Proximal nerve root spinal hemangioblastomas: presentation of three cases, MR appearance, and literature review

Massive spinal epidural infantile hemangioma, image findings, and treatment: a case report and review of literature

Spinal involvement of infantile hemangiomas is rare with the predilection to involve the epidural space. A proper diagnosis might be challenging due to the atypical location and variable/inconsistent use of the International Society for the Study of Vascular Anomalies (ISSVA) classification by radiologists, pathologists, and clinicians. A proper diagnosis of epidural infantile hemangioma is key due to the different aggressiveness of the treatment options with inconstant literature regarding the best available treatment. Herein, we present a case of a massive epidural infantile hemangioma successfully treated with only beta-blocker. We discuss the clinical, MRI, CT, ultrasound, and histological features of this lesion as we review the literature with the objective of addressing some of the confusion surrounding the subject.

Sporadic hemangioblastoma of cauda equina: A case-report and brief literature review

Hemangioblastomas are rare lesions accounting for 1-5% of all spinal cord tumors and are mostly associated with von Hippel-Lindau syndrome. Localization in the cauda equina is uncommon. In this manuscript we aim to describe a rare case of sporadic intradural extramedullary hemangioblastoma of the cauda equina and present a literature review. A systematic research was performed on Pubmed, MEDLINE, and Google Scholar, using as keywords "spinal hemangioblastoma" and "cauda equina tumors". The previous literature is integrated by the description of the present case. A 49 year-old female, presented on August 2020 to our institution suffering from claudication neurogena, right sciatica and paraesthesia in right L5 radicular dermatome for more than 3 months. Neurological examination revealed hypoesthesia on right L5 dermatome and weakness of right anterior tibialis muscle. An MRI which showed an intradural mass at L1/2 level and an angiography that showing a nidus of serpiginous vessels inside the lesion. Microsurgical en bloc resection of lesion was performed with adjuvant neurophisological intra operative monitorings. Histological examination provided the diagnosis of hemangioblastoma. After surgery symptoms and neurological impairment gradually improved. A 10 months post-operative MRI showed no residual tumor. Although intradural extramedullary hemangioblastoma of the cauda equina without von Hippel-Lindau syndrome it is a rare pathological entity, this diagnosis must be taken in for cauda equina masses. Preoperative embolization is an option to minimize intraoperative bleeding. Radiosurgery seems to prevent recurrences when the tumor is not completely excised. Complete surgical removal of the lesion is usually possible and lead to a low likelihood of recurrence.

Filum Terminale: A Comprehensive Review with Anatomical, Pathological, and Surgical Considerations

The conus medullaris is the distal tapering end of the spinal cord, and the filum terminale (FT) is regarded as a bundle of non-functional fibrous tissue; therefore, some scholars call it the spinal ligament, while others describe the human FT as "remnants of the spinal cord." It was later found that in the human spinal cord, the FT is composed of an intradural segment and an epidural segment, and the end of the FT is connected to the coccyx periosteum. Because some nerve tissue is also found in the FT, as research progresses, FT may have the potential for transplantation. A lack of exhaustive overviews on the FT in the present literature prompted us to conduct this review. Considering that a current comprehensive review seemed to be the need of the hour, herein, we attempted to summarize previous research and theories on the FT, elucidate its anatomy, and understand its pathological involvement in various diseases.

Spinal cervical extradural hemangioblastoma

Spinal cervical extradural and intra-extradural hemangioblastomas are exceptional, with only nine reported cases. This study reviews the diagnostic and surgical problems of this rare entity. Two female patients, aged 80 years and 25 years, respectively, one with Von Hippel–Lindau disease (VHLD), experienced brachial pain and weakness. On magnetic resonance imaging, a dumbbell intra-extraspinal hemangioblastoma was evidenced. The surgical resection through posterior laminectomy resulted in clinical remission of brachial pain and weakness. The magnetic resonance aspect of a dumbbell lesion suggests a neurogenic tumor; the correct preoperative diagnosis is possible in individuals with VHLD. The surgical problems include high tumor vascularity, vertebral artery control, and nerve root preservation. However, the surgical excision results in clinical remission.

