Preoperative endovascular embolization for hemangioblastoma in the posterior fossa

Embolization of Large and Giant Posterior Fossa Hemangioblastomas: The Experience of a Single Tertiary Care Center

Background  Hemangioblastomas pose an inherent surgical risk due to the potential for high intraoperative blood loss, especially in larger tumors. One approach to minimize this risk is to use preoperative embolization. Herein, we present our institutional experience treating large and giant cerebellar hemangioblastomas. Methods  We performed a retrospective chart review of 19 patients with cerebellar hemangioblastomas that had a maximal diameter of >3 cm. We performed a literature review and included individual patient-level data that met our >3 cm diameter cerebellar hemangioblastoma inclusion criteria. Results  Our cohort consisted of 19 patients that received a total of 20 resections for their cerebellar hemangioblastomas. Preoperative embolization was utilized in eight cases (38.1%). One patient experienced transient neurological complications after embolization (12.5%). Tumors of patients in the embolization group had larger median total, solid, and cystic volumes and were more likely to involve the cerebellopontine angle than those in the non-embolized group. Compared with non-embolized patients, embolized patients had less decrease in their hemoglobin, lower volumes of estimated blood loss, reduced rates of postoperative complications and permanent deficits, and greater instances of neurological improvement. The larger cohort (obtained from the combining our cohort with patients identified during a literature review) consisted of 99 patients with 39 receiving preoperative embolization. Conclusion  It is important to examine individual patient characteristics when determining eligibility for preoperative embolization. However, improvements in endovascular techniques have made preoperative embolization a safe and effective procedure with minimal risks that can be performed in many patients.

Assessing the efficacy and safety of hemangioblastoma embolization: A comprehensive systematic review and meta-analysis

BACKGROUND

Hemangioblastomas (HBs) are highly vascular tumors linked to substantial morbidity and mortality. Recently, interventional neuroradiology has evolved rapidly, spurring interest in preoperative embolization as a possible HB treatment.

PURPOSE

This study evaluates the effectiveness and safety of preoperative embolization in managing HB.

METHODS

Adhering to PRISMA guidelines, this meta-analysis considered randomized and nonrandomized studies meeting specific criteria, encompassing intracranial HB and preoperative embolization. Primary outcomes were preoperative embolization efficacy and safety. Complications were classified as major (cerebellar ischemia, ischemic strokes, intratumoral hemorrhage, subarachnoid hemorrhage) and minor (transient nystagmus, slight facial nerve palsy, nausea, transient dysarthria, hemiparesis, hemisensory impairment, thrombotic complications, extravasation).

RESULTS

Thirteen studies involving 166 patients with preoperative embolization before HB resection were included. Two studies using the Glasgow Outcome Scale (GOS) showed 5 patients with good recovery, 6 with moderate disability, and 3 with severe disability. Major complications occurred in 1% (95% CI: 0% to 3%), and minor complications occurred in 1% (95% CI: 0% to 4%). Intraoperative blood loss during resection was estimated at 464.29 ml (95% CI: 350.63 ml to 614.80 ml).

CONCLUSION

Preoperative embolization holds promise in reducing intraoperative bleeding risk in neurosurgical intracranial HB treatment, primarily due to its low complication rates. Nonetheless, additional research and larger-scale studies are essential to establish its long-term efficacy and safety. These findings highlight preoperative embolization as a valuable tool for HB management, potentially enhancing future patient outcomes.

Usefulness of posterior transpetrosal approach for the large solid cerebellopontine angle hemangioblastoma fed from multiple blood supplies: A technical case report

Background

Extra-axial cerebellopontine angle (CPA) hemangioblastomas are rare clinical entity and surgical treatment is challenging due to the anatomical difficulties and multi-directional blood supplies. On the other hand, the risk of endovascular treatment for this disease has also been reported. Herein, we successfully applied a posterior transpetrosal approach to remove a large solid CPA hemangioblastoma without preoperative feeder embolization.

Case Description

A 65-year-old man presented with a complaint of diplopia during downward gaze. Magnetic resonance imaging revealed a solid tumor with homogeneous enhancement measuring about 35 mm at the left CPA, and the tumor compressed a left trochlear nerve. Cerebral angiography disclosed tumor-staining fed by both left superior cerebellar and left tentorial arteries. After the operation, the patient's trochlear nerve palsy improved dramatically.

Conclusion

This approach offers more optimal surgical working angle to the anteromedial part compared to the lateral suboccipital approach. In addition, the devascularization from the cerebellar parenchyma can be performed more reliably than the anterior transpetrosal approach. After all, this approach can be particularly useful when vascular-rich tumors receive blood supplies from multiple directions.

Perioperative Surgical Risks in Patients With Hemangioblastomas: A Retrospective Nationwide Review in Japan

BACKGROUND

The perioperative risk of sporadic hemangioblastomas (HBs) and von Hippel-Lindau disease (VHL)-associated hemangioblastomas (VHL-associated HBs) remains unclear due to the rare prevalence of HB. Therefore, this study aimed to clarify risk factors for better surgical management of patients with HBs.

METHODS

A retrospective analysis of surgically treated HB patients registered in the Diagnosis Procedure Combination database of Japan, between 2010 and 2015, was performed. Age, sex, sporadic HBs or VHL-associated HBs, medical history, tumor location, hospital case load, postoperative complications, and Barthel index (BI) deterioration were assessed. We also evaluated the outcomes and factors of perioperative BI deterioration.

