Hemangioblastoma of the filum terminale: case report

OBJECTIVE AND IMPORTANCE

Tumors of the cauda equina and specifically the filum terminale are uncommon. We report the fourth case of a hemangioblastoma occurring in the filum terminale.

CLINICAL PRESENTATION

This 35-year-old man presented with a 4-year history of low back pain that had been previously diagnosed as a bulging disc and exhibited severe pain in response to percussion of his lower back but was neurologically intact. He was found to have a large, enhancing mass filling the thecal sac at L2-L3.

INTERVENTION

The tumor was found to be attached to the filum terminale and was cleanly dissected off en toto. Microscopically, the mass consisted of endothelial cells in addition to abundant fat-laden stromal cells and reticulum.

CONCLUSION

We present a case report and a review of the literature. Our patient was the first to exhibit no radicular complaints. The diagnosis was delayed in all four cases and was not determined until the time of surgery. Complete excision offers the best chance for cure, and spinal angiography can aid in diagnosis. However, a high index of suspicion is needed for preoperative detection.

Successful removal of a hemangioblastoma from the medulla oblongata: case report

Hemangioblastomas are histologically benign tumors that occur exclusively within the neuraxis, most commonly in the posterior fossa. They are typically cystic tumors located in the cerebellum. Excision of the vascular mural nodules leads to cure. Brain stem lesions are rarely reported. Surgical extirpation of a solid brain stem hemangioblastoma is relatively risky and requires precise microsurgical techniques. We present a woman with a hemangioblastoma embedded in the medulla oblongata. This 33-year-old woman presented with occipital headaches and sensory ataxia. Complete and detailed preoperative imaging studies were followed by successful microsurgical excision of the lesion. The patient recovered completely within 2 weeks after the operation except for mild paresthesia of the legs. Preoperative magnetic resonance imaging and cerebral angiography provided important information regarding the nature, location, and blood supply of this lesion, which facilitated its total removal. The importance of intraoperative identification and control of the feeding artery of the tumor is emphasized.

Posterolateral approach for anteriorly located cervical spine tumors: technical note

Cervical spinal cord tumors located anteriorly to the spinal cord often require an extensive anterior vertebrectomy approach for their removal followed by bone fusion and postoperative immobilization. To minimize the invasiveness of the conventional anterior approach for those tumors, the author has utilized the anterolateral approach which was originally developed for spondylotic disc disease. However, some of those tumors still can be removed by a less invasive posterior approach which violates spinal integrity to a much lesser degree. Anteriorly located tumors, in which the tumor-cord interface line extends posteriorly to a horizontal line drawn along the posterior margin of the vertebral body, can be removed by the posterolateral approach with a skin incision made at the point where the tumor-cord line intersects. Because the facet joint is thin and the pedicle is shallow in the cervical spine, only a hemilaminectomy bone window is required in this posterolateral approach for removal of such tumors. Surgical techniques of this posterolateral approach for removal of anteriorly located cervical cord tumors are described with two illustrated patients.

Sellar-sphenoid sinus hemangioblastoma: case report

A very unusual case of sellar-sphenoid sinus hemangioblastoma without stigmata of von Hippel-Lindau disease is presented. Subtotal excision of tumor was done via an extended frontobasal approach. Diagnostic controversies between hemangioblastoma and angioblastic meningioma are discussed and the relevant literature reviewed.

Syringomyelia in myotonic dystrophy due to spinal hemangioblastoma

BACKGROUND

Syringomyelia is an uncommon, poorly understood finding in patients with myotonic dystrophy.

METHODS

We describe a patient with myotonic dystrophy and neck pain in whom an extensive neuroradiologic diagnostic work-up was carried out.

RESULTS

Magnetic resonance imaging revealed a large intramedullary cavity extending from the bulbo-medullary junction to the conus medullaris. After intravenous Gadolinium-DTPA administration, an enhanced nodule was seen at T6. Spinal arteriography showed a single hypervascular nodule and slow flow perimedullary draining veins consistent with hemangioblastoma. After removal of the nodule, a partial collapse of the intramedullary cyst was observed.

CONCLUSIONS

Intramedullary tumors can underlie syringomyelia in patients with myotonic dystrophy and have to be actively investigated with modern neuroradiologic investigations.

Clinical experience with image-guided robotic radiosurgery (the Cyberknife) in the treatment of brain and spinal cord tumors

The Cyberknife is an image-guided "frameless" dedicated radiosurgical device. This instrument has several distinct advantages over frame-based systems, including improved patient comfort, increased treatment degrees of freedom, and the potential to target extracranial lesions. Clinical results thus far with respect to the treatment of malignant intracranial tumors has been promising. Additionally, the Cyberknife will likely revolutionize the application of radiosurgery to extracranial sites. A description of the components, treatment planning, and clinical results of the Cyberknife will be reviewed.

