Preoperative Embolization of Brain and Spinal Hemangioblastomas

Von Hippel-Lindau Syndrome: Multi-Organ Involvement Highlighting Its Diverse Clinical Spectrum in Two Adult Cases

There is an assortment of disorders that have multisystem involvement. Von Hippel-Lindau (VHL) syndrome, a rare autosomal dominant disease, falls in that category. VHL syndrome is associated with the formation of benign and malignant tumors in the central nervous system (CNS), adrenal gland, kidney, and eyes. In this report, we present two unusual cases of VHL syndrome presenting with multisystem engagement. The first case is of a 27-year-old male exhibiting multiple manifestations, which included hemangioblastoma of the spine, pheochromocytoma, pancreatic cyst, and retinal hemangioblastoma. The second case pertains to a 25-year-old male with various presentations ranging from retinal hemangioblastoma and pancreatitis to spinal and cerebellar hemangioblastoma. These cases emphasize the value of radiologic imaging and genetic assessment early in life when the presentation of the disease is in its preliminary stage. When an individual presents with a condition characterized by unexplained multifarious organ involvement of CNS, adrenal glands, and kidneys in the span of a few years, a differential diagnosis of VHL syndrome should be considered.

Preoperative endovascular embolization for hemangioblastoma in the posterior fossa

Intracranial hemangioblastomas (HBs) are hypervascular neoplasms mainly located in the posterior fossa of the central nervous system. Preoperative embolization of the feeding arteries is one proposal for reduction of intraoperative hemorrhage, although indications for the procedures should be evaluated carefully due to the potential complications. This retrospective study investigated clinical outcomes and complications of 15 patients with HBs in the posterior fossa to evaluate the safety and effectiveness of endovascular procedures as well as angiographical procedures. Surgical excision without presurgical embolization was performed in 8 cases, and excision with presurgical embolization was performed in 7 cases, using Guglielmi detachable coils with or without polyvinyl alcohol (GDC ± PVA) in 4 cases and only n-butyl 2-cyanoacrylate (NBCA) in 3 cases. The embolization was applied for selected cases in which feeding arteries were located in a deep site and hard to coagulate surgically. Partial embolization was achieved in 5 cases, and all feeders were successfully embolized in 2 cases. Total removal was achieved in 12 cases, and subtotal/partial removal was achieved in 3 cases. Subarachnoid hemorrhage with intratumoral hemorrhage occurred in 1 case during the angiographic procedure and in 1 case during the embolization procedures. The mean volume of intraoperative blood loss was clearly less in the NBCA group than in the GDC ± PVA group. HBs are mainly located in the posterior cranial fossa, so the risk of severe clinical complication may be high if vascular problems occur. In our series, presurgical embolization using NBCA made tumor removal safe and reduced bleeding volume in posterior fossa HBs.

Central alveolar hypoventilation syndrome due to surgical resection for bulbar hemangioblastoma

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