grade IV, 2 (high-grade: 12 cases). All ependymomas were grade II. Three of the 12 hemangioblastomas were associated with von Hippel-Lindau disease.

RESULTS

Total excision was achieved in 90% of the ependymomas and functional improvement was obtained when the preoperative neurological deficit was mild. Approximately 50% of low-grade astrocytomas could be totally excised with favorable survival outcomes, suggesting that total excision should be attempted for low-grade astrocytomas. However, total excision of high-grade tumors was difficult and the functional outcomes were poor. Cordotomy should be considered in patients with a thoracic high-grade astrocytoma. Total resection was possible in 92% of hemangioblastoma, and the functional outcomes were good, however, more attention should be paid for tumors with feeding arteries on the ventral side and for those associated with von Hippel-Lindau disease.

CONCLUSIONS

Predictors of good surgical outcome for intramedullary spinal cord tumors were histological grades of the tumors, surgical margins, and neurological status of the patient before surgery.

Gamma knife radiosurgery for intracranial haemangioblastomas

BACKGROUND

The results of gamma knife radiosurgery for haemangioblastomas were retrospectively studied to assess the efficacy for tumour growth control and clarify the clinical indications for gamma knife radiosurgery in these tumours.

METHODS

The medical records of 22 patients with 67 tumours, 12 men and 10 women aged 20-73 years (mean 51.9 years), who underwent gamma knife radiosurgery for haemangioblastomas between January 1993 and January 2006, were retrospectively reviewed. Ten patients with 54 lesions had von Hippel-Lindau disease. The mean tumour volume was 1.69 cm(3) (range 0.0097-16.4 cm(3)). Nineteen patients had undergone 1-4 open surgery procedures (mean 1.5) before gamma knife radiosurgery. Tumours without a cystic component, (the solid type), were found in 54 lesions and tumours associated with cyst, (the mural nodule with cyst type), in 13 lesions. The marginal dose was 8-30 Gy (mean 14.0 Gy).

FINDINGS

Follow-up magnetic resonance (MR) imaging was performed at 9-146 months (mean 63 months). The control rate for tumour growth was 83.6%. The only factor affecting tumour growth control was the presence of a cystic component at the time of gamma knife radiosurgery in both univariate and multivariate analysis. No complication such as radiation-induced peritumoural oedema or radiation necrosis occurred.

CONCLUSION

The presence of cystic components at the time of gamma knife radiosurgery was the only factor significantly correlated with unfavourable tumour growth control by gamma knife radiosurgery for haemangioblastomas. Gamma knife radiosurgery is effective for solid type tumours, even if the marginal dose is relatively low. Surgical removal is recommended for mural nodule with cyst type tumours, when possible.

Role of fractionated external beam radiotherapy in hemangioblastoma of the central nervous system

PURPOSE

To assess the clinical outcomes and toxicity in patients receiving fractionated external beam radiotherapy (EBRT) for hemangioblastoma of the central nervous system, treated at two Canadian radiation oncology institutions.

METHODS AND MATERIALS

Between January 1980 and December 2004, the data of all patients receiving EBRT for central nervous system hemangioblastoma were retrospectively reviewed. The patient, tumor, and treatment characteristics were collected and overall survival, disease-free survival, and EBRT-related toxicities assessed.

RESULTS

A total of 18 cases, 5 associated with von Hippel-Lindau disease (VHL) and 13 sporadic (non-VHL), with a total 31 lesions, were documented. These were located in the cerebellum in 20 and spinal cord in 8 patients. EBRT was delivered for recurrence in 12, adjuvantly for residual disease in 4, and definitively in 2. The EBRT schedules ranged from 50.0 to 55.8 Gy in 1.8-2.0-Gy daily fractions (n = 17), typically with parallel-opposed fields to the cerebellar target volumes and direct posterior fields for spinal disease. At a median follow-up of 5.1 years (range, 0.1-14.5), the 5-year OS rate was 69% (95% confidence interval [CI], 50-96%), decreasing to 30% (95% CI, 10-87%) at 10 years. The disease-free survival rate at 5 and 10 years was 57% (95% CI, 37-87%) and 30% (95% CI, 11-83%), respectively. The outcomes differed according to VHL status. The 5-year OS rate was 100% for those with VHL compared with 55% (95% CI, 32-95%) for those with non-VHL disease (log-rank p = 0.003), and the 5-year disease-free survival rate was 80% (95% CI, 52-100%) with VHL compared with 48% (95% CI, 26-89%) without (log-rank p = 0.036).

