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Bauman MM, Bouchal SM, Kerezoudis P, Cloft H, Brinjikji W, Peris Celda M, Link MJ, Parney IF. Embolization of Large and Giant Posterior Fossa Hemangioblastomas: The Experience of a Single Tertiary Care Center. J Neurol Surg B Skull Base 2023; 84:598-608. [PMID: 37854530 PMCID: PMC10581830 DOI: 10.1055/a-1946-4604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 09/13/2022] [Indexed: 10/14/2022] Open
Abstract
Background Hemangioblastomas pose an inherent surgical risk due to the potential for high intraoperative blood loss, especially in larger tumors. One approach to minimize this risk is to use preoperative embolization. Herein, we present our institutional experience treating large and giant cerebellar hemangioblastomas. Methods We performed a retrospective chart review of 19 patients with cerebellar hemangioblastomas that had a maximal diameter of >3 cm. We performed a literature review and included individual patient-level data that met our >3 cm diameter cerebellar hemangioblastoma inclusion criteria. Results Our cohort consisted of 19 patients that received a total of 20 resections for their cerebellar hemangioblastomas. Preoperative embolization was utilized in eight cases (38.1%). One patient experienced transient neurological complications after embolization (12.5%). Tumors of patients in the embolization group had larger median total, solid, and cystic volumes and were more likely to involve the cerebellopontine angle than those in the non-embolized group. Compared with non-embolized patients, embolized patients had less decrease in their hemoglobin, lower volumes of estimated blood loss, reduced rates of postoperative complications and permanent deficits, and greater instances of neurological improvement. The larger cohort (obtained from the combining our cohort with patients identified during a literature review) consisted of 99 patients with 39 receiving preoperative embolization. Conclusion It is important to examine individual patient characteristics when determining eligibility for preoperative embolization. However, improvements in endovascular techniques have made preoperative embolization a safe and effective procedure with minimal risks that can be performed in many patients.
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Affiliation(s)
- Megan M.J. Bauman
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, Minnesota, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Samantha M. Bouchal
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, Minnesota, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | | | - Harry Cloft
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, United States
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, United States
| | - Maria Peris Celda
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Michael J. Link
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Ian F. Parney
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
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Palavani LB, Andreão FF, de Abreu LV, Batista S, Borges J, Oliveira LDB, Bertani R, Filho JAA. Assessing the efficacy and safety of hemangioblastoma embolization: A comprehensive systematic review and meta-analysis. J Clin Neurosci 2023; 117:104-113. [PMID: 37788533 DOI: 10.1016/j.jocn.2023.09.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 09/16/2023] [Accepted: 09/24/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND Hemangioblastomas (HBs) are highly vascular tumors linked to substantial morbidity and mortality. Recently, interventional neuroradiology has evolved rapidly, spurring interest in preoperative embolization as a possible HB treatment. PURPOSE This study evaluates the effectiveness and safety of preoperative embolization in managing HB. METHODS Adhering to PRISMA guidelines, this meta-analysis considered randomized and nonrandomized studies meeting specific criteria, encompassing intracranial HB and preoperative embolization. Primary outcomes were preoperative embolization efficacy and safety. Complications were classified as major (cerebellar ischemia, ischemic strokes, intratumoral hemorrhage, subarachnoid hemorrhage) and minor (transient nystagmus, slight facial nerve palsy, nausea, transient dysarthria, hemiparesis, hemisensory impairment, thrombotic complications, extravasation). RESULTS Thirteen studies involving 166 patients with preoperative embolization before HB resection were included. Two studies using the Glasgow Outcome Scale (GOS) showed 5 patients with good recovery, 6 with moderate disability, and 3 with severe disability. Major complications occurred in 1% (95% CI: 0% to 3%), and minor complications occurred in 1% (95% CI: 0% to 4%). Intraoperative blood loss during resection was estimated at 464.29 ml (95% CI: 350.63 ml to 614.80 ml). CONCLUSION Preoperative embolization holds promise in reducing intraoperative bleeding risk in neurosurgical intracranial HB treatment, primarily due to its low complication rates. Nonetheless, additional research and larger-scale studies are essential to establish its long-term efficacy and safety. These findings highlight preoperative embolization as a valuable tool for HB management, potentially enhancing future patient outcomes.
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Affiliation(s)
| | - Filipi Fim Andreão
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Sávio Batista
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | | | - Raphael Bertani
- Department of Neurosurgery, University of São Paulo, São Paulo, Brazil.