Peripheral nerve hemangioblastoma

Capillary hemangioblastoma (HB) is a benign, highly vascular tumor limited almost exclusively to the central nervous system (CNS). It occurs primarily in the posterior fossa and less often in the spinal cord. We report three cases of HB occurring in peripheral nerve, two intradural tumors arising in a C4 and a cauda equina nerve root, respectively, and a third lesion in the sciatic nerve at mid thigh. The patients, 1 woman and 2 men, ranged in age from 25 to 49 years. Two had von Hippel-Lindau disease, an association usually found in one-third of CNS HBs, and one had a family history of pheochromocytoma. In every way, HBs of peripheral nerve were indistinguishable from their CNS counterpart. Ranging in size from 1.5 to 5.5 cm in diameter, the tumors were well circumscribed and contained a myriad of small caliber vessels lined by endothelial cells and surrounded by pericytes. Throughout, the lesions were rich in large, often vacuolated stromal cells. In all of the cases, these stained strongly for vimentin and neuron-specific enolase; only one showed focal S100 protein reactivity. Surgical therapy required excision of the affected nerve roots in the first two cases. In the third case, prominent extension of the tumor within epineurium permitted a microsurgical resection with sparing of sciatic nerve fascicles. No tumor recurred during a follow-up period of 5 to 20 months.

Gamma knife radiosurgery for hemangioblastomas

Thirteen patients (11 males, 2 females) with cerebral hemangioblastomas (HABs) were treated with Gamma Knife radiosurgery (GKR). Four patients had multiple lesions in the brain. The remainder had a single lesion. The total number of lesions was 20. Eight cases had recurrent or residual HABs after surgery. In one case diagnosis was confirmed following surgical resection 22 months after GKR. One case was diagnosed by computed tomography (CT), magnetic resonance imaging (MRI) and digital subtraction angiography (DSA). Three patients had von Hippel Lindau (VHL) disease. The mean tumor diameter was 20 mm (range 7.5 to .55 mm). The mean margin dose was 18 Gy (range 12 to 24 Gy). In 5 cases, there was an improvement of symptoms and reduction in tumor volume. In 4 cases the tumor volume and clinical status remained unchanged. In 3 patients, there was clinical deterioration. The cause of this was an increase in tumor cyst volume in 2 cases. Subsequent surgery resulted in clinical improvement. In a third patient with multiple lesions, deterioration was the result of adverse radiation effects in the medulla oblongata. Three patients were subjected to post GKR-surgery with subsequent histopathology. In one, this was due to cyst expansion. In one, it was at the patient's insistence in the presence of a stable clinical and radiological picture. In a third patient with a temporal lobe tumor, it was because of late-developing epileptic seizures. The histopathological findings in these patients showed varying degrees of small vessel thickening and occlusion together with loss of tumor cells. The observations varied in degree according to the time between GKR and the secondary operation. These findings indicate the effectiveness of the treatment. The reduction in vascularity suggests that GKR could make subsequent surgery less hazardous. The observations of this study suggest that while GKR is not adequately reliable for the control of HAB cysts, it can be an effective treatment for solid tumors, especially those in eloquent regions.

Intramedullary hemangioblastoma of the medulla oblongata--two case reports and review of the literature

We determined the treatment modality of hemangioblastoma of the brain stem on the bases of our two cases and 31 cases searching from the literature since 1960 which were treated surgically. Hemangioblastomas of the brain stem were categorized according to one of three locations: hemangioblastoma of the fourth ventricle attached to the floor of the ventricle (Type A), hemangioblastoma of the fourth ventricle partially embedded in the floor of the ventricle (Type E), and intramedullary hemangioblastoma of the medulla oblongata (Type I); and were evaluated their clinical features including the operative mortality and morbidity of each location. In our two cases of Type I hemangioblastoma, Case 1, removed partially, died due to sleep apnea and Case 2 lead to normal school life after hemangioblastomas were removed radically. In our review of the 33 surgically-treated cases, radical excision was carried out in 29 cases (87.9%). The mortality was 24.2% overall; that of Type A was 25%, Type E was 28.6%, and Type I was 14.3%. In terms of postoperative mortality, the location of the hemangioblastoma was irrelevant and radical excision was much better than partial removal. Hemangioblastomas of the brain stem could be removed radically by meticulous dissection of the tumor on distinct cleavage, even in cases of intramedullary location. Microsurgical dissection of medullary hemangioblastomas with low morbidity is feasible and prudent postoperative care is mandatory to reduce the operative mortality and morbidity.

Hypothermic circulatory arrest in neurovascular surgery: evolving indications and predictors of patient outcome

OBJECTIVE

One of the largest contemporary neurosurgical experiences with hypothermic circulatory arrest was analyzed for trends in patient selection and clinical variables affecting outcome.

METHODS

During a 12-year period, 60 patients underwent 62 circulatory arrest procedures: 54 had posterior circulation aneurysms, 4 had anterior circulation aneurysms, and 2 had other lesions (hemangioblastoma and vertebral artery atherosclerosis).

RESULTS

The surgical morbidity and mortality rates associated with hypothermic circulatory arrest were 13.3 and 8.3%, respectively. At late follow-up, 76% of the patients had good outcomes (Glasgow Outcome Scale scores of 1 and 2), 5% had poor outcomes (Glasgow Outcome Scale scores of 3 and 4), and 18% had died. After 1992, circulatory arrest was limited to posterior circulation aneurysms and included increasing numbers of basilar trunk aneurysms. Patient outcome correlated with preoperative neurological condition (admission Glasgow Coma Scale score, P < 0.001; Hunt and Hess grade, P = 0.037; and age, P = 0.007). Preservation of perforating arteries was paramount to achieving a good outcome (P = 0.005); duration of circulatory arrest was not.