CONCLUSIONS

Fractionated EBRT has a role in the management of extensive intracranial and/or spinal cord disease, the adjuvant treatment of residual postoperative disease, and the treatment of recurrence. More favorable outcomes were reported for VHL-associated lesions than for sporadic cases.

Multiple filum terminale hemangioblastomas symptomatic during pregnancy

✓Hemangioblastomas are low-grade, highly vascular tumors commonly associated with von Hippel–Lindau (VHL) syndrome and most often appearing in the cerebellum. They very rarely occur in the spinal nerve roots, and an origin in the filum terminale is exceptional with no instances of multiple hemangioblastomas of the filum terminale reported in the literature. Because of their vascular nature, these lesions can enlarge and become symptomatic in the context of the changes that take place during pregnancy, as has been noted with cerebellar hemangioblastomas. In any case, the evolution of spinal hemangioblastomas during pregnancy is not well known given its rarity. The conjunction of both processes—that is, multiple hemangioblastomas arising in the filum terminale and pregnancy—is unique. The authors describe the case of a 41-year-old woman with multiple hemangioblastomas of the filum terminale and no other evidence of VHL syndrome, in whom pregnancy precipitated symptoms. The interruption of gestation led to a remission of the symptoms. The literature concerning filum terminale hemangioblastomas and pregnancy is also reviewed.

A HEMANGIOBLASTOMA IN THE PINEAL REGION

OBJECTIVE

Although reported to occur throughout the central nervous system, hemangioblastomas are principally found in the cerebellum and spinal cord. Pineal region tumors comprise approximately 1% of central nervous system neoplasms. A wide variety of tumors can affect this region, the most common being germ cell tumors, gliomas, and pineal cell tumors. In the literature, we found only one case of hemangioblastoma in the pineal region in association with von Hippel-Lindau disease.

CLINICAL PRESENTATION

We describe the case of a patient with a symptomatic hemangioblastoma in the pineal region with no clinical criteria for von Hippel-Lindau disease. The patient had a 1-month history of short-term memory loss, headache, difficulty concentrating and writing, disturbed balance, and loss of bladder function. At the time of physical examination, she was awake, alert, and oriented. An ophthalmoscopic examination revealed nystagmus with conjugate upward gaze and papilledema. Radiological images showed a mass in the pineal region with obstructive hydrocephalus.

INTERVENTION

A lateral suboccipital infratentorial supracerebellar approach was used to remove the tumor, which was attached to the quadrigeminal plate. Histological examination showed the lesion to be a hemangioblastoma. The clinical findings for von Hippel-Lindau disease were negative.

CONCLUSION

The patient's neurological deficits were reversed after surgery. This case emphasizes the importance of the differential diagnosis of hemangioblastomas located in this region. These tumors can be safely removed through surgery.

Hemangioblastoma of filum terminale associated with arteriovenous shunting

BACKGROUND

Spinal arteriovenous shunt typically presents in middle age or in the elderly with a strong male predilection. The clinical presentation is usually progressive neurological deficits such as paraparesis or incontinence due to cord edema, although back pain is also a common presentation. Progress of neurological deficit is typically stopped by occlusion of the shunt (surgically or endovascularly), but the return of loss of function may be found in less than half of these patients. In contrast, spinal hemangioblastomas usually occur in adults, and the most common presentation is pain with radiculopathy. Location in the filum terminale is very rare.

