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Reecher HM, Hussain O, Treffy R, Nerva JD. Preoperative embolization and microsurgical resection of a cerebellar hemangioblastoma: embolization goals and technical nuances of the approaches. Illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2024; 7:CASE24100. [PMID: 38768516 PMCID: PMC11111415 DOI: 10.3171/case24100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 03/28/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Resection remains the optimal treatment for hemangioblastomas, highly vascular tumors commonly located in the cerebellum or spinal cord. Preoperative embolization can be used with caution to reduce intraoperative blood loss and promote gross-total resection while reducing neurological morbidity. OBSERVATIONS The authors report a case of a 44-year-old male who presented with worsening dizziness, gait imbalance, and diplopia. Imaging revealed a large vascular cerebellar mass with brainstem compression and hydrocephalus, concerning for hemangioblastoma. The patient underwent preoperative embolization of the main arterial supply from the right superior cerebellar artery, which devascularized the tumor and reduced the early venous shunting, followed by gross-total resection of the tumor. Preoperative embolization helped to facilitate safe microsurgical resection because this main arterial supply was deep to the planned surgical approach, and the Onyx cast served as a landmark of the dorsal midbrain and remaining arterial supply. This resulted in minimal intraoperative blood loss. At 2-year follow-up, the patient's diplopia and vertigo had resolved, and his gait continues to improve. LESSONS Despite controversy regarding the use of preoperative embolization for hemangioblastoma resection, the authors emphasize its safety and utility during resection of a large cerebellar hemangioblastoma. Onyx embolization provided benefit in both reducing the tumor blood supply and serving as intraoperative visual guidance.
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2
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Vargas-Urbina J, Crisanto-Silva JA, Vásquez-Perez C, Davila-Adrianzén A, Alcas-Seminario D, Lines-Aguilar W, Mamani-Choquepata R, Panta-Rojas G. Multimodal management of giant solid hemangioblastomas in two patients with preoperative embolization. Surg Neurol Int 2024; 15:144. [PMID: 38742001 PMCID: PMC11090543 DOI: 10.25259/sni_28_2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 04/04/2024] [Indexed: 05/16/2024] Open
Abstract
Background Hemangioblastomas are benign vascular neoplasms, World Health Organization grade I, with the most frequent location in the cerebellum. Complete microsurgical resection can be a challenge due to excessive bleeding, which is why preoperative embolization takes importance. Case Description Two clinical cases are presented, a 25-year-old woman and a 75-year-old man, who presented with intracranial hypertension symptoms due to obstructive hydrocephalus; a ventriculoperitoneal shunt was placed in both cases; in addition, they presented with cerebellar signs. Both underwent embolization with ethylene vinyl alcohol copolymer, with blood flow reduction. After that, they underwent microsurgical resection within the 1st-week post embolization, obtaining, in both cases, gross total resection without hemodynamic complications, with clinical improvement and good surgical outcome. It is worth mentioning that surgical management is the gold standard that allows a suitable surgical approach, like in our patients, for which a lateral suboccipital craniotomy was performed. Conclusion Solid hemangioblastomas are less frequent than their cystic counterparts. The treatment is the surgical resection, which is a challenge and always has to be considered as an arteriovenous malformation in the surgical planning, including preoperative embolization to reduce perioperative morbidity and mortality and get good outcomes.
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Affiliation(s)
- John Vargas-Urbina
- Department of Neurosurgery, Instituto Nacional de Ciencias Neurologicas, Lima, Peru
| | | | - Carlos Vásquez-Perez
- Department of Neurosurgery, Instituto Nacional de Ciencias Neurologicas, Lima, Peru
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3
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Bauman MM, Bouchal SM, Kerezoudis P, Cloft H, Brinjikji W, Peris Celda M, Link MJ, Parney IF. Embolization of Large and Giant Posterior Fossa Hemangioblastomas: The Experience of a Single Tertiary Care Center. J Neurol Surg B Skull Base 2023; 84:598-608. [PMID: 37854530 PMCID: PMC10581830 DOI: 10.1055/a-1946-4604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 09/13/2022] [Indexed: 10/14/2022] Open
Abstract
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.