RESULTS

In total, 676 patients with 609 intracranial lesions, 64 spinal lesions, and 3 with both types were eligible. Among them, 618 and 58 patients had sporadic HBs and VHL-associated HBs, respectively. The rates of perioperative BI deterioration were 12.5% and 12.2% for sporadic HBs and VHL-associated HBs, respectively. Perioperative mortality was 1.8% and 0% for sporadic HBs and VHL-associated HBs, respectively. Male sex, old age, high hospital case load, and medical history of diabetes mellitus were significantly associated with perioperative BI deterioration in all cases and sporadic HBs. Only medical history of diabetes mellitus was a significant risk factor for perioperative BI deterioration in VHL-associated HBs.

CONCLUSIONS

No differences in perioperative BI deterioration rates between sporadic HBs and VHL-associated HBs were found. However, different risk factors for perioperative BI deterioration were identified. Consideration of these risk factors is recommended in all patients undergoing surgery for HB.

Anlotinib for the Treatment of Multiple Recurrent Lumbar and Sacral Cord Hemangioblastomas: A Case Report

Background

Hemangioblastoma (HB) is a rare and highly vascularized tumor that originates from the central nervous system as well as other part of the body. They can appear sporadically or as part of von Hippel–Lindau (VHL) disease, a rare hereditary cancer syndrome. Although surgery can cure the majority of HBs, the disease shows a treatment-refractory challenge upon recurrence. HBs express a high amount of vascular endothelial growth factor (VEGF) which is responsible for angiogenesis and subsequently tumor progression. Anti-angiogenic treatment like bevacizumab has showed effect on HB, so we hypothesized that anlotinib could trigger HB regression via its inhibitory effect on VEGF.

Case Presentation

We will share our experience in treating a 62-year-old woman with multiple recurrent lumbar and sacral cord HBs. She was treated with anlotinib (8mg qd d1-14, q3w) for three months and her follow up radiological examination demonstrated marked tumor regression which was evaluated as having partial response pursuant to RECIST 1.1 system. She is currently still receiving treatment of anlotinib orally and the lesions continuously reduced.

Conclusion

We have reported that anlotinib can cause significant radiographic response in a patient with multiple recurrent lumbar and sacral cord HBs for the first time. This might enable a novel therapeutic approach for patients with multiple recurrent HB or those with multiple lesions such as in VHL disease which are difficult to resect surgically.

Treatment Strategy for Giant Solid Hemangioblastomas in the Posterior Fossa: A Retrospective Review of 13 Consecutive Cases

OBJECTIVE

To analyze radiologic characteristics, treatment strategy, and treatment outcomes of posterior fossa giant solid hemangioblastomas (GSHBs; ≥4 cm in maximum diameter).

METHODS

We performed a retrospective study of 13 consecutive patients (9 male and 4 female patients; mean age, 57.5 ± 13.3 years; range, 24-76 years) with GSHB who underwent surgical resection at a single institution between 2002 and 2018. The median follow-up was 33 months (range, 12-120 months). For each patient, neuroimaging findings, operative record, and treatment outcome were reviewed.

RESULTS

Seven tumors (53.8%) were located within cerebellar hemispheres, 4 (30.8%) in proximity to the brainstem, 1 (7.7%) within the cerebellar vermis, and 1 (7.7%) in the cerebellopontine angle. The mean maximum diameter was 4.8 ± 0.8 cm (range, 4.0-6.7 cm). Gross total resection was achieved in 11 patients (84.6%), and near-total resection in 2 patients (15.4%). Surgical complications occurred in 5 patients (38.5%); persistent neurologic deficits occurred in 2 patients (15.4%). Estimated progression-free survival after surgery was 92.3%, 80.8%, and 80.8% at 1, 5, and 10 years, respectively, whereas the estimated 1-year, 5-year, and 10-year overall survival was 100%, 90%, and 90%, respectively.

CONCLUSIONS

GSHBs are surgically challenging. The current study shows that favorable outcome can be achieved for GSHBs in the cerebellar hemispheres and vermis. For those involving the brainstem, planned near-total resection or subtotal resection in a piecemeal fashion can be attempted if en bloc resection is judged to be infeasible, and further intervention can be considered as needed.

Surgical Outcome of Large Solid Posterior Fossa Hemangioblastoma without Preoperative Embolization

BACKGROUND

 Large solid hemangioblastoma in the posterior fossa has an abundant blood supply as an arteriovenous malformation. The presence of adjacent vital neurovascular structures makes them vulnerable and difficult to operate. Complete surgical resection is always a challenge to the neurosurgeon.

MATERIAL AND METHOD

 We share the surgical difficulties and outcome in this case series of large solid hemangioblastomas without preoperative embolization as an adjunct. This study included five patients (three men and two women, with a mean age of 42.2 years). Preoperative embolization was attempted in one patient but was unsuccessful. All the patients have headache (100%) and ataxia (100%) as an initial symptom. A ventriculoperitoneal shunt was inserted in one case before definite surgery due to obstructive hydrocephalus. The surgical outcome was measured using the Karnofsky Performance Status (KPS) score.

RESULT

 The tumor was excised completely in all the cases. No intra- and postoperative morbidity occurred in four patients; one patient developed transient lower cranial nerve palsy. Mean blood loss was 235 mL, and no intraoperative blood transfusion was needed in any case. The mean follow-up period was 14.2 months. The mean KPS score at last follow-up was 80.One patient had a KPS score of 60.

