Manifestation of a sellar hemangioblastoma due to pituitary apoplexy: a case report

Supratentorial Hemangioblastoma in Adults: A Systematic Review and Comparison of Infratentorial and Spinal Cord Locations

BACKGROUND

Supratentorial hemangioblastomas are benign and highly vascularized neoplasms that appear most often in the spine and posterior cranial fossa. They can also be located in the supratentorial compartment of the brain. We conducted a systematic review of the literature to better understand the clinical insights of supratentorial hemangioblastoma in adults.

METHODS

Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the authors reviewed the English-language literature in the PubMed/MEDLINE database on supratentorial hemangioblastoma in adults, published in the past 40 years. We analyzed the differences between sporadic hemangioblastomas and hemangioblastomas associated with von Hippel-Lindau disease. In addition, we compared the characteristics of supratentorial hemangioblastomas with infratentorial and spinal cord locations.

RESULTS

We reviewed 92 articles, describing 157 supratentorial hemangioblastomas in a total cohort of 148 adult patients. Most articles reporting supratentorial hemangioblastomas were published in the United States. Supratentorial hemangioblastomas occur more frequently in women than men. The median age at the time of diagnosis was 44.48 years. The sellar/parasellar region was the most commonly tumor location, while the most common morphological type was the solid type. Almost 80% of hemangioblastomas were completely resected; the outcome was favorable in more than 3 fourth of patients.

CONCLUSIONS

Given their rarity, the literature on supratentorial hemangioblastomas is limited and based mostly on case reports. Complete surgical resection is the first choice of treatment and is associated with a good treatment outcome.

Preoperative Diagnosis of Suprasellar Hemangioblastoma with Four-Dimensional Computed Tomography Angiography: Case Report and Literature Review

Purpose Our case report presents the first case of suprasellar hemangioblastoma diagnosed preoperatively with dynamic computed tomography angiography (four-dimensional [4D] CTA) in a patient without Von Hippel-Lindau (VHL) disease. We illustrate the imaging characteristics of these exceedingly rare tumors and discuss the role of 4D CTA in confirming this diagnosis and guiding surgical management. Finally, we present a literature review of imaging findings, differential diagnosis, management, and prognosis.

Case A 39-year-old woman known for diabetes mellitus type II and dyslipidemia presented with headache, bitemporal hemianopsia, and mild hyperprolactinemia. Initial diagnosis of suprasellar meningioma separate from pituitary gland was revised to definitive diagnosis of suprasellar hemangioblastoma after 4D CTA.

Conclusion Suprasellar hemangioblastomas are extremely rare, often associated to VHL disease. They present as enhancing as suprasellar mass with prominent intra- and peritumoral vascular flow-voids on magnetic resonance imaging. 4D CTA confirms their vascular nature, demonstrates characteristic rapid shunting with feeding arteries, and enlarged draining veins, and is important in guiding surgical management.

Pituitary apoplexy without chiasm compression: A case report

The present report presents a rare case in which a patient with pituitary apoplexy (PA) without compression of the optic chiasm experienced diagnosable visual impairment in the ensuing months. Endocrinologically, the condition was a prolactinoma followed by bleeding into the pituitary gland. Due to the unexplained functional changes in the patient, an electrophysiological examination (pattern electroretinogram and pattern visual evoked potentials) was performed, which verified a bilateral non-inflammatory neurogenic lesion. This finding was confirmed by functional magnetic resonance imaging (fMRI) examination. Structural MRI did not reveal chiasm compression in the time sequence or alteration of the optic nerves (the diameter of the optic nerve at different distances from the eye and the diameter of the optic nerve sheath at different distances from the eye). Similarly, neither the retinal nerve fiber layer (RNFL) nor the vessel density was altered. The present report suggests that changes in visual fields may be due to ischemia in the area of the chiasm and optic nerves, similar to PA.

Suprasellar Hemangioblastoma with Reversible Edema-Like Change Along the Optic Tract: A Case Report and Literature Review

BACKGROUND

Hemangioblastomas usually occur in the cerebellum and are often a component of von Hippel-Lindau disease. Edema-like changes along the optic tract are commonly observed in association with tumors in the sellar and suprasellar regions, such as craniopharyngiomas and pituitary adenomas. Here, we describe a case of sporadic suprasellar hemangioblastoma with edema-like changes along the optic tract that completely resolved after surgery.