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Affiliation(s)
- Megan M.J. Bauman
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, Minnesota, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Samantha M. Bouchal
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, Minnesota, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | | | - Harry Cloft
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, United States
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, United States
| | - Maria Peris Celda
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Michael J. Link
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Ian F. Parney
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
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4
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Palavani LB, Andreão FF, de Abreu LV, Batista S, Borges J, Oliveira LDB, Bertani R, Filho JAA. Assessing the efficacy and safety of hemangioblastoma embolization: A comprehensive systematic review and meta-analysis. J Clin Neurosci 2023; 117:104-113. [PMID: 37788533 DOI: 10.1016/j.jocn.2023.09.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 09/16/2023] [Accepted: 09/24/2023] [Indexed: 10/05/2023]
Abstract
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.
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Affiliation(s)
| | - Filipi Fim Andreão
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Sávio Batista
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | | | - Raphael Bertani
- Department of Neurosurgery, University of São Paulo, São Paulo, Brazil.
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5
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AlEnazi A, Alshawi Y, Alnasser H, AlAftan M, AlQahtani M. Facial palsy following onyx embolization of a glomus tympanicum tumor: A case report and literature review. INDIAN JOURNAL OF OTOLOGY 2022. [DOI: 10.4103/indianjotol.indianjotol_220_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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6
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Haryu S, Niizuma K, Endo H, Sato K, Watanabe M, Tominaga T. Case of Clear Cell Ependymoma Successfully Treated with Preoperative Embolization. JOURNAL OF NEUROENDOVASCULAR THERAPY 2020; 14:394-399. [PMID: 37501672 PMCID: PMC10370905 DOI: 10.5797/jnet.cr.2020-0050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 04/30/2020] [Indexed: 07/29/2023]
Abstract
Objective Clear cell ependymoma (CCE) is known to be very similar to hemangioblastoma (HB) in regards to neuroimaging and histopathology. We report a rare case of CCE in which successfully underwent preoperative embolization with a prior diagnosis of HB. Case Presentation A 58-year-old woman presented with vertigo for several months. MRI showed the right cerebellar tumor mimicking solid HB. DSA revealed the hypervascular tumor supplied by branches of the posterior inferior cerebellar artery (PICA). To reduce intraoperative bleeding, preoperative embolization was performed using n-butyl-2-cyanoacrylate (NBCA). A flow-guided microcatheter was guided to the proper feeders, and diluted NBCA was injected. Sufficient devascularization was achieved. The tumor was totally resected with minimal blood loss the next day. Postoperative pathological diagnosis was CCE. Conclusion This is the first report that preoperative embolization was performed to CCE with careful techniques and recent advanced devices. Since CCE has a poorer prognosis, preoperative embolization for safety total resection may be more important.
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Affiliation(s)
- Shinya Haryu
- Department of Neurosurgery, Tohoku Medical and Pharmaceutical University, Sendai, Miyagi, Japan
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Kuniyasu Niizuma
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Hidenori Endo
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Kenichi Sato
- Department of Neuroendovascular Therapy, Kohnan Hospital, Sendai, Miyagi, Japan
| | - Mika Watanabe
- Department of Pathology, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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7
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Kord Valeshabad A, Xiao L, Amin-Hanjani S, Alsadi A, Valyi-Nagy T, Kim J. Sporadic Hemangioblastoma of the Cavernous Sinus and Meckel's Cave. J Neurol Surg Rep 2018; 79:e98-e102. [PMID: 30574445 PMCID: PMC6291399 DOI: 10.1055/s-0038-1676455] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 08/28/2018] [Indexed: 11/01/2022] Open
Abstract
Objectives To describe an extremely rare case of sporadic hemangioblastoma (HB) within the cavernous sinus and Meckel's cave with extension to the cerebellopontine angle (CPA) cistern. Methods A 73-year-old male presented with hearing loss, unilateral ptosis, and facial numbness. Results The imaging showed a complex cystic-solid mass centered at the left cavernous sinus and Meckel's cave with extension to the CPA cistern. Patient underwent retrosigmoid craniectomy for partial resection of the CPA angle component of the mass. Surgical pathology confirmed the diagnosis of HB and patient was scheduled for subsequent radiotherapy of the residual mass. Conclusions We present an exceptional case of supratentorial HB without associated von Hippel-Lindau (VHL) disease, which was predominantly located in the cavernous sinus and Meckel's cave and led to multiple cranial nerve symptoms. We describe imaging characteristics and radiologic-pathologic correlation of this atypically located HB, which can be difficult to consider in the differential diagnosis presurgically.