CONCLUSION

 Our treatment strategy is of circumferential dissection followed by en bloc excision, which is the optimal treatment of large solid hemangioblastoma. The use of adjuncts as color duplex sonography and indocyanine green video angiography may help complete tumor excision with a lesser risk of complication. Preoperative embolization may not be needed to resect large solid posterior fossa hemangioblastoma, including those at the cerebellopontine angle location.

Selection of surgical approach for cerebellar hemangioblastomas based on venous drainage patterns

Cerebellar hemangioblastomas remain surgically challenging because of the narrow, deep surgical corridors and tumor hypervascularity. Various surgical approaches are used according to the location, but optimal approaches have not been established. We propose a system of surgical approaches based on the venous drainage systems to facilitate surgical planning and achieve acceptable neurological outcomes. Cerebellar hemangioblastomas were divided into five types based on the main drainage systems: suboccipital hemangioblastomas draining to the transverse sinus (TS) or torcula, tentorial hemangioblastomas draining to the tentorial sinus or straight sinus, petrosal hemangioblastomas draining to the superior petrosal sinus (SPS), quadrigeminal hemangioblastomas draining to the galenic system, and tonsillar hemangioblastomas draining to the TS or torcula in conjunction with jugular bulb or SPS. Microsurgical approaches and patient outcome were retrospectively reviewed according to this classification. This study included 17 patients who underwent 21 operations for resection of 19 cerebellar hemangioblastomas, classified into 9 suboccipital, 4 tentorial, 2 petrosal, 2 quadrigeminal, and 2 tonsillar. Standard suboccipital craniotomies were utilized for suboccipital hemangioblastomas, the occipital transtentorial approach (OTA), and supracerebellar infratentorial approach for tentorial hemangioblastomas, the retrosigmoid approach for petrosal hemangioblastomas, OTA for quadrigeminal hemangioblastomas, and midline suboccipital approach for tonsillar hemangioblastomas. Gross total resection was achieved in all patients except one. Two patients with large hemangioblastomas (tonsillar and quadrigeminal) required second-stage operation which finally achieved gross total removal. No single approach had a significantly higher incidence of postoperative neurological deficits. Selection of the optimum surgical approach for cerebellar hemangioblastomas was successful based on the main drainage systems. Understanding of tumor growth and extension with respect to the venous drainage system is critical to select the appropriate surgical approach.

Cerebral Hemangioblastoma Without Von Hippel-Lindau Syndrome: A Report of 6 Cases

Background. Hemangioblastoma occurs mainly in the cerebellum and rarely in the cerebrum. Objective. The present study aimed to analyze the clinical manifestations and radiological and pathological features of cerebral hemangioblastoma, and to improve the recognition of this tumor and avoid misdiagnosis. Methods. The characteristics of 6 patients with cerebral hemangioblastoma were analyzed, and a retrospective review of cerebral hemangioblastoma reported in the literature was performed. Results. All 6 patients were female, aged from 22 to 70 years (55 years on average), and all cases were wild-type sporadic, in which 4 cases occurred in the frontal lobe and 2 cases occurred in the parietal lobe. Imaging revealed a solid tumor in 4 cases, a cystic tumor in 1 case, and a mixed tumor in 1 case. Microscopically, the morphology and immunophenotype of tumor cells were not different from those of classical hemangioblastoma. All 6 patients survived tumor free during the follow-up period. Conclusions. Cerebral hemangioblastoma often simulates the imaging characteristics of meningioma or glioma. Enough attention should be paid to differential diagnosis before the operation, and exact diagnosis relies on the pathological examination.

A novel neuroimaging assessment of predictive risk factors associated with intraoperative massive hemorrhage in intracranial solid hemangioblastoma

Background

A solid hemangioblastoma (SH) is a benign and highly vascularized tumor. Microsurgical treatment of SH is still challenging due to excessive intraoperative bleeding.

Methods

Sixty-six consecutive patients with SH were retrospectively analyzed. The volume of intraoperative blood loss (IBL) and the features detected by magnetic resonance imaging (MRI) were evaluated by a neurosurgeon and multiple neuroradiologists.

Results

Four striking MRI features-peritumoral edema, the flow-void effect, large draining veins, and a visible feeding artery-were related to excessive IBL. Regarding the weighted values of these risk factors, the flow-void effect was the factor most significantly correlated with IBL (P<0.01, R=0.418). The feeding artery also contributed substantially to excessive IBL (P<0.05, R=0.412). The next most influential factor was the presence of large draining veins (P<0.05, R=0.350), followed by peritumoral edema (P<0.05, R=0.308). The four major risk factors-the flow-void effect, feeding arteries, large draining veins, and peritumoral edema-were assigned point values of 3, 3, 2, and 1, respectively, for a maximum total score of 9 points. A higher total score indicates that a higher volume of bleeding is more likely to occur during surgery.

Conclusions

This study reports the potential neuroimaging-based risk factors leading to abundant IBL in SH by neuroimaging assessment. The study proposes a novel scoring system to predict IBL, potentially decreasing the risk involved in the surgical treatment of SH.

