Hemorrhagic intramedullary hemangioblastoma of the cervical spinal cord presenting with acute-onset quadriparesis: case report and review of the literature

Intramedullary hemangioblastoma of the thoracic cord with a microsurgical approach: A case report and literature review

Background

Spinal cord hemangioblastomas (HBs) account for 2-15% of all spinal cord neoplasms. They are the third most common primary intramedullary tumor (1-5%). Here, 72-year-old female presented with a thoracic intramedullary spinal HB that responded well to surgery.

Case Description

A 72-year-old female presented with a 3-4 years of progressive paresthesias and paraparesis. On examination, she exhibited diffuse distal weakness of the lower extremities. The magnetic resonance scan showed an intramedullary expansive lesion at the T1-T2 level that markedly enhanced with contrast with both proximal and distal hydromyelia. Surgery included a C7 partial and T1-T2 total laminectomies performed under microscope visualization with intraoperative monitoring. At surgery, there was a well-documented cleavage plane between the tumor and the cord; excision was facilitated using the cavitron ultrasonic surgical aspirator device.

Conclusion

Surgery is the gold standard treatment for treating/resecting HBs and should include utilization of an operating microscope and intraoperative monitoring.

Cervical intra and extramedullary hemangioblastoma with associated syringomyelia: A case report and review of the literature

Background

Spinal hemangioblastoma (HB) is a highly vascularized tumor commonly presenting in the lower thoracic and lumbar segments. It typically causes spinal compression, extensive bleeding, and/or syringomyelia.

Case Description

A 32-year-old female presented with persistent headaches with a cervical MRI showing an intradural and extradural mass extending from the obex to C2. Following surgical tumor resection, the patient's symptoms resolved.

Conclusion

Resection of spinal HB requires direct removal of the tumor mass as the accompanying cystic components typically spontaneously regress.

Surgical Management of Intramedullary Spinal Cord Tumors

Intramedullary spinal cord tumors (IMSCT) comprise a rare subset of CNS tumors that have distinct management strategies based on histopathology. These tumors often present challenges in regards to optimal timing for surgery, invasiveness, and recurrence. Advances in microsurgical techniques and technological adjuncts have improved extent of resection and outcomes with IMSCT. Furthermore, adjuvant therapies including targeted immunotherapies and image-guided radiation therapy have witnessed rapid development over the past decade, further improving survival for many of these patients. In this review, we provide an overview of types, epidemiology, imaging characteristics, surgical management strategies, and future areas of research for IMSCT.

Spontaneous massive intracystic hemorrhage due to cystic hemangioblastoma in a pediatric patient

Massive cerebellar hemorrhage from hemangioblastomas in children has never been described to our knowledge. We reported a 10-year-old child who presented with a large hematoma in the left cerebellar hemisphere. Hemangioblastomas was not expected preoperatively to be the cause. An emergency suboccipital craniotomy was performed. Histopathological examination confirmed the diagnosis of hemangioblastoma with massive hemorrhage.

Surgical management of a cervical intramedullary hemangioblastoma presenting with intracystic hemorrhage by hemi-semi-laminectomy via a posterior approach

Background and Importance

Cervical spinal cord hemangioblastoma with intracystic hemorrhage is a rare entity and presents a challenge for clinicians with regard to its timely diagnosis and appropriate treatment.

Case Presentation

A 35-year-old man presented with sudden-onset acute and progressive neck pain and severe radicular pain in his left upper limb. Motor weakness and numbness in the left upper and lower limbs with gait ataxia followed 2 days later. His initial diagnosis was acute myelitis, and he was treated with glucocorticoids for 2 weeks. Follow-up contrast-enhanced magnetic resonance imaging (MRI) suggested a spinal cystic hemangioblastoma with intracystic hemorrhage at the C3-4 level. The tumor was totally removed by minimally invasive unilateral hemi-semi-laminectomy via a posterior transcystic approach. The postoperative course was uneventful, and postoperative MRI revealed no residual tumor. The patient showed full neurological recovery at the 1.5-year follow-up, and computed tomography with a volume-rendering technique showed regrowth of the left C3 lamina.

Conclusion

Close MRI follow-up and thin-section imaging are invaluable for the timely diagnosis of spinal hemangioblastoma with intracystic hemorrhage, which was safely removed via minimally invasive microsurgery in the present case.

Intramedullary and intratumoral hemorrhage in spinal hemangioblastoma: Case report and review of literature

Background:

Intramedullary hemorrhages involving spinal hemangioblastomas are rare. They are frequently associated with devastating neurologic outcomes, despite with emergent surgical intervention. Here, we presented an example of an intramedullary hemorrhage occurring in a spinal hemangioblastoma, where the patient markedly improved with surgery. Additionally, the appropriate literature was reviewed (including intraoperative video).

Case Description:

A 49-year-old female with a 4-year history of tingling in the left lower extremity presented with vomiting, stepwise worsening of bilateral scapular pain, new upper motor neuron signs, and severe sensory loss bilaterally below C4 on the left and T4 on the right. The magnetic resonance imaging demonstrated a well-circumscribed, uniformly enhancing intramedullary tumor at the C2 level with hyperintensity on the T2 study consistent with acute hemorrhage and cord edema. An urgent C2 laminectomy was performed for gross total tumor resection. Intraoperatively, intramedullary hemorrhage was identified anterior to the tumor mass and was confirmed histopathologically. Postoperatively, the patient had no new sensorimotor deficits and fully recovered within two postoperative months.

Conclusions:

Patients presenting with acute intramedullary hemorrhage within hemangioblastomas of the spinal cord may demonstrate significant postoperative neurological recovery.

Management Strategies and Outcomes for VHL-related Craniospinal Hemangioblastomas

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.

Spontaneously developed paraplegia in a patient with Factor V Leiden mutation

Factor V Leiden (FVL) mutation is the one-point mutation in G1691A in the tenth exon of the gene for Factor V, caused by the substitution of glutamine for arginine at codon 506. We present here a patient with a mutation of the Factor V gene and taking anticoagulant therapy, who became paraplegic following surgery for dural hematoma and spontaneous spinal intramedullary hematoma. His physical examination revealed T5 ASIA A, complete paraplegia. Our case is important in the literature, as being the first case with spinal intramedullary hematoma that developed due to anticoagulant use.