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.

Novel Clinical Insights into Spinal Hemangioblastoma in Adults: A Systematic Review

BACKGROUND

Hemangioblastomas (HBs) are well-vascularized, benign central nervous system tumors and the third most common primary spinal cord tumor after astrocytoma/ependymoma, occurring sporadically or as a part of autosomal dominant von Hippel-Lindau disease, in which tumors are often multiple and prone to relapse. Spinal HBs are commonly located in the cervical cord and associated with a syrinx formation. Owing to location and growth trends, they may cause significant neurological deficit, impairing quality of life. We conducted a systematic review to understand better clinical insights into spinal HB in adults and compare spinal HB versus posterior cranial fossa HB.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for conducting systematic reviews, we reviewed the English-language literature on adult spinal HB in the MEDLINE/PubMed database over the last 40 years.

RESULTS

We reviewed 237 articles on adult spinal HB and analyzed national and continental distribution, clinical symptoms, tumor location and presence of syringomyelia, treatment strategies and postoperative complications, histology and immunochemistry, and treatment outcomes. We compared individual characteristics in sporadic and von Hippel-Lindau disease spinal HBs. Finally, we compared features of posterior cranial fossa and spinal HBs.

CONCLUSIONS

Spinal cord HBs most commonly have a dorsal intramedullary location. Total surgical tumor resection is the first treatment option; preoperative embolization may be performed to reduce intraoperative bleeding and surgical time. HBs located in the spine have decreased mortality and rate of infection, but increased rates of cardiopulmonary complications compared with HBs in the posterior cranial fossa.

A pure extradural hemangioblastoma mimicking a dumbbell nerve sheath tumor in cervical spine: illustrative case

BACKGROUND

Spinal extradural hemangioblastomas (HBs) are quite uncommon, with most reported cases involving the thoracic and lumbar areas. Therefore, the presence of a dumbbell-shaped pure extradural cervical HB is exceptional, making preoperative diagnosis particularly challenging.

OBSERVATIONS

The authors report a case of a 27-year-old woman who presented to their outpatient clinic with progressive cervicobrachialgia and numbness in the left arm. Magnetic resonance imaging showed a C5–6 intradural extramedullary lesion, and, despite some atypical features, the diagnosis of a possible neurogenic tumor was made. A multidetector computed tomography scan and angiography confirmed the expansion and remodeling of the left neural foramen as well as the highly vascularized nature of the mass. Preoperative embolization of the lesion was performed. Complete tumor resection was accomplished, followed by a C5–6 posterior fusion. Histopathology and immunohistochemistry revealed an HB.

LESSONS

HBs should be considered among the differential diagnosis of cervical extradural tumors. Exhaustive preoperative workup and surgical planning are decisive in order to attain gross-total resection with favorable outcomes.

Primary Intradural Extramedullary Sporadic Spinal Hemangioblastomas: Case Report and Systematic Review

BACKGROUND

Hemangioblastomas are benign vascular neoplasms of the central nervous system that may occur sporadically or in association with Von Hippel-Lindau disease. A minority of these lesions can occur in the spine, mostly as intramedullary masses. The authors present a rare case of primary sporadic spinal hemangioblastoma occurring as an intradural extramedullary (IDEM) lesion. Diagnostic workup and surgical management of the patient are described.

METHODS

A systematic MEDLINE search was conducted using the keywords "hemangioblastoma" and "intradural extramedullary," "extramedullary," or "cauda equina." Clinicopathological characteristics and outcomes of the present case were reviewed and compared with those in the literature.

RESULTS

A 72-year-old man was found to have an IDEM lesion in his cervical spine after presenting with neck and shoulder pain. Gross total resection was successfully performed with sacrifice of an involved dorsal nerve rootlet. Screening for Von Hippel-Lindau was negative. Thirty-three additional patients with sporadic IDEM hemangioblastomas are reported in the literature. There was a slight male preponderance (54%) with a median age of 52 years. Patients presented with pain (54%), radiculopathy (33%), or myelopathy (32%). The majority of lesions were located in the lumbosacral spine (56%). All patients underwent maximal safe resection with stable or improved clinical status.