CASE DESCRIPTION

After a review of the medical literature, we identified 7 cases of hemangioblastomas arising from the filum terminale (Am J Neuroradiol. 2005;26:936-945; Acta Neurochir [Wien]. 2000;142:1059-1062; J Neurosurg Sci. 2001;45:58-62; J Clin Neurosci. 2006;13:285-288; Neurosurgery. 1999;44:220-223; Clin Neurol Neurosurg. 1985;87:55-59). We report an additional case of a filum terminale hemangioblastoma occurring in a 64-year-old man with 1 month exacerbation of chronic low back pain. Preoperatively, it was misdiagnosed as filum terminale arteriovenous fistula.

CONCLUSION

Even with modern imaging, preoperative diagnosis can still be difficult.

Subepyndemal hemangioblastomas of the cervicomedullary junction: lessons learned in the management of two cases

OBJECTIVE

This retrospective case series analyzes two cases of hemangioblastomas in the cervicomedullary junction.

METHODS

A survey of the pediatric staff and of the operative reports from medical records with a review of the literature and medical records of patients with the condition was conducted.

RESULTS

Two patients were successfully treated surgically.

CONCLUSION

Surgery is the treatment of choice for hemangioblastomas of the cervicomedullary junction. Careful monitoring for unique complications, treatment of the tumor as a vascular malformation, and screening for von Hippel Lindau must all be employed to safely care for this challenging group of patients.

Supratentorial dural-based hemangioblastoma not associated with von Hippel Lindau complex

Hemangioblastomas are rarely found in a supratentorial location and are commonly associated with the von Hippel-Lindau complex. Therefore, patients with such tumors must be evaluated for both other hemangioblastomas within the central nervous system as well as for this complex via physical examination, radiographic examination, and genetic testing. We report the seventh case of a patient with an isolated supratentorial dural based hemangioblastoma not associated with the von Hippel-Lindau complex.

Hemangioblastoma of the filum terminale. Case report and review of the literature

Hemangioblastomas of the filum terminale are particularly rare tumors. The authors present the case of a 62-year-old woman with a 6 month history of low-back-pain, who underwent surgery for the removal of an hemangioblastoma affecting the cauda at L2-L3 level. This highly vascularized tumour is tightly adherent to the filum terminale and hence is a very challenging pathology to remove. Histologically it consisted in vascular structures interposed to a network of capillary-like vessels, surrounded by stromal cells. MRI, angiography with pre-surgical embolization, and radical surgery represent the focal points in the diagnosis and treatment of these tumours. The most relevant literature has been carefully reviewed.

Clinical characterization of retinal capillary hemangioblastomas in a large population of patients with von Hippel-Lindau disease

OBJECTIVE

To report the epidemiology and ocular phenotype of retinal capillary hemangioblastomas associated with von Hippel-Lindau (VHL) disease in a large cohort of patients and to correlate patient and ocular characteristics to visual morbidity in this population.

DESIGN

Cross-sectional study.

PARTICIPANTS

In 220 unrelated pedigrees, 335 patients affected with VHL disease and retinal capillary hemangioblastomas (RCHs) in at least 1 eye.

METHODS

Demographics of the patient population were recorded and the ocular phenotype of each patient was obtained with a comprehensive ocular examination.

MAIN OUTCOME MEASURES

The patient population was characterized and the ocular phenotype described in relationship to tumor location, number, and extent of retinal involvement. Correlations between patient demographics, ocular phenotype, and visual function were analyzed.

RESULTS

We detected RCHs unilaterally in 42.1% and bilaterally in 57.9% of patients. No correlation was detected between the age, gender, or laterality of involvement. Of involved eyes, 86.6% had tumors that could be individually visualized; of these, tumors were commonly found in the peripheral retina (84.7%) only, and less commonly in the juxtapapillary area (15.3%). The tumor count in the periphery averaged 2.5+/-1.8 per eye, with 25.2% of eyes having >1 quadrant of retinal involvement. Of involved eyes, 13.4% were enucleated or prephthsical; approximately 1 in 5 patients had > or =1 eyes so affected. Severe visual impairment (visual acuity < or =20/160) in affected eyes were more likely to be associated with increasing age, the presence of juxtapapillary lesions, and an increasing number and extent of peripheral lesions.