CASE DESCRIPTION

The patient was a 28-year-old woman with failing vision and a bitemporal hemianopia. Magnetic resonance imaging revealed a tumor accompanied by a 10-mm cyst. Fluid-attenuated inversion recovery axial magnetic resonance imaging revealed a hyperintense region along the optic tract. Other regions of the central nervous system were normal. Endoscopic transsphenoidal surgery was performed, and the histopathologic findings confirmed hemangioblastoma. Six months after surgery, the edema-like change along the optic tract had disappeared. The patient is doing well without pituitary insufficiency, pituitary hormone medications, or signs of tumor recurrence. In addition, the genetic test was negative for von Hippel-Lindau mutations.

CONCLUSIONS

When examining a patient with suprasellar tumor, clinicians must consider the possibility of hemangioblastoma. Adequate treatment can improve the edematous change and visual disturbance.

Sporadic Hemangioblastoma Arising from the Infundibulum

Hemangioblastomas are rare vascular tumors most often found in the posterior fossa and cervical spinal cord and commonly associated with von Hippel-Lindau Disease. We report a case of sporadic hemangioblastoma in a patient without von Hippel-Lindau Disease. Imaging characteristics included a solid, suprasellar mass that was homogeneously enhancing. These findings most resembled a pituicytoma or choroid glioma because of the close association with the infundibulum and the homogeneous avid enhancement. Microscopically, the neoplasm was seen to be composed of vascular channels associated with foamy stromal cells, containing clear cytoplasmic vacuoles. Microscopic and immunohistochemical findings were consistent with hemangioblastoma. Hemangioblastomas are a rare form of vascular tumor most commonly associated with von-Hippel Lindau disease. Our finding of non-cystic hemangioblastoma arising from the infundibulum demonstrates that, while rare, hemangioblastomas should be considered on the differential diagnosis for an avidly enhancing suprasellar mass.

Supratentorial haemangioblastoma without von Hippel-Lindau syndrome in an adult: A rare tumor with review of literature

Supratentorial hemangioblastomas (HBLs) are rare, benign vascular tumors of the central nervous system neoplasms. Very scarce literature is available regarding supratentorial HBL without von Hippel–Lindau (VHL) syndrome in an adult. We reviewed the literature and PubMed advanced search showed only a few results of supratentorial HBL without VHL syndrome. We reported a rare case of cystic supratentorial HBL in 39-year-old male affecting the parietal lobe without VHL syndrome. Supratentorial HBL is a rare tumor and supratentorial HBL without VHL syndrome are even rarer. Being a rare entity, not much clinical data is currently available regarding supratentorial HBLs, thus necessitating the need for further reporting and review of such cases.

Infundibular Hemangioblastoma in a Patient with Neurofibromatosis Type 1: Case Report and Review of the Literature

BACKGROUND

Supratentorial hemangioblastomas are rare tumors, most commonly occurring in the sellar/suprasellar region, cerebrum, and ventricle. They are generally found in patients with von Hippel Lindau disease but have infrequently been reported in patients without this syndrome.

CASE DESCRIPTION

A 35-year-old woman with a history of neurofibromatosis type 1 presented to our care with visual loss and headaches. Magnetic resonance imaging of the brain demonstrated an 8-mm cystic, contrast-enhancing lesion abutting the optic chiasm and optic tracts. The patient's endocrine profile was unremarkable. The tumor was resected using an endoscopic expanded transsphenoidal approach. Pathologic evaluation was consistent with hemangioblastoma. Postoperatively, the patient experienced an improvement in her visual symptoms.

CONCLUSIONS

Hemangioblastoma should be included in the differential of sellar/suprasellar mass lesions, particularly in patients with von Hippel Lindau disease. Small suprasellar lesions may be safely and effectively removed using an expanded transsphenoidal approach.