CONCLUSION

Primary IDEM hemangioblastomas are a rare entity. Differential diagnosis includes other IDEM lesions, such as schwannomas, meningiomas, or some vascular malformations. Resection of these sporadic tumors can be safely performed and result in improvement of neurologic deficits associated with mass effect from the tumor with low likelihood of recurrence.

Spinal extradural hemangioblastoma: A systematic review of characteristics and outcomes

Extradural spinal nerve root hemangioblastoma is a rare entity with very few cases reported in the literature. A comprehensive picture of the treatments and outcomes of the same is thus not available. A systematic search was done according to PRISMA guidelines. Search criteria included terms: spinal extradural hemangioblastoma, extradural hemangioblastoma, and spinal root hemangioblastoma. The parameters considered were treatment, motor, and sensory outcome, association with von-Hippel-Lindau (VHL) syndrome. Twenty-two studies (19 full text articles) were available for the review. A total of 39 cases of extradural spinal nerve root hemangioblastoma have been reported. These cases had a median age of 44 years with male predominance (2:1) and up to 48% occur in the thoracic level, similar to our case. Thirty-six percent of patients were associated with VHL syndrome. Surgical resection was the primary modality of treatment with embolization used in selected cases (20%). They had mean follow-up of 23 (±11) months. The prognosis was better than the intradural counterpart with no motor deficit and sensory deficit in only 9%. Preoperative identification of the extradural nature of this pathology and complete excision at the first surgery offers excellent outcomes compared to intradural lesion. Targeted embolization may be used in cases anticipated with high blood loss.

Functional Outcome After Resection of Von Hippel-Lindau Disease-Associated Cauda Equina Hemangioblastomas: An Observational Cohort Study

BACKGROUND

Cauda equina hemangioblastomas in von Hippel-Lindau (VHL) disease can cause significant neurological signs and symptoms. Despite their associated morbidity, the management of these tumors remains incompletely defined.

OBJECTIVE

To determine optimal management, we analyzed the functional outcomes after resection of these tumors.

METHODS

VHL patients who underwent surgical resection of cauda equina hemangioblastomas at the National Institutes of Health and the University of Virginia were included. Clinical and radiological follow-up was performed at 6- to 12-month intervals after surgery.

RESULTS

Fifteen patients underwent 18 operations for 21 cauda equina hemangioblastomas (median follow-up 5.9 years). Patients often presented with multiple symptoms, including pain (67%), numbness (50%), urinary complaints (33%), and weakness (11%). Median preoperative tumor volume was 1.2 cm 3 . Four tumors at 3 operations were not resected due to a motor nerve root origin. Gross total resection was achieved in 14 surgeries (93% of operations when resection was attempted). New mild (non-function limiting) neurological symptoms were noted after 11 operations (61%), which most often (64%) resolved within 2 weeks of surgery. At 6-month follow-up, 15 patients (83%) were stable, 2 (11%) were improved, and 1 (6%) was worse. Histological analysis revealed that all tumors originated from within the involved nerve fascicle.

CONCLUSIONS

VHL-associated cauda equina hemangioblastomas have an intrafascicular origin and require interruption of the rootlet of origin for complete resection. Motor nerve root involvement may preclude complete resection but strategies including bony decompression and/or interruption of vascular supply may provide a therapeutic option. Nevertheless, most VHL patients with symptom-producing lesions improve with resection.

Extraneuraxial Hemangioblastoma: Clinicopathologic Features and Review of the Literature