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Affiliation(s)
- Ali Kord Valeshabad
- Department of Radiology, University of Illinois at Chicago, Chicago, Illinois, United States
| | - Lekui Xiao
- Department of Radiology, University of Illinois at Chicago, Chicago, Illinois, United States
| | - Sepideh Amin-Hanjani
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, United States
| | - Alaa Alsadi
- Department of Pathology, University of Illinois at Chicago, Chicago, Illinois, United States
| | - Tibor Valyi-Nagy
- Department of Pathology, University of Illinois at Chicago, Chicago, Illinois, United States
| | - Jinsuh Kim
- Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama, United States
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8
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Akinduro OO, Mbabuike N, ReFaey K, Yoon JW, Clifton WE, Brown B, Wharen RE, Quinones-Hinojosa A, Tawk RG. Microsphere Embolization of Hypervascular Posterior Fossa Tumors. World Neurosurg 2018; 109:182-187. [DOI: 10.1016/j.wneu.2017.09.147] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 09/20/2017] [Accepted: 09/21/2017] [Indexed: 11/16/2022]
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9
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Yanez N, Cifuentes LK, Mejia M, Useche JN. Advantages of using a detachable-tip microcatheter and liquid embolic agents in the preoperative embolization of a recurrent cerebellar hemangioblastoma: A case report. Surg Neurol Int 2017; 8:239. [PMID: 29026675 PMCID: PMC5629862 DOI: 10.4103/sni.sni_123_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 07/24/2017] [Indexed: 11/04/2022] Open
Abstract
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.
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Affiliation(s)
- Nicolas Yanez
- School of Medicine, Universidad de los Andes, Bogota DC, Colombia.,Department of Diagnostic and Interventional Imaging, Hospital Universitario Fundacion Santa Fe de Bogota, Bogota DC, Colombia
| | - Luisa K Cifuentes
- Department of Diagnostic and Interventional Imaging, Hospital Universitario Fundacion Santa Fe de Bogota, Bogota DC, Colombia
| | - Marcela Mejia
- Department of Pathology, Hospital Universitario Fundacion Santa Fe de Bogota, Bogota DC, Colombia
| | - Juan N Useche
- Department of Diagnostic and Interventional Imaging, Hospital Universitario Fundacion Santa Fe de Bogota, Bogota DC, Colombia
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10
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Gupta S, Pal L, Sardhara JC, Jaiswal AK, Srivastava A, Mehrotra A, Das KK, Behari S. Recurrent or symptomatic residual posterior fossa hemangioblastomas: how are they different from their primary counterparts? Acta Neurochir (Wien) 2017; 159:1497-1510. [PMID: 28601978 DOI: 10.1007/s00701-017-3225-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 05/15/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Posterior fossa hemangioblastomas are WHO grade I benign lesions with a surprisingly high recurrence rate. This study determines the factors responsible for recurrence and the clinico-radiological and histopathological differences between primary (group A; n = 60) and recurrent/symptomatic residual (group B; n = 24) tumors. METHODS Radiologically, tumors were differentiated into cystic, cystic with a mural nodule, solid-cystic/microcystic and solid. Surgery was undertaken via a midline or lateral suboccipital approach. Histopathology differentiated them into reticular, cellular or mixed subtypes. RESULTS Truncal-appendicular ataxia in group A and von Hippel-Lindau (VHL) disease and raised intracranial pressure in group B were the predominant presentations. VHL patients in group B had a longer duration of symptoms (median 72 months) than those with non-VHL recurrences (median: 36 months). Multicentric mural nodules (n = 9/24, 37.50%, P = 0.0001) and bilateral cerebellar hemispheric involvement (n = 6/24, 25%, P = 0.0003) were exclusively seen in the preoperative radiology of group B tumors. Brainstem involvement was seen in the tumors of ten (16.67%) patients in group A and six (25.00%) patients in group B. One subset of patients required several