Suprasellar hemangioblastoma without von Hippel-Lindau disease: a case report and literature review

Suprasellar hemangioblastoma (HBL) without von Hippel-Lindau (VHL) disease is extremely rare. A 51-year-old woman presented with headache and progressively deteriorating bilateral visual disturbance for 4 months. Magnetic resonance imaging (MRI) revealed a 2.5-cm solid mass in the suprasellar region with homogeneous contrast enhancement. Our preoperative presumptive diagnosis was meningioma. Resection of the tumor was achieved via a left pterional craniotomy. The tumor was reddish in appearance and relatively firm, and was extremely vascularized, which might provide extensive blood supply through small branches of the internal carotid artery. There was a clear border between the tumor and the pituitary stalk and optic nerves. Histopathologic examination showed that the tumor was well vascularized, consisting of a reticular mesh of numerous thin-walled capillaries and abundant stromal cells. Immunohistochemistry demonstrated the positive staining for CD34, vimentin (VIM), and neuron specific enolase (NSE) in the intratumoral capillaries, while negative staining of epithelial membrane antigen (EMA) and glial fibrillary acidic protein (GFAP) was observed. Based on these results, the patient was diagnosed as HBL. After the resection, the visual field defect in the left eye was markedly improved, and no tumor recurrence was noted in 1 year follow-up. When solid lesions are highly vascularized in the suprasellar region of patients, even though no VHL disease is present, the possibility of HBL should be taken into consideration. Moreover, craniotomy is a better treatment option for suprasellar HBL without VHL disease.

Management of endocrine disease: pituitary tumour apoplexy

Pituitary tumour apoplexy (PA) is a rare clinical syndrome that occurs as a result of acute haemorrhage and/or infarction within a frequently undiagnosed pituitary tumour. The sudden enlargement of the pituitary mass undergoing PA is responsible for a wide range of acute symptoms/signs (severe headache, visual loss, diplopia, hypopituitarism, impaired consciousness) which, together with the radiological evidence of a pituitary lesion, establish the diagnosis. The optimal care of PA requires involvement of a multidisciplinary team including endocrinologist, neurosurgeon, neuroophthalmologist and the management strategy that depends on the clinical manifestations, as well as the presence of co-morbidities. Prompt surgical decompression is initially indicated in cases with severe or progressive impairment of the visual acuity or the visual fields or with altered mental state and leads to visual and neurological recovery in most of the patients. The patients with mild, stable clinical picture (including those with isolated ocular palsies) can be managed conservatively (support of fluid and electrolyte balance and stress doses of steroids in most cases) with favourable visual and neurological outcome. Frequent reassessment is mandatory because the clinical course can be unpredictable; if progression of symptoms occurs, later elective surgery is indicated and is beneficial, especially in terms of visual outcome. The endocrinological outcome is less favourable, irrespective of the treatment option, with many patients remaining on long-term replacement therapy. Despite the above guidelines, clear proof of optimal outcomes in the form of randomised controlled trials is lacking. Regrowth of the pituitary tumour years after a PA episode is possible and patients require long-term surveillance.

"Leiomyomatoid angiomatous neuroendocrine tumor" (LANT) of the pituitary reflects idiosyncratic angiogenesis in adenomas of the gonadotroph cell lineage

Based on a single-case observation, the descriptive label "leiomyomatoid angiomatous neuroendocrine tumor" (LANT) has been tentatively applied to what was perceived as a possible novel type of dual-lineage pituitary neoplasm with biphasic architecture. We report on two additional examples of an analogous phenomenon encountered in male patients, aged 59 years (Case 1) and 91 years (Case 2). Both tumors were intra- and suprasellar masses, measuring 5.6 cm × 4.4 cm × 3.4 cm, and 2.7 cm × 2 cm × 1.7 cm, respectively. Histologically, Case 1 was an FSH-cell adenoma interwoven by vascularized connective tissue septa that tended to exhibit incremental stages of adventitial overgrowth. The epithelial component of Case 2 corresponded to an LH-cell adenoma, and lay partitioned by a maze of paucicellular to hyalinized vascular axes. Irrespective of architectural variations, perivascular spindle cells exhibited immunopositivity for vimentin, muscular actin, and smooth muscle actin. Conversely, negative results were obtained for CD34, EMA, S100 protein, GFAP, and TTF-1. Ultrastructural study failed to reveal metaplastic cell forms involving transitional features between adenohypophyseal-epithelial and mesenchymal-contractile phenotype. We propose that LANT be regarded as a peculiar reflection of maladaptive angiogenesis in some pituitary adenomas, rather than a genuine hybrid neoplasm. While no mechanistic clue is forthcoming to account for this distinctive pattern, hemodynamic strain through direct arterial - rather than portal - supply of the adenoma's capillary bed may be one such explanatory factor. The apparent predilection of the LANT pattern for macroadenomas of the gonadotroph cell lineage remains unexplained.