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Huisman TAGM, Patel R, Kralik S, Desai NK, Meoded A, Chen K, Weiner HL, Curry DJ, Lequin M, Kranendonk M, Orman G, Jallo G. Advances in Imaging Modalities for Pediatric Brain and Spinal Cord Tumors. Pediatr Neurosurg 2023; 58:240-258. [PMID: 37604135 DOI: 10.1159/000531998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 07/05/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND Neuroimaging has evolved from anatomical imaging toward a multi-modality comprehensive anatomical and functional imaging in the past decades, important functional data like perfusion-weighted imaging, permeability imaging, diffusion-weighted imaging (DWI), and diffusion tensor imaging (DTI), tractography, metabolic imaging, connectomics, event-related functional imaging, resting state functional imaging, and much more is now being offered. SUMMARY Precision diagnostics has proven to be essential for precision treatment. Many minimal invasive techniques have been developed, taking advantage of digital subtraction angiography and interventional neuroradiology. Furthermore, intraoperative CT and/or MRI and more recently MR-guided focused ultrasound have complemented the diagnostic and therapeutic armamentarium. KEY MESSAGES In the current manuscript, we discuss standard imaging sequences including advanced techniques like DWI, DTI, susceptibility-weighted imaging, and 1H magnetic resonance spectroscopy, various perfusion weighted imaging approaches including arterial spin labeling, dynamic contrast enhanced imaging, and dynamic susceptibility contrast imaging. Pre-, intra, and postoperative surgical imaging including visualize imaging will be discussed. The value of connectomics will be presented for its value in neuro-oncology. Minimal invasive therapeutic possibilities of interventional neuroradiology and image-guided laser ablation and MR-guided high-intensity-focused ultrasound will be presented for treatment of pediatric brain and spinal cord tumors. Finally, a comprehensive review of spinal cord tumors and matching neuropathology has been included.
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Affiliation(s)
- Thierry A G M Huisman
- Divisions of Neuroradiology and Interventional Radiology, Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Rajan Patel
- Divisions of Neuroradiology and Interventional Radiology, Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Stephen Kralik
- Divisions of Neuroradiology and Interventional Radiology, Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Nilesh K Desai
- Divisions of Neuroradiology and Interventional Radiology, Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Avner Meoded
- Divisions of Neuroradiology and Interventional Radiology, Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Karen Chen
- Divisions of Neuroradiology and Interventional Radiology, Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Howard L Weiner
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children's Hospital and Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Daniel J Curry
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children's Hospital and Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Maarten Lequin
- Department of Radiology, Wilhelmina Children's Hospital and Princess Maxima Center for Pediatric Oncology University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mariette Kranendonk
- Department of Pathobiology, Princess Maxima Center for Pediatric Oncology University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gunes Orman
- Divisions of Neuroradiology and Interventional Radiology, Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA,
| | - George Jallo
- Department of Neurosurgery, Institute for Brain Protection Sciences, Johns Hopkins University School of Medicine, Johns Hopkins All Children's Hospital, Saint Petersburg, Florida, USA
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Miyahara K, Okada T, Tanino S, Uriu Y, Tanaka Y, Suzuki K, Sekiguchi N, Noda N, Ichikawa T, Fujitsu K. Usefulness of posterior transpetrosal approach for the large solid cerebellopontine angle hemangioblastoma fed from multiple blood supplies: A technical case report. Surg Neurol Int 2023; 14:191. [PMID: 37404484 PMCID: PMC10316202 DOI: 10.25259/sni_38_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 05/12/2023] [Indexed: 07/06/2023] Open
Abstract
Background Extra-axial cerebellopontine angle (CPA) hemangioblastomas are rare clinical entity and surgical treatment is challenging due to the anatomical difficulties and multi-directional blood supplies. On the other hand, the risk of endovascular treatment for this disease has also been reported. Herein, we successfully applied a posterior transpetrosal approach to remove a large solid CPA hemangioblastoma without preoperative feeder embolization. Case Description A 65-year-old man presented with a complaint of diplopia during downward gaze. Magnetic resonance imaging revealed a solid tumor with homogeneous enhancement measuring about 35 mm at the left CPA, and the tumor compressed a left trochlear nerve. Cerebral angiography disclosed tumor-staining fed by both left superior cerebellar and left tentorial arteries. After the operation, the patient's trochlear nerve palsy improved dramatically. Conclusion This approach offers more optimal surgical working angle to the anteromedial part compared to the lateral suboccipital approach. In addition, the devascularization from the cerebellar parenchyma can be performed more reliably than the anterior transpetrosal approach. After all, this approach can be particularly useful when vascular-rich tumors receive blood supplies from multiple directions.
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Affiliation(s)
- Kosuke Miyahara
- Corresponding author: Kosuke Miyahara, Department of Neurosurgery, National Hospital Organization Yokohama Medical Center, Yokohama, Kanagawa, Japan.