CONCLUSION

Current indications for hypothermic circulatory arrest include only giant and complex posterior circulation aneurysms that cannot be treated using conventional techniques or that recur after endovascular coiling. Surgical morbidity and mortality rates reflect the increasing complexity of the aneurysms treated but are still more favorable than the natural history of these lesions. This experience demonstrates that management in specialized neurovascular centers can minimize the morbidity associated with circulatory arrest so that it remains a viable treatment option for complex posterior circulation aneurysms.

Treatment of hemangioblastomas in von Hippel-Lindau disease with linear accelerator-based radiosurgery

OBJECTIVE

Stereotactic radiosurgery is increasingly being used to treat hemangioblastomas, particularly those that are in surgically inaccessible locations or that are multiple, as is common in von Hippel-Lindau disease. The purpose of this study was to retrospectively evaluate the effectiveness of radiosurgery in the treatment of hemangioblastomas.

METHODS

From 1989 to 1996, 29 hemangioblastomas in 13 patients with von Hippel-Lindau disease were treated with linear accelerator-based radiosurgery. The mean patient age was 40 years (range, 31-57 yr). The radiation dose to the tumor periphery averaged 23.2 Gy (range, 18-40 Gy). The mean tumor volume was 1.6 cm3 (range, 0.07-65.4 cm3). Tumor response was evaluated in serial, contrast-enhanced, computed tomographic and magnetic resonance imaging scans. The mean follow-up period was 43 months (range, 11-84 mo).

RESULTS

Only one (3%) of the treated hemangioblastomas progressed. Five tumors (17%) disappeared, 16 (55%) regressed, and 7 (24%) remained unchanged in size. Five of nine patients with symptoms referable to treated hemangioblastomas experienced symptomatic improvement. During the follow-up period, one patient died as a result of progression of untreated hemangioblastomas in the cervical spine. Three patients developed radiation necrosis, two of whom were symptomatic.

CONCLUSION

Although follow-up monitoring is limited, stereotactic radiosurgery provides a high likelihood of local control of hemangioblastomas and is an attractive alternative to multiple surgical procedures for patients with von Hippel-Lindau disease.

Multiple intracerebral haemangioblastomas in identical twins with von Hippel-Lindau disease--a clinical and molecular study

Von Hippel-Lindau (VHL) disease is an inherited autosomal dominant neoplastic disorder causing central nervous system haemangioblastomas. The VHL gene (3p25-3p26) is known to be a tumour suppressor gene, with its inactivation being responsible for a predisposition to tumour development. As far as we know, the present report of VHL disease manifestation in identical twins is unique. Genetic inquiry into the family background did not reveal this disease among their progenitors. For presymptomatic diagnosis of 17 presently unaffected family members, constitutional DNA of the twins was screened for VHL germline mutations, using loss of heterozygosity studies and exon-specific DNA sequencing. To determine the influence of somatic mutations of the VHL gene in tumourigenesis, DNA of five surgically removed intracerebral haemangioblastomas of the identical twins was analyzed in comparison with their constitutional DNA by DNA sequencing of the complete VHL coding region. However, no allelic losses were found for the VHL gene or for various other tumour suppressor genes (p53, BRCA1, BRCA2, DCC, and MCC). Furthermore, no mutations were found in the constitutional DNA of either twin sister or in the DNA of all five tumour lesions. Based on our observations, we conclude that in certain VHL families, presymptomatic molecular diagnosis of the disease is not feasible and requires close clinical surveillance of all individuals at risk.

Multiple cerebellar haemangioblastomas symptomatic during pregnancy

A patient with von Hippel-Lindau disease presented during her seventh week of pregnancy with obstructive hydrocephalus and brainstem compression caused by multiple cerebellar haemangioblastomas. Surgery was performed to relieve the hydrocephalus and remove the right cerebellar tumour. The patient's subsequent course supports the hypothesis of vascular engorgement of cerebellar haemangioblastomas during pregnancy.

Spinal cord hemangioblastoma presenting with subarachnoid hemorrhage

A 41-year-old man presented with subarachnoid hemorrhage (SAH) caused by a cervical spinal cord hemangioblastoma. There were no features to distinguish the SAH from that due to an intracranial lesion. The diagnosis was established by cerebral angiography, computed tomography, and magnetic resonance imaging. The tumor was located in the right dorsolateral aspect of the cervical spinal cord. Hemilaminectomy was performed, and the tumor was completely removed. No postoperative neurological deficit was observed. The possibility of a spinal origin for SAH should be considered if no cranial origin can be detected.

Tumor devascularization by intratumoral ethanol injection during surgery. Technical note

Preoperative reduction in tumor vascularity has been accomplished previously by selective catheterization of tumor vessels and delivery of occlusive materials. The results of percutaneous infusion of vertebral hemangiomas and other vascular lesions led the authors to speculate that rapid devascularization of tumors by direct injection of ethanol (ETOH) could be used to reduce bleeding and facilitate resection during surgery. Thus, the use of intratumoral injection of ETOH and its effects on tumor hemostasis and resectability were examined. Four patients received direct injection of ETOH into either a spinal epidural (two renal cell carcinomas and one rhabdomyosarcoma) or a large cerebellar neoplasm (hemangioblastoma). Intraoperative perfusion of the tumors with ETOH produced immediate blanching and devascularization and enhanced visualization and resection. Incremental tumor devascularization is achieved by careful injection of small amounts of ETOH directly into the lesion, producing immediate and complete regional tumor devascularization. Use of this technique reduces intratumoral bleeding and enhances the ease and effectiveness of resection.

