Diagnosis and microsurgical treatment of spinal hemangioblastoma

Perioperative Surgical Risks in Patients With Hemangioblastomas: A Retrospective Nationwide Review in Japan

BACKGROUND

The perioperative risk of sporadic hemangioblastomas (HBs) and von Hippel-Lindau disease (VHL)-associated hemangioblastomas (VHL-associated HBs) remains unclear due to the rare prevalence of HB. Therefore, this study aimed to clarify risk factors for better surgical management of patients with HBs.

METHODS

A retrospective analysis of surgically treated HB patients registered in the Diagnosis Procedure Combination database of Japan, between 2010 and 2015, was performed. Age, sex, sporadic HBs or VHL-associated HBs, medical history, tumor location, hospital case load, postoperative complications, and Barthel index (BI) deterioration were assessed. We also evaluated the outcomes and factors of perioperative BI deterioration.

RESULTS

In total, 676 patients with 609 intracranial lesions, 64 spinal lesions, and 3 with both types were eligible. Among them, 618 and 58 patients had sporadic HBs and VHL-associated HBs, respectively. The rates of perioperative BI deterioration were 12.5% and 12.2% for sporadic HBs and VHL-associated HBs, respectively. Perioperative mortality was 1.8% and 0% for sporadic HBs and VHL-associated HBs, respectively. Male sex, old age, high hospital case load, and medical history of diabetes mellitus were significantly associated with perioperative BI deterioration in all cases and sporadic HBs. Only medical history of diabetes mellitus was a significant risk factor for perioperative BI deterioration in VHL-associated HBs.

CONCLUSIONS

No differences in perioperative BI deterioration rates between sporadic HBs and VHL-associated HBs were found. However, different risk factors for perioperative BI deterioration were identified. Consideration of these risk factors is recommended in all patients undergoing surgery for HB.

Benign Spinal Tumors

Benign spinal intradural tumors are relatively rare and include intramedullary tumors with a favorable histology such as low-grade astrocytomas and ependymomas, as well as intradural extramedullary tumors such as meningiomas and schwannomas. The effect on the neural tissue is usually a combination of mass effect and neuronal involvement in cases of infiltrative tumors. The new understanding of molecular profiling of different tumors allowed us to better define central nervous system tumors and tailor treatment accordingly. The mainstay of management of many intradural spinal tumors is maximal safe surgical resection. This goal is more achievable with intradural extramedullary tumors; yet, with a meticulous surgical approach, many of the intramedullary tumors are amenable for safe gross-total or near-total resection. The nature of these tumors is benign; hence, a different way to measure outcome success is pursued and usually depends on functional rather than oncological or survival outcomes.

Spinal hemangioblastomas: analysis of surgical outcome and prognostic factors

The prognostic factors for surgically removed spinal hemangioblastomas, the impact of VHL disease on outcome, and the role of intraoperative neuromonitoring are still not completely clear. The aim of this study was to review our experience with spinal hemangioblastomas in order to assess potential predictors of neurological outcome after surgery. All cases of spinal hemangioblastomas removed at two Italian academic institutions from 1985 to 2020 were reviewed. Data about clinical presentation and symptom duration, diagnosis of VHL, surgical approach, use of IONM, duration of hospital stay, follow-up, and modified McCormick grade before and after surgery were extracted. Sixty-one patients (31 F, 30 M) underwent 69 surgeries to remove 74 spinal hemangioblastomas (37 cervical, 32 thoracic, 5 lumbar). Improvement was found in 32.3% of cases, neurological condition remained stable in 51.6% of cases, and deteriorated in 16.1% of patients. A worsening trend in VHL patients and an improvement trend in non-VHL patients were detected, despite the lack of statistical significance. Laminotomy and use of IONM were found to be associated with better outcome, although no association was found between surgery without IONM and worse outcome. In most cases, patients affected by spinal hemangioblastomas can expect a good long-term outcome. In our experience, laminotomy seems to be associated with better outcome compared to laminectomy. While its absence is not associated with worse outcome, IONM seems to be associated with a better neurological outcome. Our study suggests that the more impaired the preoperative neurological condition, the worse the outcome.

Sporadic cauda equina hemangioblastoma: surgical management in a pregnant woman

Hemangioblastoma is a rare benign vascular tumour of the central nervous system that occurs either sporadically or in association with Von Hippel-Lindau syndrome. Hemangioblastoma can be found throughout the central nervous system and usually present with late manifestations due to their slow growth rate. Cauda equina hemangioblastomas are extremely rare, and in the literature, no cases are reported on the surgical management of pregnant patients with this condition. We report the case of a young woman with back pain and sphincter dysfunctions in whom an L1-L2 hemangioblastoma was diagnosed. We describe the perioperative and surgical strategies we adopted to successfully treat the patient and preserve the fetus well-being.

Spinal Hemangioblastomas and Neuropathic Pain

BACKGROUND

Spinal hemangioblastomas (SHs) are rare and benign tumors. Primary symptoms include pain, hypoesthesia, and neuropathic pain (NP). Clinical symptoms may be as a result of tumor mass effect, peritumoral effect, syrinx, or venous congestion. No studies have focused on NP in SHs. The objective of this study was to review the rate and causes of NP in patients with SHs.

METHODS

The present study comprises a retrospective analysis of 13 patients with spinal hemangioblastomas. For the retrospective analysis of the patients, we analyzed the absence or presence of NP in the pre- and postoperative periods and its relationship with the level, location, and size of the tumor, as well as the size and location of the syrinx.

RESULTS

Postoperative NP was detected in 6 out of 13 patients. All 6 patients' tumors were located at the dorsal aspect of the spinal cord. There was a predominance of rostral syrinx location in patients with NP. Tumor size and level and syrinx size and level were not found to affect the occurrence of NP.