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Jeon C, Choi JW, Kong DS, Nam DH, Lee JI, Seol HJ. Treatment Strategy for Giant Solid Hemangioblastomas in the Posterior Fossa: A Retrospective Review of 13 Consecutive Cases. World Neurosurg 2021; 158:e214-e224. [PMID: 34728396 DOI: 10.1016/j.wneu.2021.10.169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Revised: 10/23/2021] [Accepted: 10/25/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To analyze radiologic characteristics, treatment strategy, and treatment outcomes of posterior fossa giant solid hemangioblastomas (GSHBs; ≥4 cm in maximum diameter). METHODS We performed a retrospective study of 13 consecutive patients (9 male and 4 female patients; mean age, 57.5 ± 13.3 years; range, 24-76 years) with GSHB who underwent surgical resection at a single institution between 2002 and 2018. The median follow-up was 33 months (range, 12-120 months). For each patient, neuroimaging findings, operative record, and treatment outcome were reviewed. RESULTS Seven tumors (53.8%) were located within cerebellar hemispheres, 4 (30.8%) in proximity to the brainstem, 1 (7.7%) within the cerebellar vermis, and 1 (7.7%) in the cerebellopontine angle. The mean maximum diameter was 4.8 ± 0.8 cm (range, 4.0-6.7 cm). Gross total resection was achieved in 11 patients (84.6%), and near-total resection in 2 patients (15.4%). Surgical complications occurred in 5 patients (38.5%); persistent neurologic deficits occurred in 2 patients (15.4%). Estimated progression-free survival after surgery was 92.3%, 80.8%, and 80.8% at 1, 5, and 10 years, respectively, whereas the estimated 1-year, 5-year, and 10-year overall survival was 100%, 90%, and 90%, respectively. CONCLUSIONS GSHBs are surgically challenging. The current study shows that favorable outcome can be achieved for GSHBs in the cerebellar hemispheres and vermis. For those involving the brainstem, planned near-total resection or subtotal resection in a piecemeal fashion can be attempted if en bloc resection is judged to be infeasible, and further intervention can be considered as needed.
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Affiliation(s)
- Chiman Jeon
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jung Won Choi
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Doo-Sik Kong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Do-Hyun Nam
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jung-Il Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ho Jun Seol
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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Watanabe T, Suematsu Y, Saito K, Takeishi G, Yamashita S, Ohta H, Yokogami K, Takeshima H. Selection of surgical approach for cerebellar hemangioblastomas based on venous drainage patterns. Neurosurg Rev 2021; 44:3567-3579. [PMID: 33877465 DOI: 10.1007/s10143-021-01544-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 02/09/2021] [Accepted: 04/08/2021] [Indexed: 11/25/2022]
Abstract
Cerebellar hemangioblastomas remain surgically challenging because of the narrow, deep surgical corridors and tumor hypervascularity. Various surgical approaches are used according to the location, but optimal approaches have not been established. We propose a system of surgical approaches based on the venous drainage systems to facilitate surgical planning and achieve acceptable neurological outcomes. Cerebellar hemangioblastomas were divided into five types based on the main drainage systems: suboccipital hemangioblastomas draining to the transverse sinus (TS) or torcula, tentorial hemangioblastomas draining to the tentorial sinus or straight sinus, petrosal hemangioblastomas draining to the superior petrosal sinus (SPS), quadrigeminal hemangioblastomas draining to the galenic system, and tonsillar hemangioblastomas draining to the TS or torcula in conjunction with jugular bulb or SPS. Microsurgical approaches and patient outcome were retrospectively reviewed according to this classification. This study included 17 patients who underwent 21 operations for resection of 19 cerebellar hemangioblastomas, classified into 9 suboccipital, 4 tentorial, 2 petrosal, 2 quadrigeminal, and 2 tonsillar. Standard suboccipital craniotomies were utilized for suboccipital hemangioblastomas, the occipital transtentorial approach (OTA), and supracerebellar infratentorial approach for tentorial hemangioblastomas, the retrosigmoid approach for petrosal hemangioblastomas, OTA for quadrigeminal hemangioblastomas, and midline suboccipital approach for tonsillar hemangioblastomas. Gross total resection was achieved in all patients except one. Two patients with large hemangioblastomas (tonsillar and quadrigeminal) required second-stage operation which finally achieved gross total removal. No single approach had a significantly higher incidence of postoperative neurological deficits. Selection of the optimum surgical approach for cerebellar hemangioblastomas was successful based on the main drainage systems. Understanding of tumor growth and extension with respect to the venous drainage system is critical to select the appropriate surgical approach.