Extraneuraxial hemangioblastoma occurs in nervous paraneuraxial structures, somatic tissues, and visceral organs, as part of von Hippel-Lindau disease (VHLD) or in sporadic cases. The VHL gene plausibly plays a key role in the initiation and tumorigenesis of both central nervous system and extraneuraxial hemangioblastoma, therefore, the underlying molecular and genetic mechanisms of the tumor growth are initially reviewed. The clinical criteria for the diagnosis of VHLD are summarized, with emphasis on the distinction of sporadic hemangioblastoma from the form fruste of VHLD (eg, hemangioblastoma-only VHLD). The world literature on the topic of extraneuraxial hemangioblastomas has been comprehensively reviewed with ∼200 cases reported to date: up to 140 paraneuraxial, mostly of proximal spinal nerve roots, and 65 peripheral, 15 of soft tissue, 6 peripheral nerve, 5 bone, and 39 of internal viscera, including 26 renal and 13 nonrenal. A handful of possible yet uncertain cases from older literature are not included in this review. The clinicopathologic features of extraneuraxial hemangioblastoma are selectively presented by anatomic site of origin, and the differential diagnosis is emphasized in these subsets. Reference is made also to 10 of the authors' personal cases of extraneuraxial hemangioblastomas, which include 4 paraneuraxial and 6 peripheral (2 soft tissue hemangioblastoma and 4 renal).

Sporadic hemangioblastoma of the film terminale with peritumoral cyst

Background:

Spinal hemangioblastoma originating from the film terminale are rare tumors. Here, we present a film terminale hemangioblastoma and review the appropriate literature.

Case Description:

A 37-year-old female presented with bilateral lower extremity pain without a focal neurological deficit. The magnetic resonance (MR) image demonstrated an intradural spinal tumor at the L1 level, which was accompanied by peritumoral cysts. In addition, there were multiple surpentine flow voids (e.g., consistent with torturous and convoluted vessels), which is typical for hemangioblastoma. At surgery, a spinal hemangioblastoma originating from the film terminale with peritumoral cysts at the L1 level was fully excised without producing a focal postoperative neurological deficit. Histological examination revealed stromal cells with vacuolated cytoplasm and small nuclei in a rich capillary network accompanied by several enlarged vessels. These finding were compatible with a hemangioblastoma.

Conclusions:

We reported a rare case of a hemangioblastoma originating from the conus presenting at the L1 level. Complete surgical resection was accomplished without any motor deficit.

A rare invasive hemangioma in cauda equina

PURPOSE

Typical hemangioma of cauda equina with relative clear margin has been described in some case reports, but atypical hemangioma with invasion, infiltration, and augmentation of all nerve roots in the cauda equina area has never been reported. In this paper, we reported a rare case with invasive hemangioma in cauda equina, and analyzed its radiological appearance and treatment.

METHODS

We described an atypical case of hemangioma, which was revealed by MR and intraoperative photograph without clear margin and confirmed by histopathologic diagnosis.

RESULTS

The patient was received radiotherapy (5400 cGy/25f/5w) and continued to be clinically in good condition with follow-up MR after 24 months without further surgery.

CONCLUSIONS

Surgery may be the first management modality for hemangiomas with severe or progressive neurologic deficits, and radiotherapy may be an alternative therapy to treat hemangiomas according to accurate histopathologic diagnosis.

Purely extradural spinal nerve root hemangioblastomas

Spinal nerve root hemangioblastomas present mostly as intradural-extradurally. Purely extradural spinal nerve root hemangioblastoma is a very rare entity. In this study, we aimed to analyze epidemiological perspectives of purely extradural spinal nerve root hemangioblastomas presented in English medical literature in addition to our own exemplary case. PubMed/MEDLINE was searched using the terms “hemangioblastoma,” “extradural,” “spinal,” and “nerve root.” Demographical variables of age, gender, concomitant presence of von Hippel–Lindau (VHL) disease; spinal imaging and/or intraoperative findings for tumor location were surveyed from retrieved articles. There are 38 patients with purely extradural spinal nerve root hemangioblastoma. The median age is 45 years (range = 24–72 years). Female:male ratio is 0.6. Spinal levels for purely extradural spinal nerve root hemangioblastomas, in order of decreasing frequency, are thoracic (48.6%), cervical (13.5%), lumbar (13.5%), lumbosacral (10.8%), sacral (8.1%), and thoracolumbar (5.4%). Concomitant presence of VHL disease is 45%. Purely extradural spinal nerve root hemangioblastomas are very rare and can be confused with other more common extradural spinal cord tumors. Concomitant presence of VHL disease is observed in less than half of the patients with purely extradural spinal nerve root hemangioblastomas. Surgery is the first-line treatment in these tumors.