Hemangioblastoma of the pons and middle cerebellar peduncle

A 60-year-old man with a history of four prior operations for a left cerebellar/middle cerebellar peduncle hemangioblastoma presented with hearing loss, imbalance, and ataxia (de la Monte and Horowitz, 1989). Magnetic resonance imaging (MRI) demonstrated a 3-cm cystic mass with heterogeneous enhancement in the same location. We resected the mass via reopening of the retrosigmoid approach (Lee et al., 2014). Left cranial nerves IV, V, VII, VIII, IX, X, and XI were all well identified and preserved, and feeding arteries from the brainstem were meticulously coagulated and transected without violating the tumor-brainstem interface (Chen et al., 2013). Preoperative embolization greatly aided safe resection of the mass, whose pathology revealed recurrence of hemangioblastoma (Eskridge et al., 1996; Kim et al., 2006; Sakamoto et al., 2012).

The video can be found here: https://youtu.be/3mZgY15xOZc.

Unilateral Occipital Transtentorial Approach with Multimodal Assistance for Resection of Large Supracerebellar Hemangioblastomas: Preliminary Experience of 2 Cases

BACKGROUND

The surgical resection of large supracerebellar hemangioblastomas (SHBs) is exceptionally challenging due to their vascularity and deep anatomic location and is associated with a high risk of postoperative complications and mortality. Access to the posterior incisural space can be achieved by either an infratentorial supracerebellar approach or occipital transtentorial approach (OTA). However, the optimal surgical strategy has not yet been established. Here, we report 2 cases of large SHBs that were successfully and safely resected via a unilateral OTA with multimodal assistance.

CASE DESCRIPTION

Two patients presented to our hospital with ataxia due to large, solid SHBs. After preoperative embolization, gross total resection of the SHBs was achieved via an OTA. Furthermore, endoscopic assistance was used to resect the remnant portion of the tumor in the second patient. Both patients experienced transient ataxia but were discharged from the hospital without serious complications.

CONCLUSIONS

The combination of an OTA with preoperative embolization and endoscopic assistance may reduce the intraoperative risk and contribute to improved outcome in patients with such clinically challenging tumors.

Clinical importance of the posterior meningeal artery: a review of the literature

The posterior meningeal artery, which arises from the vertebral artery, is a critical artery in neurological lesions. However, a comprehensive review of the importance of the posterior meningeal artery is currently lacking. In this study, we used the PubMed database to perform a review of the literature on the posterior meningeal artery to increase our understanding of its role in vascular lesions. The posterior meningeal artery provides the main blood supply to the paramedial and medial portions of the dura covering the cerebellar convexity. The posterior meningeal artery is often involved in dural arteriovenous fistulas occurring near the posterior fossa, and the posterior meningeal artery can be the path for transarterial embolisation or a path through which to monitor the degree of dural arteriovenous fistula embolisation. In posterior circulation ischaemia and moyamoya disease, the posterior meningeal artery can form transdural anastomoses with pial arteries at the surface of the brain, and these can help prevent ischemia. The posterior meningeal artery can also develop aneurysms, most of which are traumatic pseudoaneurysms; patients should therefore be treated in a timely manner or followed up carefully in cases of rebleeding. In addition, during a craniotomy, the posterior meningeal artery should be protected intraoperatively to avoid damaging any transdural anastomosis that may be present. In addition, when the posterior meningeal artery is the main feeding artery of an intracranial tumour, that artery is a satisfactory path for preoperative embolisation. Briefly, the posterior meningeal artery is a very important artery in neurosurgery.

Treatment Outcome of Intracranial Tumor Embolization in Japan: Japanese Registry of NeuroEndovascular Therapy 3 (JR-NET3)

Embolization for intracranial tumor is performed as a standard endovascular treatment. A retrospective, multicenter, observational study was conducted to clarify the nature, frequency, and risk factors of complications in intracranial tumor embolization. Patients were derived from the Japanese Registry of NeuroEndovascular Therapy (JR-NET3) using data taken from January 2010 through December 2014 in Japan. A total of 40,169 patients were enrolled in JR-NET3, of which, 1,545 patients (3.85%) with intracranial tumors underwent embolization. The primary end point was the proportion of patients with a modified Rankin scale (mRS) score of 0–2 (independency) at 30 days after embolization. The secondary end point was the occurrence of complications related to the procedures. The risk factors of the development of complications were analyzed. The proportion of patients with mRS scores ≤2 at 30 days after procedure was 89.5%. Complications occurred in 57 of the 1544 patients (3.7%). Multivariate analysis showed that target vessels other than external carotid artery (ECA) (OR, 3.56; 95% CI, 2.03–6.25; P <0.001) and use of liquid material (OR, 2.65; 95% CI, 1.50–4.68; P <0.001) were significantly associated with the development of complications. In JR-NET3, the primary end point was 89.5%, and the procedure-related complication rate was 3.7%. Embolization from other than ECA was significant risk factor of the complications. In addition, increasing usage of liquid embolic material worsened the risk of complications.

The usefulness of indocyanine green during surgery for hypervascular posterior fossa tumors

BACKGROUND

Cerebral hemangioblastomas are benign tumors with abundant blood flow that occur mainly in the posterior fossa. Tumor removal en bloc is important in surgical treatment because of the risk of bleeding; however, it is actually rather difficult in practice. Therefore, we propose a surgical strategy for visualizing hypervascular tumors of the posterior fossa utilizing indocyanine green (ICG).