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Affiliation(s)
- Takashi Watanabe
- Department of Neurosurgery, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake-cho, Miyazaki, 889-1692, Japan.
| | - Yuuki Suematsu
- Department of Neurosurgery, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake-cho, Miyazaki, 889-1692, Japan
| | - Kiyotaka Saito
- Department of Neurosurgery, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake-cho, Miyazaki, 889-1692, Japan
| | - Go Takeishi
- Department of Neurosurgery, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake-cho, Miyazaki, 889-1692, Japan
| | - Shinji Yamashita
- Department of Neurosurgery, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake-cho, Miyazaki, 889-1692, Japan
| | - Hajime Ohta
- Department of Neurosurgery, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake-cho, Miyazaki, 889-1692, Japan
| | - Kiyotaka Yokogami
- Department of Neurosurgery, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake-cho, Miyazaki, 889-1692, Japan
| | - Hideo Takeshima
- Department of Neurosurgery, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake-cho, Miyazaki, 889-1692, Japan
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Haryu S, Niizuma K, Endo H, Sato K, Watanabe M, Tominaga T. Case of Clear Cell Ependymoma Successfully Treated with Preoperative Embolization. JOURNAL OF NEUROENDOVASCULAR THERAPY 2020; 14:394-399. [PMID: 37501672 PMCID: PMC10370905 DOI: 10.5797/jnet.cr.2020-0050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 04/30/2020] [Indexed: 07/29/2023]
Abstract
Objective Clear cell ependymoma (CCE) is known to be very similar to hemangioblastoma (HB) in regards to neuroimaging and histopathology. We report a rare case of CCE in which successfully underwent preoperative embolization with a prior diagnosis of HB. Case Presentation A 58-year-old woman presented with vertigo for several months. MRI showed the right cerebellar tumor mimicking solid HB. DSA revealed the hypervascular tumor supplied by branches of the posterior inferior cerebellar artery (PICA). To reduce intraoperative bleeding, preoperative embolization was performed using n-butyl-2-cyanoacrylate (NBCA). A flow-guided microcatheter was guided to the proper feeders, and diluted NBCA was injected. Sufficient devascularization was achieved. The tumor was totally resected with minimal blood loss the next day. Postoperative pathological diagnosis was CCE. Conclusion This is the first report that preoperative embolization was performed to CCE with careful techniques and recent advanced devices. Since CCE has a poorer prognosis, preoperative embolization for safety total resection may be more important.
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Affiliation(s)
- Shinya Haryu
- Department of Neurosurgery, Tohoku Medical and Pharmaceutical University, Sendai, Miyagi, Japan
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Kuniyasu Niizuma
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Hidenori Endo
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Kenichi Sato
- Department of Neuroendovascular Therapy, Kohnan Hospital, Sendai, Miyagi, Japan
| | - Mika Watanabe
- Department of Pathology, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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Signorelli F, Piscopo G, Giraud S, Guerriero S, Laborante A, Latronico ME, Chimenti G, Maduri R, Chirchiglia D, Lavano A, Guyotat J, Alessio G, Gesualdo L. Von Hippel-Lindau disease: when neurosurgery meets nephrology, ophthalmology and genetics. J Neurosurg Sci 2019; 63:548-565. [DOI: 10.23736/s0390-5616.17.04153-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Management Strategies and Outcomes for VHL-related Craniospinal Hemangioblastomas. J Kidney Cancer VHL 2017; 4:37-44. [PMID: 28868236 PMCID: PMC5573741 DOI: 10.15586/jkcvhl.2017.90] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Accepted: 08/06/2017] [Indexed: 02/06/2023] Open
Abstract
Hemangioblastomas are rare and benign tumors accounting for less than 2% of all central nervous system (CNS) tumors. The vast majority of hemangioblastomas occur sporadically, whereas a small number of cases, especially in younger patients, are associated with Von Hippel–Lindau (VHL) syndrome. It is thought that loss of tumor suppressor function of the VHL gene results in stabilization of hypoxia-inducible factor alpha with downstream activation of cellular proliferative and angiogenic genes that promote tumorigenesis. VHL-related hemangioblastomas predominantly occur in the cerebellum and spine. Lesions are often diagnosed on contrast-enhanced craniospinal MRIs, and the diagnosis of VHL occurs through assessment for germline VHL mutations. Surgical resection remains the primary treatment modality for symptomatic or worrisome lesions, with excellent local control rates and neurological outcomes. Stereotactic radiotherapy can be employed in patients who are deemed high risk for surgery, have multiple lesions, or have non-resectable lesions. Given the tendency for development of either new or multiple lesions, close radiographic surveillance is often recommended for asymptomatic lesions.
