Resection of a conus medullaris hemangioblastoma: Case report

Background

Conus medullaris tumors are rare, as the majority of all spinal cord tumors occur in the cervical and thoracic regions. Hemangioblastomas of the spinal cord account for 3%-4% of all intramedullary spinal cord tumors and can be sporadic or associated with von Hippel-Lindau disease. There are only fourteen cases of conus medullaris hemangioblastomas published in the literature, herein we present the fifteenth.

Case description

A 44-year old male with von Hippel Lindau disease presented with worsening bilateral lower extremity weakness, gait imbalance as well as absent perineal and genital sensation with weak voluntary anal contraction. MRI demonstrated multiple stable spinal tumors and a 6 mm conus medullaris hemangioblastoma with growth and a new peri-tumoral cyst. The patient underwent uncomplicated surgical resection with appreciable improvement in perineal sensation and sphincteric control during post-operative course.

Conclusions

Timely resection of conus medullaris tumors can provide symptomatic relief and prevent the progression of devastating neurological deficits. Careful microsurgical dissection with appropriate patient selection allows for safe resection of conus medullaris tumors.

Combined treatment of a medulla oblongata hemangioblastoma via permanent cysto-cisternal drainage and (postponed) gamma knife radiosurgery: a case report and review of the literature

BACKGROUND

Hemangioblastomas are histologically benign tumors with a variable degree of morbidity and mortality based on various factors, including their anatomical location. The following paper illustrates a unique approach of combined therapy of a brainstem hemangioblastoma (HB) not associated with von Hippel-Lindau disease (vHLd) located in the medulla oblongata.

CASE DESCRIPTION

A 21-year-old preschool teacher presented with vertigo, followed by dysphagia, trouble coughing, tongue paresis and headache and vomiting. Magnetic resonance imaging (MRI) revealed a large cystic lesion with a small intramural nodule located in the left anterolateral medulla oblongata directly behind the vertebral artery. The diagnosis of hemangioblastoma was supported by digital subtraction angiography.

CONCLUSION

Combined therapy consisted primarily of acute surgical fenestration and permanent drainage of the cystic portion of the tumor, due to symptomatic expansion. Follow-up stereotactic gamma knife radiosurgery was performed after 2 years for minor progression of the tumor nodule. To the best of our knowledge, this is the first time such approach has been described in the literature for this pathology.

A mobile hemangioblastoma of the cauda equina: Case report and review of the literature

Context: Cases of migratory spinal tumors have been reported since 1963. Most involve spinal schwannomas, which are benign tumors of the lining of nerve cells. We report a rare case of a mobile spinal hemangioblastoma, which is a type of benign vascular tumor. Findings: A 50-year-old man visited the hospital for painful swelling in his lower back. An MRI scan indicated that a lesion was at the L5 vertebral level. Two weeks later, however, an enhanced MRI showed that the lesion had migrated to the L4 vertebral level. During surgery, the location of the lesion remained consistent with the enhanced MRI reviewed. The histopathological diagnosis was hemangioblastoma. Conclusion: This is the first known report of a mobile spinal hemangioblastoma. Mobile spinal hemangioblastoma requires careful preoperative and intraoperative evaluation of its real-time location to avoid performing surgery at the wrong vertebral level.

Noncystic cerebellopontine angle hemangioblastoma: A case of an atypical location

•

Cerebellopontine angle hemangioblastoma is a rare condition.

•

Magnetic resonance imaging evaluation is important for the differential diagnosis of hemangioblastoma.

•

Surgical planning in hemangioblastoma surgery is a central key point.

Introduction

Extra-axial cerebellopontine angle (CPA) hemangioblastoma is a rare condition in which the correct differential diagnosis from other CPA lesions can affect the best treatment choice. These are benign tumors that are highly vascularized and mostly present in the cystic form. About twenty-six cases have been reported in the literature with this same location and with a noncystic aspect.

Presentation of case

We report a case of a 63-year-old male with a complaint of progressive headache associated with imbalance and difficulty walking. Neurological examination showed discreet facial paresis, left dysmetria and mild gait ataxia. Magnetic resonance imaging (MRI) showed a solid mass with isointensity on T1-weighted sequences; hypointensity and a heterogeneous appearance on T2-weighted sequences; and intense homogeneous contrast enhancement located in the left CPA region extending superiorly to the tentorial notch. The first diagnosis was meningioma, but during the microsurgical suboccipital retrosigmoid approach, it was observed that the lesion was extremely bloody with several vessels on its surface. We achieved gross total resection, and the pathology confirmed hemangioblastoma.