CONCLUSIONS

This large cohort of VHL patients with RCHs has enabled a systematic and quantitative characterization of the demographics, ocular features, and visual function in VHL disease. Clinical correlations between the visual morbidity and ocular features of the disease were also performed, producing measures that can help clinicians to estimate visual prognoses better based on the ocular phenotype of the disease.

[Retinal angiomatosis. Ocular manifestation of von Hippel-Lindau disease]

Von Hippel-Lindau disease (VHL disease) is a rare multisystem disorder of autosomal dominant inheritance with high penetrance. Inactivation of the VHL-protein leads to an increased expression of hypoxia induced growth factors. Predilection sites for tumor growth are the retina, the central nervous system and various visceral organs. Retinal capillary hemangioblastoma is one of the earliest manifestations of VHL disease. The lifetime risk of permanent visual loss defined as a visual acuity of 0.5 or less is about 35% in gene carriers. It increases to 60% if there is already retinal capillary hemangioblastoma. If VHL disease is suspected, a careful ophthalmological examination should be included in the clinical screening program. Having confirmed the diagnosis, regular ophthalmoscopic monitoring is essential in order to detect developing tumors at an early stage. Therapeutic options for small to medium sized peripheral tumors are laser or cryocoagulation; larger- hemangioblastomas can be treated by brachytherapy using ruthenium plaques, while asymptomatic juxtapapillary tumors can be observed at regular intervals.

Pituitary stalk hemangioblastoma: The fourth case report and review of the literature

Supratentorial hemangioblastomas (HBL) have been rarely described in the literature. Herein we report the fourth case of pituitary stalk HBL diagnosed concurrently with cerebellar HBLs in a 51-year-old woman with von Hippel-Lindau disease. Complete resection of the lesion was achieved using left frontopterional craniotomy and no recurrence was observed after 8 years of follow-up. The clinical presentation, radiological features, pathological findings, and the management of this particular case are discussed in the light of the available literature. To our knowledge, this case is the only pituitary stalk HBL with total resection, and a long follow-up fully documented.

Recurrent dural based cystic cerebellar haemangioblastoma in a patient with von Hippel-Lindau disease

Surgical excision of cerebellar haemangioblastomas, once they become Symptomatic, is the standard treatment in patients with von Hippel-Lindau disease. This case report describes a von Hippel-Lindau disease patient with a rare recurrent symptomatic dural based cystic haemangioblastoma.

von Hippel-Lindau disease-associated hemangioblastomas are derived from embryologic multipotent cells

BACKGROUND

To determine the origin of the neoplastic cell in central nervous system (CNS) hemangioblastomas in von Hippel-Lindau disease (VHL) and its role in tumor formation and distribution, we characterized and differentiated neoplastic cells from hemangioblastomas removed from VHL patients.

METHODS AND FINDINGS

A total of 31 CNS hemangioblastomas from 25 VHL patients were resected and analyzed. Tumor cells from the hemangioblastomas were characterized, grown, and differentiated into multiple lineages. Resected hemangioblastomas were located in the cerebellum (11 tumors), brainstem (five tumors), and spinal cord (15 tumors). Consistent with an embryologically derived hemangioblast, the neoplastic cells demonstrated coexpression of the mesodermal markers brachyury, Flk-1 (vascular endothelial growth factor-2), and stem cell leukemia (Scl). The neoplastic cells also expressed hematopoietic stem cell antigens and receptors including CD133, CD34, c-kit, Scl, erythropoietin, and erythropoietin receptor. Under specific microenvironments, neoplastic cells (hemangioblasts) were expanded and differentiated into erythrocytic, granulocytic, and endothelial progenitors. Deletion of the wild-type VHL allele in the hematopoietic and endothelial progeny confirmed their neoplastic origin.

CONCLUSIONS

The neoplastic cell of origin for CNS hemangioblastomas in VHL patients is the mesoderm-derived, embryologically arrested hemangioblast. The hematopoietic and endothelial differentiation potential of these cells can be reactivated under suitable conditions. These findings may also explain the unique tissue distribution of tumor involvement.

[Diagnosis and micro-neurosurgery for the fourth cerebral ventricle tumors]

OBJECTIVE

To investigate the diagnostic method and analyze the result of microneurosurgical treatment for tumors of the fourth cerebral ventricle.