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Kieran I, Zakaria Z, Kaliaperumal C, O'Rourke D, O'Hare A, Laffan E, Caird J, King MD, Murray DJ. Possible toxicity following embolization of congenital giant vertex hemangioma: case report. J Neurosurg Pediatr 2017; 19:296-299. [PMID: 27935467 DOI: 10.3171/2016.5.peds13345] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors describe the case of a 3-year-old boy with a giant congenital vertex hemangioma who underwent presurgical embolization with Onyx (ethylene-vinyl alcohol copolymer dissolved in dimethyl sulfoxide) and Glubran ( N-butyl-2-cyanoacrylate). This vascular tumor had no intracranial vascular communication as assessed by pre-embolization MRI and catheter angiography. All embolizations were performed by direct percutaneous injection. One week following the last embolization procedure the child presented with a 24-hour history of ataxia and extrapyramidal tremor. He was diagnosed with a possible immune-mediated reaction to Onyx or Glubran, which was treated with an urgent surgical excision of the hemangioma followed by intravenous administration of immunoglobulin and steroids. To the authors' knowledge, this is the first case of possible immune-mediated toxicity secondary to either Onyx or Glubran administration. This case highlights the need for awareness of potential toxic reactions to these embolic agents in the treatment of hemangiomas in the pediatric patient.
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Affiliation(s)
| | | | | | | | - Alan O'Hare
- Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland
| | - Eoghan Laffan
- Radiology, Temple Street Children's University Hospital; and
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Safety and outcomes of preoperative embolization of intracranial hemangioblastomas: A systematic review. Clin Neurol Neurosurg 2016; 150:143-151. [PMID: 27668858 DOI: 10.1016/j.clineuro.2016.09.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 09/05/2016] [Accepted: 09/18/2016] [Indexed: 11/23/2022]
Abstract
INTRODUCTION While preoperative embolization is often reserved for large and highly vascular tumors in order to minimize blood loss, its safety and efficacy in the treatment of hemangioblastomas (HB) is unclear. We present the largest systematic review focusing on the safety and outcome of preoperative embolization of intracranial HB. MATERIALS AND METHODS To identify all cases of preoperative embolization for HB, a literature search was conducted via Medline (OVID and PubMed), Scopus, Embase, and Web of Science. Studies that were in English, included intracranial hemangioblastomas treated with preoperative embolization and provided sufficient disaggregated clinical data for each patient were included. Historical control patients with non-embolized intracranial HB undergoing resection were similarly identified. RESULTS A total of 111 patients that underwent preoperative embolization of HB prior to planned resection were identified. Patient age ranged from 12 to 72 years, with a cohort of 63% males and 36% females. Nine studies comprising 392 non-embolized patients were included as controls. Gross total resection was achieved in 83.7% of embolized and 95.6% of non-embolized patients. Intraoperative blood transfusion was required in 15.3% of embolized and 0.51% of non-embolized controls, while rates of post-operative hemorrhage were 8.4% and 1.6%, respectively. Complication rates from embolization were 11.7% and following consequent surgery were 20.7%. DISCUSSION Embolization did not increase rates of gross total resection, decrease estimated blood loss, or decrease incidence of complications. Not only does embolization fail to mitigate surgical risks, the embolization procedure itself carries significant risk for complications. Embolization should not be standard of care for intracranial HB.
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The analysis of correlative factors affecting long-term outcomes in patients with Solid Cerebellar Hemangioblastomas. Clin Neurol Neurosurg 2016; 150:59-66. [PMID: 27588372 DOI: 10.1016/j.clineuro.2016.08.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 08/26/2016] [Accepted: 08/27/2016] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Analyze the factors affecting postoperative outcomes in patients with solid cerebellar hemangioblastomas. PATIENTS AND METHODS We retrospectively analyzed the clinical data of 22 patients with sporadic solid cerebellar hemangioblastomas. Data regarding the clinical materials and imaging features, diameter of the lesion, operative approaches and postoperative complications were analyzed in all patients. The factors that may affect the recovery of postoperative patients were analyzed by univariate analysis and logistic regression multivariate analysis. RESULTS All 22 patients were diagnosed with sporadic solid cerebellar hemangioblastomas; total resection was achieved in 21 of 22 patients (95.5%). Six patients with combined obstructive hydrocephalus received a ventricle-peritoneal shunt preoperatively. The mean duration of the follow-up period was 25.5 months (range, 6-72 months). Tumor recurrence occurred in two patients with poor prognosis at 12 months and 56 months after surgery. According to outcome, patients were divided into the poor group (4 of 22 patients, 18.2%), in which neurological symptoms persisted postoperatively, or were worse than preoperatively, and the good group (18 of 22 patients, 81.8%) with no neurological signs or improved symptoms postoperatively. After univariate analysis, the factor affecting the final outcome was postoperative hemorrhage (P=0.003). Moreover, multiple logistic regression analysis via R software indicated that postoperative hemorrhage (p=0.008) was correlated with outcomes. CONCLUSIONS Postoperative hemorrhage is a factor correlated with final outcomes of patients with sporadic solid cerebellar hemangioblastomas.