Spinal nerve root haemangioblastoma associated with reactive polycythemia

Haemangioblastomas are uncommon tumours that usually occur in the cerebellum and, less commonly, in the intramedullary spinal cord. The extramedullary spinal canal is an uncommon location for these tumours. Also haemangioblastoma at this site is not known to be associated with polycythemia. We present the clinical, imaging, and histological findings of an adult patient with extramedullary spinal haemangioblastoma and reactive polycythemia. Radiography and computed tomography (CT) revealed a medium-sized tumour that most likely arose from an extramedullary spinal nerve root. This tumour appeared to be slow growing as evidenced by the accompanying well-defined bony resorption with a sclerotic rim and mild neural foraminal widening. Magnetic resonance imaging revealed prominent flow voids consistent with tumoural hypervascularity. CT-guided biopsy was performed. Although preoperative angiographic embolisation was technically successful, excessive intraoperative tumour bleeding necessitated tumour debulking rather than complete tumour resection. Histology of the resected specimen revealed haemangioblastoma. Seven months postoperatively, the patients back pain and polycythemia have resolved.

Epidural capillary hemangioma: A review of the literature

Hemangiomas in the spinal epidural area are very rare lesions, and most of these lesions are of the cavernous type. Only seven cases of capillary hemangiomas have been reported in the English literature, and all of these cases occurred in adulthood. Here, we report on a 17-month-old girl who presented with an inability to walk. MRI revealed an epidural mass, which was diagnosed as an epidural capillary hemangioma in the thoracic region. To our best knowledge, this case is the first epidural capillary hemangioma case to occur in childhood that has been reported.

Clinical features and surgical outcomes of primary cauda equina tumours

BACKGROUND

To identify clinical features, radiological findings and surgical outcomes of primary cauda equina tumours.

METHODS

A consecutive series of 64 operations in 60 patients with primary cauda equina tumours from April 1999 to May 2009 at one institution comprised the study. The cases were divided into tumours of neural sheath origin (TNS, n = 48) and tumours of non-neural sheath origin (TNNS, n = 22). We analysed pain intensity, neurological abnormalities, MRI findings, surgical extent and functional outcome.

RESULTS

The TNS group showed more leg pain (76 % vs. 44 %, p = 0.019) with higher intensity (6.1 ± 1.5 vs. 4.6 ± 1.9, p = 0.04). Motor weakness and bladder dysfunction were more common in the TNNS group (p = 0.028 and p = 0.00 in each). Flow voids of MRI were more frequently observed in TNNS (50 % vs. 4 %, p = 0.01). The TNS group achieved total removal in all operations compared with total removal in 77 % in the TNNS group (p = 0.001). The TNNS group showed higher recurrence rates (18 % vs. 0 %, p = 0.009). The TNS group showed higher improvement of JOA scores postoperatively (p = 0.049). Surgical complications were observed less frequently in the TNS group (19 % vs. 78 %, p = 0.000).

CONCLUSIONS

TNS differs from TNNS by causing more frequent leg pain, higher pain intensity and more frequent flow voids. TNS has better surgical outcomes than TNNS in terms of higher rates of total removal, fewer surgical complications, better functional outcomes and less recurrence.

Intra-extradural dumbbell-shaped hemangioblastoma manifesting as subarachnoid hemorrhage in the cauda equina

A 56-year-old man presented with a rare intra-extradural dumbbell-shaped hemangioblastoma in the lumbar spine associated with von Hippel-Lindau (VHL) disease manifesting as subarachnoid hemorrhage. The tumor, which was exiting at the right L2-3 intervertebral foramen, was removed successfully by total facetectomy and posterior spinal fusion at the L2-3 segment. Nine years later, a recurrent tumor due to VHL was also totally removed with minimal neurological complications. Accurate diagnosis of this vascular-rich lesion is essential for developing an adequate surgical strategy. The dumbbell-shaped tumor requires total facetectomy and spinal reconstruction, and care should be taken to preserve the entire nerve root origin by only identifying the affected nerve fascicles at the origin, if possible. Postoperative adhesion must be minimized for second surgery in patients with genetic disease such as VHL, who are likely to suffer recurrence.