CASE DESCRIPTION

Case 1 involved a 48-year-old male with a history of von Hippel-Lindau (VHL) disease. Magnetic resonance imaging (MRI) revealed a solid tumor measuring 3.0 cm in diameter in the right cerebellopontine angle. We performed surgery because the tumor was pressing against the brainstem. Surgery was performed via the posterior subtemporal transtentorial approach in order to visualize the feeding artery and draining vein intraoperatively. The vessels were confirmed by ICG and the tumor was removed en bloc. Case 2 involved a 30-year-old woman. Signs of increased intracranial pressure were noted, and an MRI revealed a solid tumor 3.5 cm in diameter in the left cerebellar hemisphere. Surgery was performed via the midline suboccipital approach. Similarly, we confirmed the vessels using ICG and the tumor was removed en bloc.

CONCLUSIONS

For hypervascular tumors of the posterior fossa, preoperative image assessment is important. Furthermore, the use of ICG during surgery is advantageous for surgical strategies where the feeding arteries and draining veins exist superficially in the operative field and are therefore easier to remove en bloc.

Staged multi-modality treatment approaches for giant cerebellopontine angle hemangioblastomas

Giant hemangioblastomas (HBs) located in the cerebellopontine angle (CPA) present rare, high risk neurosurgical challenges. En bloc resection has been traditionally recommended for HBs, however this approach may pose unacceptable risk with giant tumors. Alternative treatment strategies have not been well described and the relevant literature is scant. This case review includes an illustrative patient with a giant, symptomatic CPA HB. It was felt that the neurovascular and tumor attributes were favorable for a multi-modality treatment strategy rather than circumferential dissection to remove this formidable tumor. A staged approach consisting of preoperative HB devascularization, debulking and piecemeal resection followed by radiosurgery for a small residuum produced an excellent clinical outcome. Variations of this unconventional multi-modality strategy may reduce the perioperative morbidity of carefully selected patients with giant CPA HBs. A thorough literature review is provided.

Hemangioblastomas of the Posterior Cranial Fossa in Adults: Demographics, Clinical, Morphologic, Pathologic, Surgical Features, and Outcomes. A Systematic Review

BACKGROUND

Posterior cranial fossa (PCF) hemangioblastomas are benign, highly vascularized, and well-differentiated tumors with well-described histopathologic features. Although relatively rare, this tumor is the most prevalent primary tumor of the cerebellum in adults.

OBJECTIVE

Because the demographics of patients with such a tumor (as well as the clinical, morphologic, pathologic, surgical features, and outcomes) are not fully understood, we systematized characteristic patient and tumor features.

METHODS

We undertook a systematic review of the English-language literature in PubMed for PCF hemangioblastomas in adults published in the past 31 years. We analyzed geographic distribution and year of publication of articles; demographic data of patients; presenting symptoms and clinical signs; tumor location and morphology; histopathologic features, extent of tumor resection, perioperative blood loss, and postoperative complications; length of hospital stay; and outcomes.

RESULTS

We reviewed 207 articles describing 1759 infratentorial hemangioblastomas in a cohort of 1515 adult patients. We found female predominance in patients with Von Hippel-Lindau disease (VHLD) compared with male predominance in the general patient group. Symptoms of intracranial hypertension were more common in the VHLD group compared with the general group of patients. The cerebellar location was more common in the VHLD group and solid (parenchymatous) tumor was the most common type. Most patients underwent total resection but rate of resection did not differ between the general and VHLD groups. Most patients had a favorable outcome.

CONCLUSIONS

The literature of adult PCF hemangioblastomas is limited and general surgical experience with such tumors is scarce because of their rarity. Rates of postoperative complications and mortality remain higher than expected. However, prognosis and surgical outcomes are generally favorable. Nevertheless, surgery of adult PCF hemangioblastomas is a demanding and challenging task.

Unusual case of hemangioblastoma of the cerebellopontine angle

Background:

Hemangioblastomas are the most common primary tumor of the posterior fossa. There are few cases of hemangioblastoma of the cerebellopontine angle (CPA). When present in this location, hemangioblastoma presents a diagnostic challenge as its imaging findings closely resemble those of vestibular schwannoma (VS), which is much more common in the CPA.

Case Description:

We report the case of a 42-year-old man presenting with vertigo and diplopia found to have a CPA tumor with imaging resembling VS. He underwent retrosigmoidal resection of his tumor, which was found to be a hemangioblastoma.

Conclusion:

Hemangioblastoma, though rare in the CPA, should be considered in the differential diagnosis of CPA tumors.

Advantages of using a detachable-tip microcatheter and liquid embolic agents in the preoperative embolization of a recurrent cerebellar hemangioblastoma: A case report

BACKGROUND

The preferred treatment for intracranial hemangioblastomas is surgical resection with or without preoperative embolization, however, embolization remains controversial due to risks such as distal tip entrapment, vascular injury during navigation, and embolic agent migration.

CASE DESCRIPTION

A 54-year-old woman was admitted for surgical resection and preoperative embolization of a cerebellar hemangioblastoma. Although experience using Onyx with detachable and nondetachable tip microcatheters has been well reported in a variety of clinical circumstances, we describe the first case of a presurgical embolization of an intra-axial tumor using a second-generation detachable-tip microcatheter and a nonadhesive liquid embolic agent. Following the procedure, a nearly complete angiographic obliteration was achieved, as well as a successful subsequent surgical resection.