METHODS

Tumor of the fourth ventricle was clinically diagnosed in 86 patients basing on the preliminary assessment of symptom and CT or MRI findings. Of these 86 patients treated with micro-neurosurgery, the tumors in 62 were totally removed, subtotally in 19, and partially in 5. Forty-two patients received postoperative radiotherapy.

RESULTS

Three patients died postoperatively within ten days, and symptoms in 83 were improved after treatment. The average survival period was over 3 years. The pathology included 32 medulloblastomas, 23 ependymoma, 15 astrocytoma, 10 hemangiblastomas, 2 choroid plexus papillomas, and 4 epidermoid cysts.

CONCLUSION

Medulloblastoma, astrocytoma and hemangiblastoma are suggested to be removed totally whenever technically possible according to the site, character and volume of the tumor. For ependymoma, if close to the brain stem, is recommended to be subtotally removed. Postoperative radiotherapy may be beneficial for malignant types.

Rare Intramedullary Hemorrhage of a Brainstem Hemangioblastoma

OBJECT

Hemorrhages caused by hemangioblastomas are very rare and mostly located in the subarachnoid space. Intraparenchymal bleedings due to hemangioblastomas are even less frequent, and these hemorrhages are almost exclusively located in the supratentorial brain, cerebellum and spinal cord. We report the first case of a brainstem hemorrhage due to a hemangioblastoma of the medulla oblongata.

CASE REPORT

A 47-year-old woman presented with acute onset of headache, anarthria, inability to swallow, left-sided hemiparesis and hemidysesthesia with varying states of vigilance, finally developing acute respiratory failure. Cranial computed tomography (CT) scanning and magnetic resonance imaging (MRI) revealed a small hemangioblastoma of the posterior medulla oblongata causing intraparenchymal hemorrhage and acute occlusive hydrocephalus due to intraventricular hematoma extension.

RESULT

After implantation of an external ventricular catheter to treat acute hydrocephalus, the hemangioblastoma as well as its associated hemorrhage could be removed in toto via a microsurgical posterior median suboccipital approach with minimal foramen magnum enlargement. During the follow-up period of six months postoperatively the patient showed good recovery with only slight residual neurological deficits.

CONCLUSION

The most common causes of brainstem hemorrhages are arterial hypertension and cavernous hemangiomas. However, hemangioblastomas should not be ignored as a possible differential diagnosis for intraparenchymal brainstem hemorrhage. While the prognosis in hypertensive brainstem bleedings is mostly disastrous and surgery rarely indicated, an operative therapy should be considered in cases of hemorrhages caused by underlying tumors. Especially in the treatment of hemangioblastoma, the surgical management strategy is crucial for a successful result. Therefore, the authors recommend including the search for hemangioblastomas into the diagnostic workup in patients with brainstem hemorrhages.

[Diagnosis and treatment of spinal cord hemangioblastoma]

OBJECTIVE

To study the diagnosis and treatment of spinal cord hemangioblastoma.

METHOD

The clinical data of 42 patients with spinal cord hemangioblastoma who were operated on between 1997 and 2005 were analyzed.

RESULT

Spinal cord hemangioblastoma mostly showed space occupying lesions with clear boundary and Dd-DTPA homogenous enhancement by MRI. All the 42 patients underwent complete excision. 27 patients showed improvement of their symptoms, the 6 patients failed to show any change, and neurological deficits were aggravated in the 5 patients.

CONCLUSION

MRI and DSA are helpful in qualitative and localized diagnoses of the spinal cord hemangioblastoma. Surgical outcomes are favorable.

Disseminated haemangioblastoma without evidence of the von Hippel-Lindau syndrome or haemangioblastomatosis--A case report and clinico-pathological correlation

A 71-year-old Caucasian female presented to our service with disseminated cranial and spinal haemangioblastomata but no other features to suggest the von Hippel-Lindau syndrome. We feel that this represents cellular dissemination through the cerebro-spinal fluid and may be an intermediate step to the development of frank haemangioblastomatosis. By comparing this presentation to that of other tumours we have suggested a potential pathological mechanism and have discussed its management.