resurgeries for repeated recurrences. Abnormal vascular proliferation and papillary projections into adjacent brain, and highly cellular stroma were unique histological features at recurrence. Total resection was achieved in 45 group A and 19 group B patients. The outcome based on the Karnofsky performance scale (KPS) was assessed at follow-up at 6 weeks (A: n = 60, B: n = 24): KPS0: A = 4, B = 1; KPS10-40 (dependent): A: 4, B = 5; KPS50-70 (independent for daily needs): A = 36, B = 16; KPS80-100 (fully independent): A = 16; B = 2. CONCLUSIONS In recurrent/residual tumors, the radiological as well as histopathological features showed a distinctive change toward a more aggressive nature. Higher incidences of multiple mural nodules, bilateral spread, remote recurrence and VHL disease at preoperative radiology; as well as proliferative angioarchitecture, an irregular brain tumor interface and highly cellular stroma at histology were found in these patients compared to their primary counterparts.
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Affiliation(s)
- Shruti Gupta
- Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Lily Pal
- Department of Pathology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Jayesh C Sardhara
- Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Awadhesh K Jaiswal
- Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Arun Srivastava
- Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Anant Mehrotra
- Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Kuntal Kanti Das
- Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Sanjay Behari
- Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, 226014, India.
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Laviv Y, Thomas A, Kasper EM. Hypervascular Lesions of the Cerebellopontine Angle: The Relevance of Angiography as a Diagnostic and Therapeutic Tool and the Role of Stereotactic Radiosurgery in Management. A Comprehensive Review. World Neurosurg 2016; 100:100-117. [PMID: 28049034 DOI: 10.1016/j.wneu.2016.12.091] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 12/18/2016] [Accepted: 12/20/2016] [Indexed: 01/08/2023]
Abstract
BACKGROUND The cerebellopontine angle (CPA) is a narrowed skull base area containing important cranial nerves and vessels and bordering with eloquent areas of the posterior fossa. Tumors of the CPA are a heterogeneous group and can have extradural, intradural/extra-axial, or intra-axial origins. Their vascular supply changes depending on their anatomic origin. Symptomatic, large CPA tumors require surgical resection in order to prevent irreversible, severe neurological damages. However, its tight and strategical location make surgery in the CPA very challenging and require appropriate pre-surgical planning. Pre-surgical diagnosis is of great importance as it allows us to choose the optimal management for the particular patient. This is of further significance when encountering high-risk lesions such as hypervascular tumors. Neurosurgeons should utilize every available pre-surgical diagnostic modalities as well as neo-adjuvant treatments in order to reduce such risks. METHODS We review all reported cases of hypervascular lesions of the CPA and discuss the roles of angiography and stereotactic radiosurgery in their management. RESULTS Three lesions of the CPA can be considered as truly hypervascular: hemangioblastomas, hemangiopericytomas and paragangliomas. All lesions share many radiological features. However, each lesion has a different anatomical origin and hence, has a characteristic vascular supply. Pre-surgical angiography can be utilized as a diagnostic tool to narrow down the differential diagnosis of a vascular CPA lesion, based on the predominant supplying vessel. In addition, pre-surgical embolization at time of angiography will narrow the associated surgical risks. CONCLUSIONS Angiography is a crucial diagnostic and therapeutic tool, helping both in narrowing the presurgical differential diagnosis and in controlling intraoperative bleeding. Because of the high surgical risks associated with resection of vascular tumors in the CPA, noninvasive treatments, such as stereotactic radiosurgery, also may have a crucial role.