CONCLUSION

Preoperative embolization with detachable-tip microcatheters and liquid embolic agents should be taken into consideration when assessing patients with hemangioblastomas of the posterior fossa due to the reduced risks of cardiac arrest, hemorrhage, and death.

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.

Surgical treatment of cerebellar hemangioblastomas

BACKGROUND

Hemangioblastomas (HBL) are uncommon tumors of the central nervous system (CNS), corresponding to 1-2.5% of all intracranial tumors. They can present sporadically or in patients with von Hippel-Lindau (VHL) disease and are most often located in the cerebellum, brainstem, and spinal cord. VHL disease is a multiple neoplasia syndrome inherited in an autosomal dominant fashion and caused by a VHL suppressor gene deletion. We present our experience in the management of patients with cerebellar HBL.

METHODS

Thirty consecutive patients with cerebellar HBL were included in this study. Hospital charts, radiological images, and operative records were reviewed. Modified Rankin scores were used to evaluate the clinical course.

RESULTS

Thirty patients diagnosed with cerebellar HBL were operated. Complete total resection was achieved in 93% of the cases. Postoperatively, 83% of the patients showed good functional recovery.

CONCLUSIONS

HBL of the cerebellum should be resected when symptomatic or when the tumor (or a tumor-associated cyst) shows signs of enlargement. Surgical intent should seek en bloc resection to minimize intraoperative bleeding. Patients with HBLs must be tested for VHL gene mutations, and in confirmed cases, relatives should be offered genetic counseling.

[Hemangioblastomas of the posterior fossa: Report of 16 cases and literature review]

OBJECTIVE

The aim of this study is to describe the results of 16 patients with posterior fossa hemangioblastoma, treated with microsurgical techniques.

METHOD

Between June 2005 and December 2015, 16 patients with posterior fossa hemangioblastoma were operated on, underwent microsurgical resection. The sex, age, imaging findings, symptoms, and postoperative results were analyzed.

RESULTS

Eleven patients were men and 5 were women. The average age of the patients was 44 years. The most common form was cystic with nodule (57%); in 31% of the cases the lesion was purely solid. One case (6%) showed a lesion purely cystic, and one case was solid-cystic (6%). The major presenting symptoms were headache and cerebellar syndrome (43%); in 25% of the cases the patients suffered intracranial hypertension syndrome. The total resection was achieved in all the cases; in one patient an embolization was performed before surgery. Regarding postoperative complications: two patients developed ataxia (improved after three months), 1 patient presented a CSF leak (improve with an external spinal drainage). In addition, one patient died because postoperative complications.

CONCLUSION

The major features in patients with posterior fossa hemangioblastoma are a cystic with nodule form, presenting symptoms of headache and cerebellar syndrome. The total resection is possible, with a low morbi-mortality rate.

Safety and outcomes of preoperative embolization of intracranial hemangioblastomas: A systematic review

INTRODUCTION

While preoperative embolization is often reserved for large and highly vascular tumors in order to minimize blood loss, its safety and efficacy in the treatment of hemangioblastomas (HB) is unclear. We present the largest systematic review focusing on the safety and outcome of preoperative embolization of intracranial HB.

MATERIALS AND METHODS

To identify all cases of preoperative embolization for HB, a literature search was conducted via Medline (OVID and PubMed), Scopus, Embase, and Web of Science. Studies that were in English, included intracranial hemangioblastomas treated with preoperative embolization and provided sufficient disaggregated clinical data for each patient were included. Historical control patients with non-embolized intracranial HB undergoing resection were similarly identified.

RESULTS

A total of 111 patients that underwent preoperative embolization of HB prior to planned resection were identified. Patient age ranged from 12 to 72 years, with a cohort of 63% males and 36% females. Nine studies comprising 392 non-embolized patients were included as controls. Gross total resection was achieved in 83.7% of embolized and 95.6% of non-embolized patients. Intraoperative blood transfusion was required in 15.3% of embolized and 0.51% of non-embolized controls, while rates of post-operative hemorrhage were 8.4% and 1.6%, respectively. Complication rates from embolization were 11.7% and following consequent surgery were 20.7%.

DISCUSSION

Embolization did not increase rates of gross total resection, decrease estimated blood loss, or decrease incidence of complications. Not only does embolization fail to mitigate surgical risks, the embolization procedure itself carries significant risk for complications. Embolization should not be standard of care for intracranial HB.

Safety and Efficacy of Preoperative Embolization of Intracranial Hemangioblastomas

BACKGROUND

Intracranial hemangioblastomas are highly vascular tumors that account for 1% to 2% of all central nervous system tumors. Preoperative embolization has been proposed to limit the often significant intraoperative blood loss associated with resection and potentially make the tumor more soft/necrotic and thus more amenable to gross total resection. The safety and efficacy of preoperative embolization of intracranial hemangioblastomas, however, are not well characterized.

OBJECTIVE

To evaluate the safety and efficacy of preoperative endovascular embolization of intracranial hemangioblastomas using a variety of embolic agents.

METHODS

A retrospective review of all surgically resected intracranial hemangioblastomas treated with preoperative embolization between 1999 and 2014 at 2 high-volume centers was performed. Clinical and radiographic criteria, including von Hippel-Lindau status, magnetic resonance imaging tumor characteristics, embolization-related complications, degree of angiographic devascularization, intraoperative blood loss, ability to obtain gross total resection, transfusion requirements, and operative time, were analyzed.