[Parkinsonian hemi-syndrome as the initial manifestation of supratentorial cystic hemangioblastoma in a patient with Von Hippel-Lindau disease]

INTRODUCTION

Retino-cerebellar hemangioblastomatosis or Von Hippel-Lindau (VHL) disease is a phacomatosis with a dominant autosomal pattern of inheritance, which is characterized by the presence of hemangioblastomas of the central nervous system (cerebellum and spinal medulla), retinal angiomas and tumors (pheochromocytoma, clear cell carcinoma) or cysts of the abdominal viscera.

CLINICAL CASE

We present the case of a 22 year old female with Von Hippel-Lindau disease, in whom a cystic hemangioblastoma of the basal ganglia of the left hemisphere was diagnosed when she complained of difficulty in carrying out fine movements of the right hand and tremor for some months. The supratenorial site of cystic hemangioblastomas in the clinical context of Von Hippel-Lindau disease is very rare and clinical presentation of a parkinsonian hemisyndrome is exceptional. In our search through the literature we have found tumors with many types of histology (meningiomas, glial tumors, craniopharyngioma, epidermoid cysts) in the origin of tumoral parkinsonism.

CONCLUSIONS

However, we have found no previous case of cystic hemangioblastomas. We also emphasize that there was full resolution of the condition after total removal of the tumour.

[The surgical treatment of medullocervical tumors]

The study included 12 operated patients with medullocervical gliomas. Two of them had hemangioblastomas, 6-ependymomas, 4-astrocytomas with different degree of dedifferentiation. The gross total tumor removals were achieved in 4 patients with ependymomas and patient with hemangioblastomas. Two patients with ependymomas and one with hemangioblastoma had their tumors removed subtotally. All astrocytomas were partially excised. The neurological long tract signs were alleviated almost in all ependymoma and hemangioblastoma patients after surgery. Complication rate was the highest in the astrocytoma group. The authors discussed indications and contraindications for surgery depending on the tumor type.

Anesthetic management for a combined Cesarean section and posterior fossa craniectomy

A 33-year-old primigravida presented with intracranial tumor during the third trimester of pregnancy. She underwent a ventriculoatrial shunt and a combined cesarean section and posterior fossa craniectomy during this period. The neuroanesthetic requirement for this patient is prevention of rise in intracranial pressure with a slow and smooth induction and maintenance. Cesarean section demands rapid induction with minimum anesthetic until the delivery of the baby. Achieving these contradictory requirements at the same time can be challenging to an anesthesiologist. We report the anesthetic management of this patient during the above surgical procedures. Perioperative management of such patients with regard to use of uterine stimulants and prevention of venous stasis also are discussed.

Supratentorial haemangioblastoma: appearances on MR imaging

Haemangioblastoma is a rare, benign tumour of vascular origin which usually occurs in the posterior fossa. Supratentorial haemangioblastomas are exceptionally rare. In this report we present three cases of supratentorial haemangioblastoma with MRI findings.

Unilateral sensori-neural hearing disturbance caused by intramedullary cerebellar tumors--three case reports

Three patients presented with unilateral sensori-neural hearing disturbance as the initial symptom of cerebellar tumors: a 19-year-old female with a medulloblastoma (Case 1), a 45-year-old male with a cerebellar low-grade glioma (Case 2), and a 49-year-old female with a cerebellaer hemangioblastoma (Case 3). In Cases 1 and 2, the whole length of the eight cranial nerve was intact according to magnetic resonance imaging and intraoperative findings. In Case 3, the intracerebellar tumor had bulged into the cerebellopontine cistern, compressing the eighth cranial nerve near the brainstem. Auditory evoked brainstem responses showed only the first wave in all three patients, and the following waves could not be discriminated. Unilateral sensori-neural hearing disturbance occurs very rarely in patients with intramedullary cerebellar lesions because the auditory neural pathway is bilaterally innervated. Intramedullary tumors may cause unilateral sensori-neural hearing disturbance by infiltrating or causing edematous changes of the eighth cranial nerve or the cochlear nucleus in the brainstem, or by compressing the nerve in the cistern. The symptoms are the same as those of acoustic neurinoma, so intramedullary cerebellar tumors should be considered in the differential diagnosis of unilateral sensorineural hearing disturbance.

Mutism, oropharyngeal apraxia and dysarthria after posterior fossa tumour excision

Mutism and oropharyngeal apraxia are unusual complications of surgery on the cerebellum. They usually occur in children undergoing surgery for midline cerebellar tumours. Adults are rarely affected. The pathophysiology of the syndrome, which is reversible, is uncertain with possible involvement of vermian and paravermian structures. Two patients--one child and one adult--who developed mutism after cerebellar surgery are presented.

Hemangioblastoma of the posterior fossa. The role of multimodality treatment

The authors made a review of a series of patients with hemangioblastomas of the posterior fossa treated between 1973 and 1993. A total of 32 patients were analyzed with 24 patients receiving resection, 8 patients receiving radiosurgery and 2 patients receiving conventional radiotherapy. The mortality in the patients with a resection was considered acceptable with 2 deaths (8%) and with a morbidity of 3 patients (12.5%). A review of the literature suggests that conventional radiotherapy with high doses (45-60 Gy) may have a role in the post-operative control of hemangioblastomas and in some cases could be employed even before the resection in order to facilitate the surgery. The radiosurgical treatment is regarded like adjuvant. Poor results were obtained with radiosurgery in large tumors where low doses (less than 20 Gy) were used. Because of the rarity and complexity of these tumors, mainly when associated with von Hippel-Lindau disease, a multicenter study could be useful with the assessment of the optimal utilization and combination of these treatment modalities.