Extra and intradural spinal Hemangioblastoma

Hemangioblastomas of the central nervous system (CNS) are low-grade highly vascularized tumors that may be sporadic or associated with Von Hippel-Lindau disease. Extradural hemangioblastomas are uncommon and those located extra and intradurally are even rarer. This study uses an illustrative case and literature review to discuss the difficulties to consider the correct diagnosis and to select the best surgical approach. A 57 years-old white male patient presented with myelopathy and right C5 radiculopathy. The images showed a lobulated, hourglass shaped, highly enhanced extra/intradural lesion that occupied the spinal canal and widened the C4-C5 right intervertebral foramen. Total resection of the intradural lesion was achieved through a posterior approach, but the extradural part could only be partially removed. Complete improvement was observed after four months of follow-up and the residual tumor has been followed up clinically and radiologically. Even though the preoperative impression was of a spinal schwannoma, the histopathological examination revealed grade I hemangioblastoma as per WHO. Despite their rarity, current complementary exams allow considering the diagnosis of hemangioblastoma preoperatively. That is essential to a better surgical planning in view of the particular surgical features of this lesion.

Thoracic nerve root hemangioblastoma: a rare cause of posterior mediastinal mass

BACKGROUND

Hemangioblastomas are benign tumors that occur sporadically or as part of von Hippel-Lindau disease. Occasionally, they have an extramedullary location along the nerve roots and, rarely, are purely extradural.

CASE DESCRIPTION

We report a rare case of a completely extradural large hemangioblastoma in a 32-year-old man presenting with radiculopathy and a posterior mediastinal mass. Screening revealed a similar tumor in the right cerebellar hemisphere. The patient underwent a right paramedian suboccipital craniotomy and total excision of the cerebellar tumor, followed by a left lateral thoracotomy and complete excision of the mediastinal lesion. The patient had an uneventful recovery.

CONCLUSIONS

Hemangioblastomas should be considered in the diagnosis of posterior mediastinal tumors in the presence of typical imaging features or with associated intra-axial tumors, so as to plan preoperative angiography and embolization.

Rare nerve lesions of non-nerve sheath origin: a 17-year retrospective series

CONTEXT

Peripheral nerve masses are frequently encountered in surgical pathology practice. However, once a peripheral nerve mass is determined not to be a nerve sheath neoplasm, differential diagnostic considerations drop off sharply.

OBJECTIVE

To review our experience with surgically resected nerve masses.

DESIGN

Retrospective search of pathology database. Rare neoplasms were studied by cytogenetic analysis or gene microarray.

RESULTS

Four hundred fifty-eight cases were identified. After elimination of common lesions (mostly nerve sheath tumors), 37 cases (8%) remained, almost all of which were of non-nerve sheath origin: for example, hemangioma, metastatic neuroendocrine pancreatic carcinoma, meningiomas invading nerve fascicles, and primary extrarenal rhabdoid tumor and Ewing sarcoma of nerve. The latter showed rearrangement of the EWSR1 locus (22q12). The gene expression pattern of an undifferentiated sarcoma, presenting as ropelike nerve enlargement, clustered with malignant peripheral nerve sheath neoplasms but not other sarcomas or neuroepithelial tumors.

CONCLUSIONS

Diverse benign and malignant conditions can affect peripheral nerve.

Typical magnetic resonance features of a haemangioblastoma, an uncommon nerve root lesion: case report and literature review

Haemangioblastomas are uncommon tumours of the central nervous system. Nerve root haemangioblastomas with both intradural and extradural components are extremely rare. We present a case of a C2 nerve root haemangioblastoma in a 64-year-old man where the preoperative diagnosis was a spinal meningioma. An unexpectedly vascular tumour was found at initial procedure. Urgent catheter angiography was performed and the tumour was embolized prior to complete excision at a subsequent procedure.