RESULTS

A total of 54 patients underwent surgery, with 24 undergoing preoperative embolization followed by surgical resection, and 30 patients undergoing surgical resection alone. Embolization-related neurological complications were seen in 6 patients (25%), including 3 hemorrhages when polyvinyl alcohol particles (P = .04) were used and 3 infarctions when liquid embolic agents were used (P = .27). Permanent neurological deficits were seen in 15%.

CONCLUSION

Preoperative embolization of intracranial hemangioblastomas should be performed with caution, given the potential for neurological morbidity. Further studies are needed to help guide patient and embolic agent selection.

Differentiating Hemangioblastomas from Brain Metastases Using Diffusion-Weighted Imaging and Dynamic Susceptibility Contrast-Enhanced Perfusion-Weighted MR Imaging

BACKGROUND AND PURPOSE

On DWI and DSC-PWI, hemangioblastomas and brain metastases may exhibit different signal intensities depending on their cellularity and angiogenesis. The purpose of this study was to evaluate whether a hemangioblastoma can be differentiated from a single brain metastasis with DWI and DSC-PWI.

MATERIALS AND METHODS

We retrospectively reviewed DWI, DSC-PWI, and conventional MR imaging of 21 patients with hemangioblastomas and 30 patients with a single brain metastasis. Variables of minimum ADC and relative ADC were acquired by DWI and the parameter of relative maximum CBV, by DSC-PWI. Minimum ADC, relative ADC, and relative maximum CBV values were compared between hemangioblastomas and brain metastases by using the nonparametric Mann-Whitney test. The sensitivity, specificity, positive and negative predictive values, accuracy, and the area under the receiver operating characteristic curve were determined.

RESULTS

Both the minimum ADC values and relative ADC ratios were significantly higher in hemangioblastomas compared with brain metastases (P < .001 for both minimum ADC values and relative ADC ratios). The same was true for the relative maximum CBV ratio (P < .002). The threshold value of ≥6.59 for relative maximum CBV provided sensitivity, specificity, and accuracy of 95.24%, 53.33%, and 70.59%, respectively, for differentiating hemangioblastomas from brain metastases. Compared with relative maximum CBV, relative ADC had high sensitivity (95.24%), specificity (96.67%), and accuracy (96.08%) using the threshold value of ≥1.54. The optimal threshold value for minimum ADC was ≥1.1 × 10^-3 mm²/s.

CONCLUSIONS

DWI and DSC-PWI are helpful in the characterization and differentiation of hemangioblastomas from brain metastases. DWI appears to be the most efficient MR imaging technique for providing a distinct differentiation of the 2 tumor types.

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.

Solid hemangioblastoma in the cerebellopontine angle: Importance of external carotid blood supply with regard to the probable site of origin and preoperative embolization

BACKGROUND

Hemangioblastoma (HBL) is rare in the cerebellopontine angle (CPA) with questionable origin and limited access for circumferential dissection and "en-bloc" excision. We report a case of surgical removal of large solid CPA-HBL and discuss the pattern of blood supply suggesting its origin and indicating preoperative embolization.

CASE DESCRIPTION

The solid and highly vascular CPA-HBL had feeders mainly from neuromeningeal division of ascending pharyngeal branch of external carotid artery, suggesting true extra-axial origin. We could achieve "en-bloc" excision without significant blood loss or morbidity using preoperative embolization.

CONCLUSION

Large solid HBL is rare in CPA necessitating arduous "en-bloc" excision. The pattern of blood supply probably indicates the site of origin and safety of preoperative embolization.

Role of preoperative embolization for intradural spinal hemangioblastomas

Spinal hemangioblastomas (HB) are relatively rare neoplasms with a high degree of vascularity. Therapy for symptomatic tumors involves total resection when possible. Due to the enriched blood supply of these neoplasms, there is a high risk of significant intraoperative blood loss, which can lead to perioperative complications. Preoperative embolization of HB has been suggested to reduce blood loss and operative morbidity, but its use remains controversial. Data on the risks and benefits of preoperative embolization for this tumor remains limited. We identified and analyzed all 29 reported cases of preoperative embolization of intradural spinal HB within the literature. There were 18 men and nine women, and patients ranged from 24 to 61 years of age. Mean tumor size was 3.5 cm. Cervical and thoracic location was most common, accounting for 48.3% and 20% of cases, respectively. Complications from embolization and surgery were minimal, with no deaths or permanent neurological morbidity. Minimal intraoperative bleeding and excellent rates of gross total resection were reported with preoperative embolization. However, outcomes from microsurgery alone from historical series have similarly reported excellent outcomes. While there is no established standard, preoperative embolization should be reserved for particularly high risk patients with risk of intraoperative bleeding.

Large solid hemangioblastoma in the cerebellopontine angle: complete resection using the transcondylar fossa approach

Hemangioblastomas (HBMs) in the cerebellopontine angle (CPA) have rarely been reported. When they are within the CPA, they may be misdiagnosed as vestibular schwannoma (VS) or cystic meningioma. Therefore, differential diagnosis is important for the safe treatment of the lesion. Large solid HBMs, similar to intracranial arteriovenous malformations (AVMs), are difficult to surgically remove from an eloquent area because of their location and hypervascularity. We report a case of an HBM in the CPA, which manifested as a hearing impairment or VS. Similar to AVM surgery, the tumor was widely opened and removed en bloc without a new neurological complication using the modified transcondylar fossa approach without resection of the jugular tubercle. Accurate diagnosis, pre-operative embolization, and a tailored approach were essential for the safe treatment of the HBM in the CPA.