Stereotactic multiple are radiotherapy. IV--Haemangioblastoma

Our initial experience in the treatment of haemangioblastoma using conventional external beam radiotherapy and stereotactic radiotherapy (radiosurgery), by the linear accelerator method, is reported. Six haemangioblastomas in five patients were treated with a mean follow-up of 40 months (range 14-60). Five haemangioblastomas in four patients were treated with stereotactic radiotherapy, where four showed complete radiological response and the fifth was static. Neurological symptoms and signs improved in those patients. The sixth haemangioblastoma was situated close to the pituitary and optic chiasm, and was treated with conventionally fractionated external beam radiotherapy. The lesion showed partial response. No complications were noted in this patient group. This series complements and extends the relatively sparse published literature demonstrating that radiotherapy is an effective option for treating haemangioblastomas. Radiosurgery often lends itself particularly well to these discrete lesions allowing highly focused treatment. For patients with multiple and metachronous cerebellar haemangioblastomas as part of the von Hipple-Lindau syndrome, the data support a policy of conventionally fractionated external beam radiotherapy to the whole cerebellum of 50-55 Gy followed, after a period of time, by radiosurgery to persisting lesions (patients 3 and 4).

[Clinical features of hemangioblastomas of the central nervous system]

OBJECTIVE

To study the clinical features of hemangioblastomas of the central nervous system (CNS).

METHODS

174 patients with hemangioblastomas of CNS were reviewed from 1982 to 1995. All patients were verified pathologically.

RESULTS

The tumors occurred mainly in patients between 21 and 40 years of age, and more often in men than in women. Most tumors were in the posterior fossa. CT scan of 119 patients showed that 95 hemangioblastomas appeared as cysts. Magnetic resonance imaging (MRI) for 47 patients showed that 32 had cysts. 49 patients were examined with angiography or DSA. 164 tumor mural nodules and solid masses were completely resected. The subtotal removal of others was performed. These patients received radiotherapy.

CONCLUSION

Enhanced MRI is the examination of choice for preoperative evaluation of cystic hemangioblastomas. Angiography or DSA is necessary in the diagnosis of bigger solid masses. The findings suggest that patients' age and degrees of section could affect the recurrence of hemangioblastoma.

Preoperative embolization of solid cervicomedullary junction hemangioblastomas: report of two cases

Solid cervicomedullary haemangioblastomas represent a small but technically challenging subset of posterior fossa haemangioblastomas because of their site, high vascularity and tendency to bleed. We present our experience with preoperative embolisation of two solid cervicomedullary haemangioblastomas. In both cases the main feeding artery was the posterior inferior cerebellar artery. Arterial pedicles were catheterised with a microcatheter. The embolic material was small particles (150-250 microm) of polyvinyl alcohol. The result was almost complete preoperative obliteration of the vessels of the tumours. The procedure was well tolerated and facilitated easier bloodless, successful resection in both cases, 24 h after embolisation.

Diagnosis and treatment of solid brainstem tumors in adults

OBJECTIVE

To evaluate the diagnosis and aggressive surgical approach for brainstem tumors.

METHODS

A series of 24 adult patients with brainstem tumors were involved. Magnetic resonance (MR) imaging was performed on all patients. Surgical technique, potential risk and management of complications were described.

RESULTS

Diagnosis was confirmed by MR imaging and histological examination in all the patients. Tumors were totally or subtotally removed in twenty-two patients. Signs and symptoms were improved in 19 patients on discharge.

CONCLUSIONS

Our study shows that MR imaging has an important value for localizing tumors, identifying their nature and selecting appropriate surgical approaches. Most brainstem tumors, except for high-grade gliomas and small ventral tumors, are amenable to an aggressive surgical approach. The favorable results depend upon the appropriate surgical approach, microsurgical technique and intensive care after operation. Total removal can provide both high-quality survival and favorable long-term prognosis.

Successful surgical removal of an asymptomatic optic nerve hemangioblastoma in von Hippel-Lindau disease

An asymptomatic patient with a family history of von Hippel-Lindau disease carried the abnormal gene for this disease. An imaging survey that consisted of computed tomography, magnetic resonance imaging, and cerebral angiography revealed an optic nerve hemangioblastoma. The potential for visual loss in the future was the indication for microsurgical intervention. This was the first asymptomatic optic nerve hemangioblastoma to be imaged and the first to be successfully removed without any permanent neurological deficits or vision loss.

Hemangioblastoma and oculomotor pathology

We examined voluntary eye movements of 20 ophtalmologically screened patients (mean age of 51 years) with operated hemangioblastoma (HAB) in the cerebellum. Constant and pseudo-random saccades and pseudo-random smooth pursuit eye movement (PRPEM) test (with 4 frequency combinations) were evaluated. As controls 38 healthy subjects were examined. In the logistic regression analysis latency and accuracy of constant saccades were the best predictors for operated HAB with correct overall classification rate of 79.3%. Accuracy was worse and latency longer in operated HAB group than in control group. In pseudo-random saccades correct classification between the groups was achieved in 82.8% of all cases with latency and accuracy as predictors. In PRPEM test the best frequency combinations in differentiating operated HAB patients from controls were 0.25 and 0.425 Hz for gain, and 0.3 and 0.7 Hz for phase and gain, the correct overall classification rate being 73.3% in both cases. The characteristic changes in voluntary eye movements after removal of cerebellar hemangioblastoma seem to be insufficient timing of initiating the eye movement.

