Posterior approach for anteriorly located cervical spinal cord hemangioblastomas: technical note

Hemangioblastoma and von Hippel-Lindau disease: genetic background, spectrum of disease, and neurosurgical treatment

INTRODUCTION

Hemangioblastomas are rare, histologically benign, highly vascularized tumors of the brain, the spinal cord, and the retina, occurring sporadically or associated with the autosomal dominant inherited von Hippel-Lindau (VHL) disease. Children or adults with VHL disease have one of > 300 known germline mutations of the VHL gene located on chromosome 3. They are prone to develop hemangioblastomas, extremely rarely starting at age 6, rarely at age 12-18, and, typically and almost all, as adults. There is a plethora of VHL-associated tumors and cysts, mainly in the kidney, pancreas, adrenals, reproductive organs, and central nervous system. Due to a lack of causal treatment, alleviation of symptoms and prevention of permanent neurological deficits as well as malignant transformation are the main task. Paucity of data and the nonlinear course of tumor progression make management of pediatric VHL patients with hemangioblastomas challenging.

METHODS

The Freiburg surveillance protocol was developed by combining data from the literature and our experience of examinations of > 300 VHL patients per year at our university VHL center.

RESULTS

Key recommendations are to start screening of patients at risk by funduscopy with dilated pupils for retinal tumors with admission to school and with MRI of the brain and spinal cord at age 14, then continue biannually until age 18, with emergency MRI in case of neurological symptoms. Indication for surgery remains personalized and should be approved by an experienced VHL board, but we regard neurological symptoms, rapid tumor growth, or critically large tumor/cyst sizes as the key indications to remove hemangioblastomas. Since repeated surgery on hemangioblastomas in VHL patients is not rare, modern neurosurgical techniques should encompass microsurgery, neuronavigation, intraoperative neuromonitoring, fluorescein dye-based intraoperative angiography, intraoperative ultrasound, and minimally invasive approaches, preceded in selected cases by endovascular embolization. Highly specialized neurosurgeons are able to achieve a very low risk of permanent morbidity for the removal of hemangioblastomas from the cerebellum and spinal cord. Small retinal tumors of the peripheral retina can be treated by laser coagulation, larger tumors by cryocoagulation or brachytherapy.

CONCLUSION

We consider management at experienced VHL centers mandatory and careful surveillance and monitoring of asymptomatic lesions are required to prevent unnecessary operations and minimize morbidity.

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.