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Ene CI, Xu D, Morton RP, Emerson S, Levitt MR, Barber J, Rostomily RC, Ghodke BV, Hallam DK, Albuquerque FC, McDougall CG, Sekhar LN, Ferreira M, Kim LJ, Chang SW. Safety and Efficacy of Preoperative Embolization of Intracranial Hemangioblastomas. Oper Neurosurg (Hagerstown) 2016; 12:135-140. [PMID: 29506092 DOI: 10.1227/neu.0000000000001014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Accepted: 07/20/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Intracranial hemangioblastomas are highly vascular tumors that account for 1% to 2% of all central nervous system tumors. Preoperative embolization has been proposed to limit the often significant intraoperative blood loss associated with resection and potentially make the tumor more soft/necrotic and thus more amenable to gross total resection. The safety and efficacy of preoperative embolization of intracranial hemangioblastomas, however, are not well characterized. OBJECTIVE To evaluate the safety and efficacy of preoperative endovascular embolization of intracranial hemangioblastomas using a variety of embolic agents. METHODS A retrospective review of all surgically resected intracranial hemangioblastomas treated with preoperative embolization between 1999 and 2014 at 2 high-volume centers was performed. Clinical and radiographic criteria, including von Hippel-Lindau status, magnetic resonance imaging tumor characteristics, embolization-related complications, degree of angiographic devascularization, intraoperative blood loss, ability to obtain gross total resection, transfusion requirements, and operative time, were analyzed. RESULTS A total of 54 patients underwent surgery, with 24 undergoing preoperative embolization followed by surgical resection, and 30 patients undergoing surgical resection alone. Embolization-related neurological complications were seen in 6 patients (25%), including 3 hemorrhages when polyvinyl alcohol particles (P = .04) were used and 3 infarctions when liquid embolic agents were used (P = .27). Permanent neurological deficits were seen in 15%. CONCLUSION Preoperative embolization of intracranial hemangioblastomas should be performed with caution, given the potential for neurological morbidity. Further studies are needed to help guide patient and embolic agent selection.
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Affiliation(s)
- Chibawanye I Ene
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - David Xu
- Department of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Ryan P Morton
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Samuel Emerson
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Michael R Levitt
- Department of Radiology, University of Washington, Seattle Washington
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Robert C Rostomily
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Basavaraj V Ghodke
- Department of Neurological Surgery, University of Washington, Seattle, Washington.,Department of Radiology, University of Washington, Seattle Washington
| | - Danial K Hallam
- Department of Neurological Surgery, University of Washington, Seattle, Washington.,Department of Radiology, University of Washington, Seattle Washington
| | - Felipe C Albuquerque
- Department of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Cameron G McDougall
- Department of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Laligam N Sekhar
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Manuel Ferreira
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Louis J Kim
- Department of Neurological Surgery, University of Washington, Seattle, Washington.,Department of Radiology, University of Washington, Seattle Washington
| | - Steve W Chang
- Department of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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14
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Sultan A, Hassan T, Aboul-Enein H, Mansour O, Ibrahim T. The value of preoperative embolization in large and giant solid cerebellar hemangioblastomas. Interv Neuroradiol 2016; 22:482-8. [PMID: 26934897 DOI: 10.1177/1591019916633244] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2016] [Accepted: 01/25/2016] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Solid cerebellar hemangioblastomas are highly vascular lesions and may cause catastrophic hemorrhage during excision. METHODS This retrospective study enrolled 10 patients (7 men and 3 women, with a mean age of 38.2 ± 12.5 years) with solid cerebellar hemangioblastomas. All patients had a solitary tumor and underwent surgical resection of the lesion through a suboccipital approach. The basic features, serial radiographic examinations, and operative records were analyzed. RESULTS The most common presenting symptoms were headache (100%), ataxia (100%), and long tract manifestations (60%). Three patients had experienced failed surgery previously due to massive intraoperative bleeding. Three patients were confirmed as having Von Hippel-Lindau disease. The average size of the tumor was 40.7 ± 8.7 mm in its maximal diameter (range 25-58 mm). Total endovascular occlusion obtained in six patients, near total occlusion in three patients, and incomplete occlusion in one patient. Nine (90.0%) patients underwent gross total resection and one (10.0%) underwent partial resection. After the primary surgery, eight (80.0%) patients experienced improvement in their symptoms, two (20.0%) maintained their pre-treatment status, and none showed neurological deterioration following tumor resection. Blood loss during surgery after embolization was minimal and controllable. CONCLUSION Preoperative embolization improves safety and efficacy of the microsurgical excision of such tightly located very vascular tumors. Embolization changes the concept of this lesion surgery into piecemeal removal rather than a total mass extraction technique. Liquid agents are superior to particles in obliteration of such lesions.
