Hemangioblastoma of the Cauda Equina : A Case Report and Review of the Literature

Introduction : Hemangioblastoma in the spine mainly occurs at the cervical and thoracic levels and is often associated with von Hippel-Lindau (VHL) syndrome. Here, we reported a quite rare case of spinal sporadic hemangioblastoma arising from the cauda equina. Case presentation : A 66-year-old woman presented with a 5-year history of low back and leg pain. Imaging revealed a hypervascular intradural extramedullary tumor in the lumbar region. Preoperative angiography helped to identify the feeding arteries and draining vein, and so facilitated subsequent tumor resection. The pain was dramatically improved but weakness of the left tibialis anterior and left extensor hallucis longus muscles persisted. Discussion : We reported a rare case of spinal hemangioblastoma arising from the cauda equina. Preoperative angiography may be useful for diagnosis and understanding of the anatomy of feeding veins. J. Med. Invest. 69 : 312-315, August, 2022.

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.

Intradural, extramedullary hemangioblastoma at the level of the conus medullaris: illustrative case

BACKGROUND

Hemangioblastomas are rare, slow-growing, and highly vascularized tumors that typically occur in the cerebellum and spinal cord. The cervical and thoracic regions are the most common spinal sites, and the tumors are usually intramedullary.

OBSERVATIONS

The authors report the case of a man whose chest computed tomography performed for managing coronavirus disease 2019 incidentally revealed an enhancing area in the spinal canal at T12–L1. The patient reported low back pain as well as leg numbness and tingling. Magnetic resonance imaging of the lumbar region with and without gadolinium contrast demonstrated an intradural, extramedullary lesion with displacement of the conus medullaris. The differential diagnosis included a schwannoma and myxopapillary ependymoma. Bilateral T12–L1 laminectomies were performed with resection of the mass. The general pathologist rendered the frozen section diagnosis of a spindle cell neoplasm, suggesting the differential diagnosis of schwannoma or myxopapillary ependymoma. Immunohistochemistry was positive for inhibin, GFAP, reticulin, CD31, SOX-10, S100, and EMA. A World Health Organization grade 1 hemangioblastoma was confirmed.

LESSONS

Spinal surgeons should be cognizant of the presenting symptoms and differential diagnosis of hemangioblastomas at the level of the conus medullaris, especially when the tumor is diagnosed incidentally. Additional investigations should be performed to determine whether von Hippel-Lindau syndrome is associated with the hemangioblastoma, as this combination portends a different clinical presentation, multiple tumor locations, and tumor recurrence following resection.

[Hemangioblastomas of the filum terminale and cauda equina]

Hemangioblastoma of the filum terminale and cauda equina is a rare tumor of nervous system. There are only few case reports in the literature. In this manuscript, the authors analyze the diagnosis and treatment of patients with this disease. MRI data and intraoperative images of stage-by-stage resection allow one to get an idea about radiological characteristics of hemangioblastoma of the filum terminale and surgical intervention. The authors discuss the world experience of surgical treatment and consider intraoperative complications.

Sporadic hemangioblastoma of cauda equina: An atypical case report

Background

Hemangioblastomas account for about 1%-3% of all central nervous system tumors. They are usually associated with the Von Hippel-Lindau syndrome and typically occur in the posterior fossa, or throughout the spinal neuraxis. Here, we report the unusual case of a sporadic cauda equina hemangioblastoma.

Case Description

A 28-year-old Caucasian female patient presented with progressive low back pain of 2 months duration. The magnetic resonance (MR) revealed a heterogeneous intradural and extramedullary lesion at the L2 level; with intravenous contrast, there were vascular flow voids and surrounding vasogenic edema (i.e., measuring 4.1 cm × 3.5 cm). The patient underwent an L2 right hemilaminectomy under intraoperative neurophysiological monitoring. She was discharged the 4^th postoperative day, neurologically intact. Literature describes 21 previous reports of sporadic isolated spinal hemangioblastomas.

Conclusion

Although rare, sporadic, and isolated hemangioblastomas of the cauda equina should be included among the differential diagnoses of intradural spinal lesions, particularly when enhanced MR studies document serpentine flow voids.

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.