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Affiliation(s)
- Yosef Laviv
- Division of Neurosurgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
| | - Ajith Thomas
- Division of Neurosurgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ekkehard M Kasper
- Division of Neurosurgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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12
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Ene CI, Xu D, Morton RP, Emerson S, Levitt MR, Barber J, Rostomily RC, Ghodke BV, Hallam DK, Albuquerque FC, McDougall CG, Sekhar LN, Ferreira M, Kim LJ, Chang SW. Safety and Efficacy of Preoperative Embolization of Intracranial Hemangioblastomas. Oper Neurosurg (Hagerstown) 2016; 12:135-140. [PMID: 29506092 DOI: 10.1227/neu.0000000000001014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Accepted: 07/20/2015] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Chibawanye I Ene
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - David Xu
- Department of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Ryan P Morton
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Samuel Emerson
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Michael R Levitt
- Department of Radiology, University of Washington, Seattle Washington
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Robert C Rostomily
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Basavaraj V Ghodke
- Department of Neurological Surgery, University of Washington, Seattle, Washington.,Department of Radiology, University of Washington, Seattle Washington
| | - Danial K Hallam
- Department of Neurological Surgery, University of Washington, Seattle, Washington.,Department of Radiology, University of Washington, Seattle Washington
| | - Felipe C Albuquerque
- Department of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Cameron G McDougall
- Department of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Laligam N Sekhar
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Manuel Ferreira
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Louis J Kim
- Department of Neurological Surgery, University of Washington, Seattle, Washington.,Department of Radiology, University of Washington, Seattle Washington
| | - Steve W Chang
- Department of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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13
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Sultan A, Hassan T, Aboul-Enein H, Mansour O, Ibrahim T. The value of preoperative embolization in large and giant solid cerebellar hemangioblastomas. Interv Neuroradiol 2016; 22:482-8. [PMID: 26934897 DOI: 10.1177/1591019916633244] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2016] [Accepted: 01/25/2016] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Solid cerebellar hemangioblastomas are highly vascular lesions and may cause catastrophic hemorrhage during excision. METHODS This retrospective study enrolled 10 patients (7 men and 3 women, with a mean age of 38.2 ± 12.5 years) with solid cerebellar hemangioblastomas. All patients had a solitary tumor and underwent surgical resection of the lesion through a suboccipital approach. The basic features, serial radiographic examinations, and operative records were analyzed. RESULTS The most common presenting symptoms were headache (100%), ataxia (100%), and long tract manifestations (60%). Three patients had experienced failed surgery previously due to massive intraoperative bleeding. Three patients were confirmed as having Von Hippel-Lindau disease. The average size of the tumor was 40.7 ± 8.7 mm in its maximal diameter (range 25-58 mm). Total endovascular occlusion obtained in six patients, near total occlusion in three patients, and incomplete occlusion in one patient. Nine (90.0%) patients underwent gross total resection and one (10.0%) underwent partial resection. After the primary surgery, eight (80.0%) patients experienced improvement in their symptoms, two (20.0%) maintained their pre-treatment status, and none showed neurological deterioration following tumor resection. Blood loss during surgery after embolization was minimal and controllable. CONCLUSION Preoperative embolization improves safety and efficacy of the microsurgical excision of such tightly located very vascular tumors. Embolization changes the concept of this lesion surgery into piecemeal removal rather than a total mass extraction technique. Liquid agents are superior to particles in obliteration of such lesions.
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Affiliation(s)
- Ahmed Sultan
- Department of Neurosurgery, Alexandria University School of Medicine, Egypt The Research Center of Computational Neurovascular Biomechanics, Somoha University Hospital, Alexandria, Egypt
| | - Tamer Hassan
- Department of Neurosurgery, Alexandria University School of Medicine, Egypt The Research Center of Computational Neurovascular Biomechanics, Somoha University Hospital, Alexandria, Egypt
| | - Hisham Aboul-Enein
- Department of Neurosurgery, Alexandria University School of Medicine, Egypt
| | - Osama Mansour
- The Research Center of Computational Neurovascular Biomechanics, Somoha University Hospital, Alexandria, Egypt Department of Interventional Neurology, Alexandria University School of Medicine, Egypt
| | - Tamer Ibrahim
- Department of Neurosurgery, Alexandria University School of Medicine, Egypt The Research Center of Computational Neurovascular Biomechanics, Somoha University Hospital, Alexandria, Egypt
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