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Affiliation(s)
- Ahmed Sultan
- Department of Neurosurgery, Alexandria University School of Medicine, Egypt The Research Center of Computational Neurovascular Biomechanics, Somoha University Hospital, Alexandria, Egypt
| | - Tamer Hassan
- Department of Neurosurgery, Alexandria University School of Medicine, Egypt The Research Center of Computational Neurovascular Biomechanics, Somoha University Hospital, Alexandria, Egypt
| | - Hisham Aboul-Enein
- Department of Neurosurgery, Alexandria University School of Medicine, Egypt
| | - Osama Mansour
- The Research Center of Computational Neurovascular Biomechanics, Somoha University Hospital, Alexandria, Egypt Department of Interventional Neurology, Alexandria University School of Medicine, Egypt
| | - Tamer Ibrahim
- Department of Neurosurgery, Alexandria University School of Medicine, Egypt The Research Center of Computational Neurovascular Biomechanics, Somoha University Hospital, Alexandria, Egypt
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15
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Ampie L, Choy W, Khanna R, Smith ZA, Dahdaleh NS, Parsa AT, Bloch O. Role of preoperative embolization for intradural spinal hemangioblastomas. J Clin Neurosci 2015; 24:83-7. [PMID: 26585384 DOI: 10.1016/j.jocn.2015.09.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 09/18/2015] [Indexed: 11/30/2022]
Abstract
Spinal hemangioblastomas (HB) are relatively rare neoplasms with a high degree of vascularity. Therapy for symptomatic tumors involves total resection when possible. Due to the enriched blood supply of these neoplasms, there is a high risk of significant intraoperative blood loss, which can lead to perioperative complications. Preoperative embolization of HB has been suggested to reduce blood loss and operative morbidity, but its use remains controversial. Data on the risks and benefits of preoperative embolization for this tumor remains limited. We identified and analyzed all 29 reported cases of preoperative embolization of intradural spinal HB within the literature. There were 18 men and nine women, and patients ranged from 24 to 61 years of age. Mean tumor size was 3.5 cm. Cervical and thoracic location was most common, accounting for 48.3% and 20% of cases, respectively. Complications from embolization and surgery were minimal, with no deaths or permanent neurological morbidity. Minimal intraoperative bleeding and excellent rates of gross total resection were reported with preoperative embolization. However, outcomes from microsurgery alone from historical series have similarly reported excellent outcomes. While there is no established standard, preoperative embolization should be reserved for particularly high risk patients with risk of intraoperative bleeding.
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Affiliation(s)
- Leonel Ampie
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, 676 N. St. Clair Street, Suite 2210, Chicago, IL 60611-2911, USA
| | - Winward Choy
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, 676 N. St. Clair Street, Suite 2210, Chicago, IL 60611-2911, USA
| | - Ryan Khanna
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, 676 N. St. Clair Street, Suite 2210, Chicago, IL 60611-2911, USA
| | - Zachary A Smith
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, 676 N. St. Clair Street, Suite 2210, Chicago, IL 60611-2911, USA
| | - Nader S Dahdaleh
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, 676 N. St. Clair Street, Suite 2210, Chicago, IL 60611-2911, USA
| | - Andrew T Parsa
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, 676 N. St. Clair Street, Suite 2210, Chicago, IL 60611-2911, USA
| | - Orin Bloch
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, 676 N. St. Clair Street, Suite 2210, Chicago, IL 60611-2911, USA.