[Hemangioblastoma: description of a disease picture and report of 41 cases]

Hemangioblastomas are benign tumors of the central nervous system (CNS) with a predominance of the cerebellar hemispheres. They are one of the most frequent tumors of the posterior fossa in adults. In this retrospective study the data of 41 operated patients (23 men and 18 women) with a hemangioblastoma of the CNS are demonstrated. The mean age of the patients was 42.2 years (Range 4-70 years). 76% of the hemangioblastomas were located in the cerebellum, 9% in the cerebral hemispheres, 7% in the spinal canal and 5% in the brain stem. Signs of increased intracranial pressure and cerebellar dysfunction were the most frequent symptoms. Complete tumor removal was achieved in 90% of all operated cases. 82% of the hemangioblastomas were cystic and 18% solid. The mean diameter of the tumor cysts was 36 mm (Range 20-60 mm) and 18 mm (Range 2-40 mm) of the solid tumors. In 7% of the cases tumor recurrence was seen with a mean time interval of 5.7 years.

Normotensive bilateral pheochromocytoma with Lindau disease: case report

A 46-year-old man was found to have numerous cerebellar hemangioblastomas on magnetic resonance imaging (MRI). He denied any symptoms and had no history of hypertension, but his family history was remarkable for a father who died of renal cell carcinoma. Computed tomography (CT) of the abdomen revealed bilateral adrenal pheochromocytomas with significant enhancement in the regions where 131I-metaiodobenzylguanidine (MIBG) had noticeably accumulated. Endocrinological examinations demonstrated high plasma and urine catecholamine concentrations which were very responsive to metoclopramide and glucagon loading tests, without a significant change in blood pressure. After resection of bilateral pheochromocytomas, he underwent an operation for the cerebellar tumors. Since pheochromocytomas associated with Lindau or von Hippel-Lindau (VHL) disease have a tendency to multiple occurrence in normotensive patients, we suggest that patients with a family history involving VHL lesions should undergo cranial MRI, abdominal CT, MIBG scintigraphy and endocrinological examinations.

Gamma knife radiosurgery in 11 hemangioblastomas

One suprasellar, one mesencephalic, and nine cerebellar hemangioblastomas were treated with the gamma knife in 10 patients (median age 48 years) in Stockholm between 1978 and 1993. Four patients had von Hippel-Lindau disease, a dominant inherited trait predisposing to multiple hemangioblastomas. Six hemangioblastomas were treated with radiotherapy at a median margin dose of 25 Gy (20-35 Gy) before 1990 and the next five with a median of 10 Gy (5-19 Gy). Computerized tomography or magnetic resonance images were available for 10 of the 11 hemangioblastomas at a median follow-up time of 26 months (4-68 months) after radiosurgery. The solid part of six hemangioblastomas shrank in a median of 30 months, whereas four hemangioblastomas were unchanged at a median of 14 months. Five hemangioblastomas had an adjoining cyst and three of these cysts had to be evacuated after radiosurgery. One solitary hemangioblastoma later developed a de novo cyst that also needed evacuation. One patient with two cerebellar hemangioblastomas (margin dose 25 Gy each) developed edema at 6 months and required a shunt and prolonged corticosteroid treatment. The combined follow-up data of the 23 hemangioblastomas in 15 patients from previous literature and the present series indicate that, first, a solitary small- or medium-sized hemangioblastoma usually shrinks or stops growing after radiosurgery. The recommended margin dose is 10 to 15 Gy. Second, the adjoining cyst often does not respond to radiosurgery but requires later, sometimes repeated evacuation.

[A case of cystic hemangioblastoma of the medulla oblongata]

Cystic hemangioblastoma of the brain stem is an extremely rare clinical entity. Only eight cases have been reported in the literature. This is a report of a case of successful extirpation of a cystic hemangioblastoma of the medulla oblongata. A 47-year-old man was admitted to our clinic with the complaint of progressive numbness on his left upper limb since January 1995. Neurological examination revealed numbness and decreased vibration sensation on his left upper limb. MRI showed a cystic 1.5 x 2.0 cm lesion on the medulla oblongata, and with administration of Gd-DTPA, a small mass lesion on the dorsolateral side of the medulla oblongata. Left vertebral angiogram revealed a tumor fed directly from the left vertebral artery. An operation was performed using a suboccipital approach. The dorsal surface of the medulla was swollen edematously, suggesting the site of a cyst, which emptied by means of opening the wall. The reddish tumor was embedded on the left dorsolateral surface of the medulla oblongate. A total extirpation of the tumor was carried out under microscopic procedure. Histologically, the tumor was diagnosed as a hemangioblastoma. The patient was free from his distressing numbness immediately after the operation, and discharged without neurological deficit.

Cerebellar haemangioblastoma with extensive dissemination

Haemangioblastomas are benign tumours of uncertain origin. They are composed of capillaries and/or cavernous spaces interspersed with interstitial cells. Malignant spread, distant metastases and subarachnoid seeding are very rare, and only two such cases have been reported in the English literature. We report a third such case in a 4-year-old girl. The recurrence and extensive spread were excellently demonstrated by MRI.