CONCLUSIONS

The present study shows that NP is observable in both pre- and postoperative periods. Proximity of the tumor to the dorsal root entry zone, and especially the presence of rostral syrinx, are the main factors affecting postoperative NP symptomatology. It is concluded that the combination of these factors and iatrogenic injury of anatomic pathways of NP within the spinal cord are responsible for postoperative NP.

Surgical management and outcome of adult posterior cranial fossa and spinal hemangioblastoma: a 6-case series and literature review

OBJECTIVE

Hemangioblastomas of the posterior cranial fossa and spinal cord in adults are excessively vascularized, well-differentiated, and scarce tumors with no metastatic potential. This paper discusses its surgical management and outcome, pointing out their morphological, radiological, and histopathological aspects. This report based on a personal series of six patients and on a literature review.

METHODS

A single-institution personal 6-case series of adult patients diagnosed and operated on by a senior neurosurgeon (KIA) due to posterior cranial fossa or spinal cord hemangioblastoma was analyzed. For easier understanding of hemangioblastoma, we have classified them into four different types.

RESULTS

The tumors, which were all surgically treated, were located in the posterior cranial fossa in five patients (4 cerebellar, 1 brain stem) and intramedullary in the thoracic spinal cord in one patient. All patients successfully recovered neurologically after a complete tumor resection, having no post-operative neurological deficit or other complications.

CONCLUSION

Surgical management of cerebellar and spinal cord hemangioblastoma in adults is highly dependent on its morphological features, as well as on microsurgical technique applied. Since huge differences exist between the cystic/nodular tumor type (Type 1) and the solid type and its two additional variants (Types 2-4), morphology is the most important consideration when deciding surgical approach. Despite significant morphological differences among different subtypes of hemangioblastomas, their histology appears to be relatively similar. Nonetheless, a meticulous and refined surgical technique has to be utilized to achieve a successful outcome.

Microsurgical Resection of Spinal Cord Hemangioblastoma: 2-Dimensional Operative Video

This video demonstrates microsurgical resection of spinal cord hemangioblastoma. Hemangioblastomas are rare, benign, highly vascularized tumors classified as grade I according to World Health Organization classification systems. About 3% of all intramedullary tumors are hemangioblastomas.1,2 Spinal cord hemangioblastomas are either sporadic3,4 or manifestations of von Hippel-Lindau (VHL) disease in 20% to 45% of patients.5,6 A 30-year-old male presented with sudden onset urinary incontinence. Magnetic resonance imaging showed contrast enhancing intramedullary tumor with adjacent cyst in T11, and syringomyelia extending to C1. Surgical resection followed rules that apply to resection of arteriovascular malformations: coagulation of arterial feeders precedes the coagulation of the draining vein, which is preserved until the end of surgery.2,4,5,7,8 First, posterior midline myelotomy was performed and the tumor cyst was drained in order to develop a dissection plane. Following this, we continuously separated dorsal nerve roots from the tumor nodule using microsurgical technique. The key step in tumor resection is devascularization of the tumor, achievable in 2 ways.2,7,9-13 The circumferential detachment of the normal pia from the tumor pia is crucial in developing a plane of dissection. The coagulation and division of arterial feeders while preserving the drainage vein further devascularizes the tumor. Once the tumor mural nodule was detached from the spinal cord, the drainage vein was coagulated last and the tumor was removed. The patient fully recovered from his incontinence and was neurologically intact. Screening for VHL disease was negative. Written consent was obtained directly from the patient.

Post-traumatic carotid-cavernous fistula in a pediatric patient: a case-based literature review

BACKGROUND

Carotid-cavernous fistula (CCF) is a shunt between the carotid artery and the cavernous sinus. Traumatic CCFs are diagnosed in 0.2% of head traumas being only 4.6% of the pediatric population. Classified by Barrow in 1985, type A CCF is the most frequent, occurring in 75% of cases. Type A is characterized by direct and high-flow CCF that generally can occur as a result of traumatic injury or rupture of an intracavernous aneurysm.

CASE PRESENTATION

The subject was an 8-year-old boy with penetrating trauma to his left eye. During the initial evaluation, a computed tomography (CT) scan was unremarkable, and after relief of symptoms, the patient was discharged. Seven days later, he developed grade I proptosis, conjunctival chemosis, ophthalmoplegia (III, IV, and VI cranial nerve palsies), and left-sided ptosis and mydriasis. Arteriography confirmed a post-traumatic CCF, and the patient was treated with an endovascular detachable balloon.

CONCLUSION

CCF should be suspected in craniofacial traumas with ocular symptoms. The presence of a skull base fracture on CT is a poor predictor of CCF associated with head trauma. Early diagnosis and treatment can prevent permanent neurological deficits and unfavorable outcomes.

Hydrocephalus: a rare initial manifestation of sporadic intramedullary hemangioblastoma : Intramedullary hemangioblastoma presenting as hydrocephalus

BACKGROUND

Intramedullary hemangioblastomas are rare benign vascular tumors, infrequent in pediatric patients. Clinical symptoms vary according to the age of presentation, tumor size, location, and concomitant syringomyelia. This is the second reported case of hemangioblastoma presenting with acute hydrocephalus.

CASE PRESENTATION

A 3-month-old infant with acute hydrocephalus was asymptomatic after a ventriculoperitoneal shunt was placed. She returned 3 months later with irritability, acute paraplegia, and respiratory distress. Magnetic resonance imaging (MRI) showed an intramedullary T8-T9 tumor with syringomyelia. She underwent surgical resection with good results during the 6-month follow-up.

CONCLUSION

Intramedullary tumors may present as hydrocephalus and other nonspecific symptoms, with invariably delayed diagnosis in children, but must be considered in suspicious cases.