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16
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Suzuki M, Umeoka K, Kominami S, Morita A. Successful treatment of a ruptured flow-related aneurysm in a patient with hemangioblastoma: Case report and review of literature. Surg Neurol Int 2014; 5:S430-3. [PMID: 25324977 PMCID: PMC4199150 DOI: 10.4103/2152-7806.141887] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 07/29/2014] [Indexed: 11/30/2022] Open
Abstract
Background: No cerebral aneurysms on the feeder associated with hemangioblastomas that ruptured before resection have been reported. We report a patient with a ruptured flow-related aneurysm associated with cerebellar hemangioblastoma and a tumor feeder treated simultaneously by a single procedure of embolization using N-butyl cyanoacrylate before tumor removal. Case Description: A 36-year-old female with a cerebellar tumor was admitted to our institute. Four days later, she suffered a massive subarachnoid hemorrhage mainly in the posterior fossa. Left vertebral angiograms showed an aneurysm on the feeding artery, posterior inferior cerebellar artery. Both the aneurysm and its main feeder were simultaneously treated by a single procedure of embolization using N-butyl cyanoacrylate. Their complete obliteration was confirmed angiographically. Four days after the procedure, we removed the tumor and the embolized aneurysm. The pathological diagnosis was hemangioblastoma and flow-related ruptured aneurysm. Conclusion: Cerebral angiography should be performed to rule out vascular abnormalities such as cerebral aneurysms adjacent to the tumor in patients with hemangioblastoma who present with intracranial hemorrhage. We emphasize the usefulness of embolization with N-butyl cyanoacrylate for hemangioblastoma with ruptured feeder aneurysm, by which the aneurysm and the feeder could be simultaneously embolized.
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Affiliation(s)
- Masanori Suzuki
- Department of Neurosurgery, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai, Chiba, Japan
| | - Katsuya Umeoka
- Department of Neurosurgery, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai, Chiba, Japan
| | - Shushi Kominami
- Department of Neurosurgery, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai, Chiba, Japan
| | - Akio Morita
- Department of Neurosurgery, Nippon Medical School Hospital, 1-1-5, Sendagi, Bunkyoku, Tokyo, Japan
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17
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Jito J, Nozaki K. Treatment strategies for cerebellar hemangioblastomas: simple or further studies? World Neurosurg 2014; 82:619-20. [PMID: 25151228 DOI: 10.1016/j.wneu.2014.08.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 08/14/2014] [Indexed: 11/16/2022]
Affiliation(s)
- Junya Jito
- Department of Neurosurgery, Shiga University of Medical Science, Otsu, Japan
| | - Kazuhiko Nozaki
- Department of Neurosurgery, Shiga University of Medical Science, Otsu, Japan.
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18
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Direct transcranial puncture for Onyx embolization of a cerebellar hemangioblastoma. J Clin Neurosci 2014; 21:1040-3. [DOI: 10.1016/j.jocn.2013.08.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Accepted: 08/20/2013] [Indexed: 11/23/2022]
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19
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Liu AH, Peng TM, Wu Z, Xiao XR, Jiang CH, Wu ZX, Li YX. Clinical effectiveness of preoperative embolization for cerebellar hemangioblastoma. Asian Pac J Cancer Prev 2013; 14:5179-83. [PMID: 24175797 DOI: 10.7314/apjcp.2013.14.9.5179] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
The cerebellar hemangioblastoma (CHB) has an abundant blood supply and deep anatomical location. Complete surgical resection is generally very difficult. This study investigated the safety and effectiveness of preoperative embolization followed by surgical resection of CHB in a large cohort of patients. A database of 125 CHB patients with surgical resection in Beijing Tiantan Hospital between July 2006 and July 2012 was reviewed. Of those, 46 cases (experimental group) received preoperative embolization, 79 cases (control group) underwent surgery without embolization. Patient demographics, tumor size, duration of surgery, blood loss, blood transfusion, complications and follow-up results were collected and analyzed retrospectively. In the experimental group, the Kamofsky score (KS) was 80-100 in 40 cases (86.9%), 40-70 in 4 cases (8.7%), and below 40 in 2 cases (4.3%). Among 31 cases with follow-up, KS was 80-100 in 27 cases (87.1%), 40-70 in 2 cases (6.5%), and 0 in 2 cases (6.5%). In control group, KS was 80 -100 in 65 cases (82.2%), 40-70 in 6 cases (7.6%), 10-30 in 3 cases (3.8%), and 0 in 3 cases (3.8%). Among 53 cases with follow-up, KS was 80-100 in 44 cases (83.0%), 40-70 in 4 cases (7.5%), 10-30 in 1 case (1.9%), and 0 in 4 cases (7.5%). There were statistically significant differences between the experimental and control groups in tumor size, duration of surgery, amount of intraoperative blood loss and transfusion (p <0.01). However, complications (p = 0.31) and follow-up results (p = 0.76) showed no significant differences between groups. Selective preoperative embolization of those CHB patients with richer blood supply, higher hemorrhage risk, is safe and effective, and is a reliable adjuvant therapy for complete surgical resection of CHB.
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Affiliation(s)
- Ai-Hua Liu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China E-mail : ,
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