Radiosurgery for hemangioblastoma: results of a multiinstitutional experience

PURPOSE

Between June 1988 and June 1994. 38 hemangioblastomas were treated with stereotactic radiosurgery (SR) at three SR centers to evaluate the efficacy and potential toxicity of this therapeutic modality as an adjuvant or alternative treatment to surgical resection.

METHODS AND MATERIALS

SR was performed using either a 201-cobalt source unit or a dedicated SR linear accelerator. Of the 18 primary tumors treated, 16 had no prior history of surgical resection and were treated definitively with SR and two primary lesions were subtotally resected and subsequently treated with SR. Twenty lesions were treated with SR after prior surgical failure (17 tumors) or failure after prior surgery and conventional radiotherapy (three tumors). Eight patients were treated with SR for multifocal disease (total, 24 known tumors). SR tumor volumes measured 0.05 to 12 cc (median: 0.97 cc). Minimum tumor doses ranged from 12 to 20 Gy (median: 15.5 Gy).

RESULTS

Median follow-up from the time of SR was 24.5 months (range: 6-77 months). The 2-year actuarial over-all survival was 88 +/- 15% (95% confidence interval). Two-year actuarial freedom from progression was 86 +/- 12% (95% confidence interval). The median tumor volume of the lesions that failed to be controlled by SR was 7.85 cc (range: 3.20-10.53 cc) compared to 0.67 cc (range: 0.05-12 cc) for controlled lesions (p - 0.0023). The lesions that failed to be controlled by SR received a median minimum tumor dose of 14 Gy (range: 13-17 Gy) compared to 16 Gy (range: 12-20 Gy) for controlled lesions (p = 0.0239). Seventy-eight percent of the surviving patients remained neurologically stable or clinically improved. There were no significant permanent complications directly attributable to SR.

CONCLUSIONS

This report documents the largest experience in the literature of the use of SR in the treatment of hemangioblastoma. We conclude that SR: (a) controls the majority of primary and recurrent hemangioblastomas; (b) offers the ability to treat multiple lesions in a single treatment session, which is particularly important for patients with Von Hippel-Lindau Syndrome; and that (c) better control rates are associated with higher doses and smaller tumor volumes.

Symptomatic intrasellar hemangioblastoma in a child treated with subtotal resection and adjuvant radiosurgery. Case report

The first documented case of a symptomatic intrasellar hemangioblastoma is described, occurring in an 11-year-old girl with stigmata of von Hippel-Lindau disease who presented with headaches, progressive bitemporal hemianopsia, and adenohypophysial dysfunction. A subtotal resection of the lesion was achieved with two separate surgical procedures: a transsphenoidal approach and a subfrontal craniotomy. Subsequent growth of residual tumor was treated with combined conventional radiotherapy and stereotactic radiosurgery. Two years following completion of these adjuvant therapies, no residual tumor was evident on magnetic resonance imaging. Previous experience with hemangioblastoma in this region, as well as the rationale for radiotherapy in the treatment of incompletely resected lesions, is reviewed.

Testicular embryonal cell carcinoma metastasizing to the site of a previously excised cerebellar haemangioblastoma

We report a patient with von Hippel-Lindau disease in whom a metastatic embryonal cell carcinoma from the testis occurred at exactly the same site from which a cerebellar haemangioblastoma had been excised 12 years earlier.

Preoperative embolization of highly vascular brain tumors: clinical and histopathological findings

This report concerns the clinical and histopathologic findings in five patients with meningioma and two with hemangioblastoma who underwent embolization with polyvinyl alcohol (PVA) particles before surgery. Angiography revealed loss of tumor stain from the main feeders in all seven patients, with markedly decreased contrast enhancement of computed tomography (CT) and magnetic resonance imaging (MRI) in six of them. Tumor excision was readily accomplished in all instances, with minimal bleeding from the tumor. In the patient operated 1 day after embolization there were almost no necrotic lesions, even though hemorrhage, presumably due to the surgical procedure was noted. Necrotic lesions and island-like residual tumor cells around the vessels were seen in the patient operated two days after embolization. Extended necrotic lesions were noted among patients who underwent surgery at day 4 and thereafter. Revasculization was not found, even in the patient operated one week after embolization. Massive bleeding (due presumably to the surgical procedure, suggesting recanalization) was noted in the tissue of a hemangioblastoma patient who underwent surgery 13 days after embolization, even though tumor excision was easy. In the patient subjected to the surgical procedure 694 days following embolization, the CT and MRI performed 2 months later, revealed contrast enhancement similar to that seen before the operation. Moreover, angiography, done after 5 months, demonstrated tumor stain as had been noted before embolization. The histopathologic examination of this case reveal the presence of extended necrotic lesions, a large number of macrophages that contained PVA particles, and destruction of the walls of the onceoccluded vessels. In addition, there were many blood-filled vessels that had achieved recanalization. These findings suggest that it is desirable to operate within 7 days after embolization, since recanalization occurs during this period, even though PVA particles remain unabsorbed for a long time.