Multiple filum terminale hemangioblastomas symptomatic during pregnancy

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

Imaging of a thoracic spinal nerve haemangioblastoma by three-dimensional digital angiography

Haemangioblastomas occur sporadically or in association with Von Hippel-Lindau (VHL) disease. Occasionally, they are associated with intrathecal cauda equina nerve roots and rarely with spinal nerve roots. The occurrence of a completely extrathecal, thoracic spinal nerve haemangioblastoma is exceptional, with only one case previously described in the English-language literature. We report an extradural thoracic spinal nerve haemangioblastoma in a patient with VHL disease causing a progressive thoracic radiculopathy. The advantages of three-dimensional digital angiography will be discussed. Three-dimensional reconstruction of the images acquired by rotational digital subtraction angiography is one of the most promising developments to improve surgical planning for complex vascular lesions.

Proximal nerve root capillary hemangioma presenting as a lung mass with bandlike chest pain: case report and review of literature

BACKGROUND

Capillary hemangiomas occasionally occur in the peripheral nervous system (PNS), presenting as mass lesions causing proximal nerve root symptoms, thus prompting neurosurgical intervention. In contrast to cavernous angiomas, which may also occasionally involve the PNS, capillary hemangiomas have little or no tendency for acute or chronic bleeding and, hence, lack the apoplectic symptomatic onset and neuroimaging features of hemosiderin deposition as seen in cavernous angiomas.

CASE DESCRIPTION

A 56-year-old man presented with chronic, radiating, bandlike, chest wall pain. Chest radiograph revealed an apical lung mass suspicious for malignancy. Subsequent magnetic resonance imaging revealed an enhancing dumbbell-shaped mass extending into the spinal canal and chest cavity at T3, causing a slight degree of lung compression. Differential diagnostic considerations included schwannoma, neurofibroma, and meningioma. At operation, the spongy, reddish purple vascular tumor was easily separated from dura but had to be excised en bloc, with the T3 nerve root at the neural foramen. The large intrathoracic portion measuring 37 x 41 mm was left behind. Pathology was consistent with a capillary hemangioma.

CONCLUSIONS

We present the second case in the English language literature of a dumbbell-shaped, epidural capillary hemangioma with intrathoracic extension. We review the literature on proximal nerve capillary hemangiomas and contrast these with cavernous angiomas and capillary hemangioblastomas, both of which occasionally involve proximal nerves. Unlike capillary hemangioblastomas, which may be multiple and associated with von Hippel-Lindau (VHL) syndrome, capillary hemangiomas are solitary lesions and have not been associated with an inherited disorder.

Characterization of Hemangioblastomas of Spinal Nerves

OBJECTIVE:

Hemangioblastoma is classified as a benign tumor of the central nervous system. Peripheral nervous system hemangioblastomas to date have been described only in a few case reports. Experience in treating patients with these rare lesions, which harbor diagnostic and therapeutic pitfalls, is limited.

METHODS:

To characterize these lesions better, we reviewed our hemangioblastoma database for patients who underwent surgery for extradural hemangioblastoma of the spinal nerve.

RESULTS:

Between 1983 and 2003, six patients underwent surgery for spinal nerve hemangioblastomas at our institution. These tumors occurred in 2% of all patients with hemangioblastomas of the central nervous system, or 6% of all patients with spinal hemangioblastomas. The occurrence did not differ in von Hippel-Lindau disease cases versus sporadic cases. Radiographically, the tumors easily could be mistaken for schwannomas or metastases; however, they did have some typical features. If a hemangioblastoma was not suspected primarily, profuse bleeding could complicate surgery. Most of the tumors arose from the dorsal sensory fascicles. The vascular supply was from extradural circulation. In general, the surgical outcome of these lesions was good, and permanent neurological deficit was rare. However, local recurrence was observed in three of six patients.

CONCLUSION:

These tumors harbor diagnostic and therapeutic pitfalls. In general, the tumors are surgically more challenging, and clinically significant bleeding as well as local tumor recurrence is more common than in intradural hemangioblastomas, mostly because of the frequency of incorrect initial radiographic diagnosis. We suggest that because of the surgical consequences, hemangioblastoma should always be considered to be an important radiological differential diagnosis for nerve sheath tumors. Angiography can bring clarification to ambiguous cases.