Radiosurgical pathology of brain tumors: metastases, schwannomas, meningiomas, astrocytomas, hemangioblastomas

Systematic human pathological background to brain tumor radiosurgery explaining biological and pathophysiological effects of focused irradiation barely exists. The goal of this study was to explore histopathological changes evoked by single high-dose irradiation in a set of different brain tumors following Gamma Knife radiosurgery (GKRS). Light microscopy revealed that GKRS evokes degenerative and proliferative pathological changes in the parenchyma, stroma and vessels of the irradiated tumors. Three main histological types of gamma radiolesions, that is acute, subacute and chronic variants of tissue reactions were recognized in different neoplasms irrespective of their ontogenetic nature. Acute type gamma radiolesions were characterized mainly with necrotic changes and appeared either early or in a delayed time interval. Subacute type gamma radiolesions expressed resorptive activity also with early or delayed chronology. Chronic type lesions showed a reparative tendency but presented only at the delayed stage. These changes seem to follow each other consecutively. There was no significant relation between morphological characteristics of the generated tissue reaction and the time interval elapsed after GKRS. This relative time and environment autonomy of the developed pathological lesions with similar histological picture in different neoplasms suggests either a vascular mechanism or/and a genetically directed origin presumably induced by the ionizing energy of high-dose irradiation.

Hemangioblastoma of the Optic Nerve-Case Report-

A 64-year-old man presented with a rare sporadic hemangioblastoma arising in the left optic nerve manifesting as left visual disturbance gradually progressive over 5 years. Magnetic resonance imaging revealed a well-enhanced mass in the left optic nerve. Partial resection of the tumor was performed via the frontoorbital approach. The histological diagnosis was optic nerve hemangioblastoma. Hemangioblastoma must be considered in the differential diagnosis of optic nerve tumors even in the absence of other lesions associated with von Hippel-Lindau disease.

Advanced reactive astrogliosis associated with hemangioblastoma versus astroglial-vascular neoplasm ("angioglioma")

Hemangioblastomas of the central nervous system are often accompanied by a cyst exhibiting an extensive astroglial reaction. The cyst's wall might be composed of various astroglial elements including reactive pilocytic or gemistocytic and hypertrophic astrocytes. The small tissue samples composed of compact gliotic tissue are sometimes nonrepresentative for primary hemangioblastoma tumour and might be confused with both pilocytic and diffuse infiltrative astrocytoma. Moreover, vascular anomalies of hemangioblastoma-like pattern could be combined with true neoplastic glial proliferation. Such association of glioma with certain types of vascular anomalies has been designated as angioglioma. In the current study we evaluated a series of hemangioblastomas accompanied by advanced astrogliosis of adjacent brain tissue. In some cases the histopathological features of pilocytic gliosis with numerous Rosenthal fibres and eosinophilic granular bodies strongly suggest the diagnosis of pilocytic astrocytoma. One tumour was identified as an angioglioma exhibiting a combination of hemangioblastoma-like tissue and pilocytic astrocytoma. The recognition of such an entity is important in differential tumour diagnosis and prognosis.

Neurosurgical management of intramedullary spinal cord tumors in children

The majority of intramedullary spinal cord tumors in children are low-grade glial tumors. They become symptomatic with pain, neurologic deficits or spinal deformity. The diagnosis is most readily obtained using magnetic resonance imaging. The natural history is significant for slow progression of symptoms. Surgery is the best treatment and is also indicated to confirm the histological diagnosis. In case of a low-grade tumor or a vascular lesion such as hemangioblastoma or cavernoma, a total or near-total resection is attempted. For astrocytomas the resection almost always remains biologically incomplete, but a near-total resection is still associated with a long progression-free survival. Neurologic morbidity is relatively low during long-term follow-up but can be up to 30% for transient motor deficits. The risk for neurologic deterioration is higher for patients with pronounced dysfunction preoperatively. This is an important argument for early surgical resection. Surgery is performed using the spectrum of microsurgical techniques as well as advanced technology, e.g. lasers and intraoperative neurophysiological monitoring with motor evoked potentials. High-grade tumors are resected conservatively and treated with radiation and chemotherapy. The prognosis of high-grade glial tumors remains poor.