Successful treatment of a ruptured flow-related aneurysm in a patient with hemangioblastoma: Case report and review of literature

Background:

No cerebral aneurysms on the feeder associated with hemangioblastomas that ruptured before resection have been reported. We report a patient with a ruptured flow-related aneurysm associated with cerebellar hemangioblastoma and a tumor feeder treated simultaneously by a single procedure of embolization using N-butyl cyanoacrylate before tumor removal.

Case Description:

A 36-year-old female with a cerebellar tumor was admitted to our institute. Four days later, she suffered a massive subarachnoid hemorrhage mainly in the posterior fossa. Left vertebral angiograms showed an aneurysm on the feeding artery, posterior inferior cerebellar artery. Both the aneurysm and its main feeder were simultaneously treated by a single procedure of embolization using N-butyl cyanoacrylate. Their complete obliteration was confirmed angiographically. Four days after the procedure, we removed the tumor and the embolized aneurysm. The pathological diagnosis was hemangioblastoma and flow-related ruptured aneurysm.

Conclusion:

Cerebral angiography should be performed to rule out vascular abnormalities such as cerebral aneurysms adjacent to the tumor in patients with hemangioblastoma who present with intracranial hemorrhage. We emphasize the usefulness of embolization with N-butyl cyanoacrylate for hemangioblastoma with ruptured feeder aneurysm, by which the aneurysm and the feeder could be simultaneously embolized.

Clinical effectiveness of preoperative embolization for cerebellar hemangioblastoma

The cerebellar hemangioblastoma (CHB) has an abundant blood supply and deep anatomical location. Complete surgical resection is generally very difficult. This study investigated the safety and effectiveness of preoperative embolization followed by surgical resection of CHB in a large cohort of patients. A database of 125 CHB patients with surgical resection in Beijing Tiantan Hospital between July 2006 and July 2012 was reviewed. Of those, 46 cases (experimental group) received preoperative embolization, 79 cases (control group) underwent surgery without embolization. Patient demographics, tumor size, duration of surgery, blood loss, blood transfusion, complications and follow-up results were collected and analyzed retrospectively. In the experimental group, the Kamofsky score (KS) was 80-100 in 40 cases (86.9%), 40-70 in 4 cases (8.7%), and below 40 in 2 cases (4.3%). Among 31 cases with follow-up, KS was 80-100 in 27 cases (87.1%), 40-70 in 2 cases (6.5%), and 0 in 2 cases (6.5%). In control group, KS was 80 -100 in 65 cases (82.2%), 40-70 in 6 cases (7.6%), 10-30 in 3 cases (3.8%), and 0 in 3 cases (3.8%). Among 53 cases with follow-up, KS was 80-100 in 44 cases (83.0%), 40-70 in 4 cases (7.5%), 10-30 in 1 case (1.9%), and 0 in 4 cases (7.5%). There were statistically significant differences between the experimental and control groups in tumor size, duration of surgery, amount of intraoperative blood loss and transfusion (p <0.01). However, complications (p = 0.31) and follow-up results (p = 0.76) showed no significant differences between groups. Selective preoperative embolization of those CHB patients with richer blood supply, higher hemorrhage risk, is safe and effective, and is a reliable adjuvant therapy for complete surgical resection of CHB.

Percutaneous trans-hepatic gelfoam-cyanoacrylate glue embolization for ruptured post-traumatic hepatic artery pseudo-aneurysm in a limited-resource scenario

INTRODUCTION

We present our experience with an indigenously designed percutaneous trans-hepatic ultrasound-guided Gelfoam sponge cum cyanoacrylate glue-based embolization technique for the treatment of a ruptured post-traumatic aneurysm of a branch of the right hepatic artery (RHA) as a 'life-saving emergent' procedure in a patient unfit for surgery or endovascular intervention and in a 'limited-resource' scenario (non-availability of Digital Subtraction Angiography Suite).

CASE DETAILS

An 8-year-old boy sustained crush-injury to the right lobe of the liver in a road-traffic accident and presented in shock. After resuscitation, a laparotomy and repair of the right lobe of liver were undertaken. Bleeding restarted 1 week after the surgery; the patient bled from drain site and went into shock. Exploration was not advisable in view of poor general condition, and sepsis, deranged coagulation and parental reluctance in view of guarded prognosis. Multi-detector Computed Tomography Angiography was performed after resuscitation which revealed active bleed from a ruptured pseudo-aneurysm of a branch of RHA.

TECHNIQUE

The bleeding artery was identified with duplex sonography and was embolized by the percutaneous trans-hepatic route proximal to the site of pseudo-aneurysm and rupture by a two-step process. Initially, a thin paste/'slurry' made of powdered gelfoam dissolved in sterile saline was injected into the bleeding vessel. Subsequently, the area was sealed by injecting 1.0 ml of N-butyl-2-cyanoacrylate glue. Hemostasis was confirmed by Color and Power Doppler Ultrasonography both post-procedure and after 48 h. With supportive management, the patient showed a rapid recovery and was discharged after 2 weeks. He continues to be well at 3-month follow-up.

CONCLUSION

The technique was effective in controlling hemostasis and life-saving in our set-up.