Congenital spinal cord haemangioblastoma: another cause of spinal cord section syndrome in the newborn

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.

[Epidemiology, treatment and follow-up of central nervous system hemangioblastomas in von Hippel-Lindau disease]

INTRODUCTION

Central nervous system (CNS) hemangioblastomas (HGB) are rare vascular tumors. The goal of this study was to analyze their epidemiology, treatment and prognosis in association with von Hippel-Lindau (VHL) disease.

METHODS

We retrospectively reviewed a series of patients treated in our department for a CNS HGB with VHL disease between 1996 and 2008. We analyzed pre- and postoperative clinical and radiological characteristics, number of visceral lesions (fundoscopy, abdomino-pelvian CT, metanephrines), clinical course (modified Rankin Scale and McCormick scale) and late prognosis (Kaplan-Meier survival curves).

RESULTS

We studied 19 cases (sex-ratio 0.9, mean age 36). The mean time to diagnosis was 61days. The main symptom was intracranial hypertension for cerebellar lesions (7/15) and a sensitive-motor deficit for medulla oblongata (2/5) or spinal lesions (5/11). Preferred locations were cerebellum (15/31), often nodulo-cystic appearance, followed by spinal cord (11/31), frequently coming with adjacent syringomyelia. Multiple locations and visceral lesions were found in two-third of the cases. Surgical removal was complete in more than three-quarter of the cases. Mean follow-up duration was 9years. Postoperative mortality rate was 16%. In cerebellar and medulla oblongata locations together, final mRS was ≤1 in 17 of the 20 cases. In spinal cord locations, final McCormick score was ≤2 in all the cases. After delayed follow-up, about two-third of patients experienced recurrence or new progressive CNS lesions.

CONCLUSION

HGB are rare CNS tumors. VHL disease should be considered when an HGB is diagnosed before 30, is located at the spinal cord, comes with multiple other CNS lesions or with typical peripheral lesions. Microsurgical removal is the gold standard treatment and can offer good functional results.

Diagnosis and management of brain and spinal cord tumors in the neonate

Congenital central nervous system (CNS) tumors are rare, accounting for <5% of childhood CNS tumors. Although the definition remains arbitrary, 'congenital' is often defined as CNS tumors diagnosed at birth or within a few months after birth. Congenital CNS tumors are now increasingly detected on prenatal ultrasound, with polyhydramnios as the most frequent finding. After delivery, most congenital CNS tumors are associated with macrocrania and hydrocephalus. Teratomas are the most common congenital CNS tumors; other common tumors include astrocytomas, embryonal tumors such as medulloblastomas, and choroid plexus tumors. Choroid plexus tumors (predominantly papillomas) have the best outcome, as aggressive surgical resection can be curative. Other congenital CNS tumors have a collectively poor prognosis, although some subtypes may benefit from complete resections and chemotherapy. Given the rare incidences and diverse pathology of congenital CNS tumors, multicenter studies are required to accurately assess treatment efficacy and outcome measures.

Fetal capillary haemangioblastoma: an exceptional tumour. A review of the literature

We report a case of a fetal haemangioblastoma located in the cerebellopontine angle. On prenatal ultrasonographic examination a hyperechogenic and heterogeneous mass with a major vascularization on colour Doppler imaging was observed. It increased progressively and laminated the cerebellum. A neoplastic tumour was suspected but its extent into the cerebral peduncle was unclear. Diagnosis was made at autopsy using histological, immunohistochemical and flow cytometric evaluation. Haemangioblastoma is an exceptional congenital tumour, which is either sporadic or integrated in von Hippel-Lindau disease (VHLD). We discuss the obstetrical management of prenatal brain tumours and the genetic counselling of haemangioblastoma.

Progressive spasticity in an infant

A 15-month-old girl with progressive spasticity presented for evaluation of cerebral palsy. Neurological examination revealed severe asymmetric spasticity with normal cranial nerves. Bayley developmental assessment showed a mental age of 12 months and a motor age of 9 months. Magnetic resonance imaging scan of the brain was normal, however a scan of the cervical spine showed an enhancing intramedullary lesion. Surgical exploration revealed an aneurysm which was successfully embolized. The differential diagnosis of cervical cord lesions in infants is discussed.

A rational approach to radiological screening in von Hippel-Lindau disease

OBJECTIVES

To optimise radiological screening in von Hippel-Lindau disease (VHL) while minimising cost and morbidity.

METHODS

A model of VHL was based on retrospective studies, and Bayes's theorem used to calculate the probability of the gene's presence and the likelihood of further lesions in affected families. A six year follow up was conducted to test the validity of the model.

RESULTS

Follow up confirmed the accuracy and validity of the model. Posterior fossa haemangioblastomas occur in 79.2% of VHL cases, supratentorial, retinal and spinal haemangioblastomas in 6.9%, 42.8%, and 22.0%, phaeochromocytomas in 5.2%, and renal carcinomas in 14.5%. Population incidences are 1:15,700 live births (posterior fossa), 1:780,000 (supratentorial), and 1:116,000 (spinal). The birth rate of subjects with VHL is 1:43,000; new mutations occur in 1:178,000 live births. Penetrance is 90%; 40% present with multiple lesions and 6.4% die within two years after diagnosis.

CONCLUSIONS

For most patients presenting with a VHL-type lesion, with sufficient clinical and pedigree data, the presence or absence of the VHL gene, and the probability of further lesions occurring, can be assessed with a high degree of accuracy using the method described in this paper. Those cases in the non-VHL group do not require long term radiological follow up, nor do their relatives require radiological screening. Subjects in the VHL group should be screened for renal carcinoma indefinitely from the age of 20 years, and all clinically unaffected relatives should be screened genetically for the VHL gene. (Those found negative for the gene do not require further screening, but those found positive should be screened.)