Hémangioblastome « en sablier » de la huitième racine cervicale

Hemangioblastomas involving cervical nerve roots are extremely rare. Only one case has been previously reported in the literature. We report the case of a 33-year-old man presenting with a 6-month history of upper limb pain. MRI and cervical angiography demonstrated the presence of a dumbell (intra and extradural) and highly vascularized tumor of the right C7-T1 foramina. Histological examination eventually confirmed the diagnosis of hemangioblastoma. Total removal of such a lesion may require combined (anterior and posterior) approaches and preoperative embolization.

Molecular pathology and CXCR4 expression in surgically excised retinal hemangioblastomas associated with von Hippel-Lindau disease

PURPOSE

The surgical excision of retinal vascular lesions including hemangioblastomas is rarely practiced. This study investigates the pathological characteristics of 4 patients (3 with von Hippel-Lindau [VHL] disease and 1 with a vasoproliferative retinal tumor) who underwent ocular tumor resection. von Hippel-Lindau is an autosomal dominant disease caused by a defect of the VHL tumor suppressor gene. The VHL protein is required for oxygen-dependent degradation of hypoxia-inducible factor 1alpha. This factor regulates vascular endothelial growth factor (VEGF) and the chemokine receptor CXCR4. Retinal hemangioblastoma is the most common tumor observed in VHL disease. We investigated the expression of CXCR4; its ligand, CXCL12/SDF-1alpha; VEGF; and the VHL gene in VHL disease-associated retinal hemangioblastomas.

DESIGN

Interventional case series with immunohistological and molecular pathological analyses.

PARTICIPANTS

Immunohistochemistry and molecular pathology of the surgically excised retinal lesions were performed.

INTERVENTION

Large retinal hemangioblastomas (1-3 disc diameters) and vasoproliferative tumors were resected surgically after laser photocoagulation in 4 patients. The excised tissues were snap frozen and evaluated by histology. Molecular pathology was performed for the VHL gene, and immunohistochemistry and molecular detection (reverse transcription polymerase chain reaction) were carried out for VEGF, CXCR4, and CXCL12.

MAIN OUTCOME MEASURES

Evaluation of clinical presentations and molecular pathology of the excised retinal lesions.

RESULTS

Large retinal hemangioblastomas were resected successfully from the 3 VHL cases. Postoperatively, all patients were stable. Molecular analyses disclosed the loss of heterozygosity at the VHL allele locus in the VHL retinal hemangioblastomas but not in the vasoproliferative tumor. High levels of transcript and protein were found for VEGF and CXCR4, whereas low levels of CXCL12 mRNA were expressed in the retinal hemangioblastomas associated with VHL disease. In contrast, very low levels of VEGF and CXCR4 mRNA were detected in the vasoproliferative tumor. Furthermore, increased expression of VEGF and CXCR4 was detected in more active hemangioblastomas.

CONCLUSIONS

Surgical resection of large retinal hemangioblastomas may be useful for therapy in selected VHL patients. Activated VHL lesions produce more VEGF. This is the first demonstration of CXCR4 expression in VHL disease-associated retinal hemangioblastomas. We suggest targeting CXCR4 as an additional therapeutic strategy for VHL disease-associated retinal hemangioblastomas.

Outcomes of Surgical Resection of Large Solitary Hemangioblastomas of the Craniocervical Junction with Limitations in Preoperative Angiographic Intervention: Report of Three Cases

INTRODUCTION

Hemangioblastomas of the central nervous system may occur sporadically, or in association with von Hippel-Lindau (vHL) disease. The treatment of large solitary hemangioblastomas of the posterior cranial fossa mandates a combination of angiographic intervention and surgery. However, large tumors may derive their vascularity from major cerebellar vessels, which can make their embolization hazardous.

AIM

To describe the surgical outcomes of three cases of large hemangioblastomas with compression of the medulla oblongata, where the potential for preoperative embolization was extremely limited.