Hemangioblastomas of the spinal cord and the brainstem: diagnostic and therapeutic features

Hemangioblastomas of the spinal cord and the brainstem make up 4% of all spinal tumors and are less common than cerebellar hemangioblastomas. CT and MRI are essential for preoperative diagnosis. Nevertheless, cerebral and spinal angiography are also mandatory, since they allow a detailed study of the vascular situation, which is decisive for exact planning of a surgical strategy. The purpose of this study was to evaluate the diagnostic and therapeutic factors which influence surgical morbidity and postoperative outcome. Twelve patients harbouring spinal(8 cases) or medullary (4 cases) hemangioblastomas, all symptomatic with sensorimotor deficits corresponding to the level of the lesion were evaluated. All patients were treated in our department between December 1989 and September 1994. Complete resection of the lesion was achieved in each case. Postoperatively, none of the patients showed deterioration. Nine patients had immediate postoperative improvement of neurological signs and symptoms; in three patients the initial neurological deficits remained unchanged during the in-patient period. Late postoperative outcome demonstrated a clear improvement; in only one patient was there no change of the clinical signs, while in the other 11 patients a significant improvement of pre-existing neurological deficits was experienced. We conclude that microsurgical resection of spinal and medullary hemangioblastomas with low morbidity is feasible.

Is unchanged tumor volume after radiosurgery a measure of outcome?

We report three patients who underwent Gamma Knife radiosurgery for benign tumors (meningioma, neurinoma and hemangioblastoma), in whom an 'unchanged tumor volume' demonstrated by postirradiation follow-up neuroimaging could be regarded as a successful treatment results, as compared with preradiosurgery tumor growth. It is our view that unless significant tumor growth has been observed before radiosurgery, 'unchanged in size' after radiosurgery cannot be regarded as a successful treatment result. Because relatively few hemangioblastoma patients have been treated radiosurgically, this report emphasizes the course of one case with hemangioblastoma.

Von Hippel-Lindau's disease: report of three cases and review of the literature

The authors present the autopsy findings of two related patients and the biopsy findings of a third member of the family. The oldest member was 34 years old at death and on postmortem examination he had haemangioblastomas in the retina, cerebellum, medulla and spinal cord. Other findings were renal cell carcinoma, phaechromocytoma, cysts of kidney and pancreas, hydromyelia and atypical meningiomas. His brother died when 30 years old. The autopsy revealed haemangioblastomas of cerebellum, renal cell carcinoma and a clear cell cystadenoma of epididymus. The third patient was the daughter of the first and presented with headache and dizziness. CT-scan showed a cerebellar haemangioblastoma. Epidemiological considerations on the commonest visceral and CNS lesions and a review of current diagnostic criteria are discussed.

Cerebellar hemangioblastoma complicating pregnancy. A case report

BACKGROUND

Cerebellar hemangioblastomas are unusual benign neoplasms that may go undetected for years. When associated with pregnancy, however, these tumors may undergo rapid expression and promote progression of symptomatology.

CASE

A 28-year-old woman with ataxia and left-sided weakness was diagnosed with cerebellar hemangioblastoma in the second trimester of pregnancy following repeated hospital admissions for nausea and vomiting. Surgical removal was uneventful, and she delivered vaginally at term.

CONCLUSION

Cerebellar hemangioblastomas, although rare, should be considered in the differential diagnosis of persistent nausea and vomiting when accompanied by an abnormal neurologic examination.

Hemangioblastoma of the IV ventricle

A case of solid hemangioblastoma in the IV ventricle in a 16-year-old boy is reported because of the rarity of this type of lesion. Microsurgical removal of the lesion was accomplished without any side effects in this highly vascular tumor in a strategic location.

Posterolateral cervical or thoracic approach with spinal cord rotation for vascular malformations or tumors of the ventrolateral spinal cord

This report describes a technique for exposing the ventrolateral quadrant of the spinal cord through an extended posterolateral approach that can be used in both cervical and thoracic regions. The surgical technique includes the following: 1) a midline skin incision with a transverse extension at the level of pathology; 2) unilateral division and retraction of the paraspinous muscles; 3) laminectomy and unilateral removal of facets and pedicles; 4) dural incision over the dorsal root entry zone; 5) multilevel division of the ipsilateral dentate ligaments; and 6) elevation and rotation of the spinal cord with dentate traction stiches. This technique provides exposure of the ventral root entry zone, the ipsilateral half of the ventral surface of the cord, and the anterior spinal artery. The surface of the spinal cord beyond the anterior spinal artery is not seen. This approach has been used for the treatment of seven ventrolateral spinal cord lesions: five spinal arteriovenous malformations (two Type II, one Type III, two Type IV), one hemangioblastoma, and one cavernous angioma. All the lesions were completely excised. Two patients had mild new neurological deficit after surgery, and one adolescent developed mild asymptomatic thoracic kyphosis, but no other spinal instability was observed over a follow-up period of 1 to 4 years. This operative approach provides significant advantages for ventrolateral perimedullary or intramedullary lesions of the cervical or thoracic spinal cord.

Cerebellar hemangioblastoma with intracystic hemorrhage--case report

A 45-year-old male presented with sudden onset of severe headache, mild disorientation, and gait disturbance due to intracystic hemorrhage from a cerebellar hemangioblastoma. He was successfully treated with ventricular drainage followed by total removal of the tumor. Reported cases of intracranial hemangioblastoma with massive hemorrhage show male predominance, tend to be solid rather than cystic, and occur in supratentorial more than infratentorial locations. Thin-walled and dilated vessels in the present and other cases were a possible cause of hemorrhage. Massive hemorrhage from hemangioblastoma is rare but needs prompt treatment because of the relatively high mortality.