CASES

Three patients (all males; 68, 36 and 38 years) presented with a history of chronic headache and caudal cranial nerve deficiencies. Diagnostic imaging showed large vascular lesions (4 x 3, 4 x 5 and 5 x 5 cm) at the craniocervical junction, compressing the brainstem. There were no concomitant findings associated with vHL disease.

TREATMENT

Staged treatment was administered. Preoperative embolization was attempted at first. One patient (68 yrs) showed a PICA occlusion and associated cerebellar infarction after embolization; embolization was deemed hazardous in the other two. In the second phase, the lesions were removed via a midline suboccipital approach with resection of the arch of altas. Complete removal was possible in all three cases. POSTOPERATIVE COURSE AND FOLLOW-UP: The caudal cranial nerve deficiencies deteriorated soon after surgery in all three patients. A tracheotomy was required in two patients, which was removed uneventfully during the rehabilitation phase. Ventriculo-peritoneal shunts were implanted in two patients. MRI follow-up three (1 case) and four years (2 cases) after surgery showed no relapse. The Karnofsky Index scores were 80, 70 and 90 in the three patients aged 68, 36 and 38, respectively.

CONCLUSION

Total microneurosurgical removal of large hemangioblastomas at the craniocervical junction with limited preoperative embolization (associated with morbidity) should be seriously considered. Although the early outcome is not encouraging, the long-term outcomes seem favorable.

Surgical treatment of hemangioblastomas of the central nervous system in pediatric patients

OBJECTIVE

Hemangioblastomas are histologically benign lesions that occur sporadically or as a manifestation of von Hippel-Lindau disease (VHL). The treatment strategy of these neoplasms is complicated by their unpredictable growth patterns and the often irreversible neurological deficits they may cause. This study aims to outline the neurosurgical treatment options and to address the ongoing debate of surgical timing in pediatric patients with VHL.

PATIENTS AND METHODS

Thirteen consecutive pediatric patients (mean age 15.1 years) who were surgically treated for intracranial (n=8) or spinal hemangioblastomas (n=5) were included in this study (range of clinical follow up 12-86 months). Ten patients were affected by von Hippel-Lindau and three were with sporadic tumors. Serial examinations, preoperative MRI studies, and operative findings were reviewed.

RESULTS

Patients with cerebellar and intramedullary hemangioblastomas did not develop additional neurological deficits postoperatively. Two patients with brainstem tumors exhibited transient hemiparesis and caudal nerve palsy, respectively. Both patients recovered completely from their postoperative deficits. Preoperatively symptomatic patients with spinal tumors did not deteriorate nor improve after surgery. During the observed follow-up periods, no tumor recurrences were observed.

CONCLUSION

Central nervous system (CNS) hemangioblastomas in pediatric patients can be surgically treated with low morbidity. Based on our experience, we recommend considering also the surgical removal of asymptomatic hemangioblastomas with proven radiological progression to prevent the development of permanent neurological deficits. Molecular screening of every pediatric patient and family is mandatory to enable the detection of extraneurological tumors and the development of an efficient therapeutic strategy.

Supratentorial cystic hemangioblastoma with infratentorial extension--a unique location and a rare infant case

INTRODUCTION

Supratentorial occurrence of hemangioblastoma is an exceedingly rare event. Even rarer is the occurrence of a supratentorial hemangioblastoma in infancy.

CASE REPORT

We hereby report the case of an 18-month-old girl who presented with irritability, increasing head size, and an open fontanelle. MR scans demonstrated triventricular hydrocephalus and a cystic mass within the left lateral ventricle. There was an 18 x 15 x 13 mm enhancing nodule along the medial aspect of the cyst. The cystic mass was mainly supratentorial but there was a caudal extension through the tentorial incisura that compressed the cerebellum. At surgery, the content of the cyst was xanthochromic. Enhancing medial nodule was extremely vascular and was extirpated totally. The pathological diagnosis was reticular variant of hemangioblastoma.

CONCLUSION

The child is well at 4 years of age. An extensive review of the English literature revealed only three such cases. All three cases survived the operation.