Discussion

Although it is rare, hemangioblastoma should be one of the differential diagnoses when dealing with CPA solid lesions with high contrast enhancement and heterogeneity on T2-weighted MRI. Analysis of the radiological characteristics allows a greater chance of confirmation and is one of the main tools for surgical planning.

Conclusion

Correct preoperative evaluation and the possibility that hemangioblastoma may arise from the CPA can avoid trans-operative risks mainly related to bleeding and can improve results.

Hemangioblastoma: clinicopathologic study of 42 cases with emphasis on TFE3 expression

Hemangioblastomas (HBs) histologically overlap with TFE3 rearrangement-associated tumors, which present as alveolar architecture and clear or eosinophilic granular cytoplasm. However, whether TFE3 is expressed in HBs remains unexplored. Herein, we analyzed the clinicopathologic features of 42 HBs emphasizing studies of TFE3 expression. Of 42 cases, 38 were sporadic and 4 were regarded as a part of von Hippel-Lindau (VHL) syndrome according to clinical presentation. Nineteen patients were male and 23 were female. Patient age ranged from 17 to 70 years (median 43). Tumor size ranged from 0.4 to 4.8 cm (mean 2.2 cm). Follow-up ranged from 1 to 60 months and 6 patients developed recurrence. Immunohistochemistry staining showed that 36 (86%) of 42 HBs expressed TFE3 in nuclei of tumor cells, of which 21 were evaluated as high TFE3 expression levels. Increased TFE3 expression was significantly associated with older ages (P=0.018) and larger tumor size (P=0.001). Seventeen HBs with high TFE3 expression were negative for rearrangement and amplification of TFE3 by FISH analysis, 3 of which including 2 sporadic and 1 VHL-related HBs demonstrated trisomies or tetrasomies of X-chromosome in 7%~18% of tumor cells. All 3 cases occurred in female, presented with a larger tumor size and displayed a similar morphologic appearance with high cellularity and hyperchromatic nuclei. Our study first reports TFE3 expression and its clinicopathological relevance in HBs. We hypothesize that TFE3 might be involved in the pathogenesis of non-VHL-related HBs. Furthermore, HBs with strong TFE3 expression should be differentiated from brain-metastatic TFE3-rearranged tumors.

A solitary hemangioblastoma of the posterior brain fossa: the role of radiotherapy

We report here the case of a patient admitted for management of posterior fossa cerebral hemangioblastoma. A 16-year-old male patient with a history of intracranial hypertension syndrome consisting of progressively worsening headache, vomiting, especially morning and jet vomiting, and decreased visual acuity. The patient's symptomatology worsened a few days later with the appearance of a disturbance of balance with enlargement of the sustentation polygon. The patient initially benefited from a brain computed tomography (CT) scan that objectified a solidocystic process of the posterior brain fossa. The patient then underwent a surgical excision that was considered partial and the diagnosis of hemangioblastoma was made on the surgical specimen. Since the surgical removal was partial the patient was referred to our training where he received external radiotherapy on his hemangioblastoma of the posterior brain fossa. The patient was examined one month after the end of irradiation; he presented a spectacular improvement in his neurological symptomatology with a clear regression of balance disorders. The standard treatment for cerebellar hemangioblastoma is complete microsurgical removal, but our results show a high level of efficacy for fractional photon radiotherapy after partial surgery of this benign tumour.

Molecular Advances in Central Nervous System Mesenchymal Tumors

Mesenchymal tumors of the central nervous system (CNS) comprise an array of neoplasms that may arise from or secondarily affect the CNS and its immediate surroundings. This review focuses on meningiomas and solitary fibrous tumors, the most common primary CNS mesenchymal tumors, and discusses recent advances in unveiling the molecular landscapes of these neoplasms. An effort is made to underscore those molecular findings most relevant to tumor diagnostics and prognostication from a practical perspective. As molecular techniques become more readily used at the clinical level, such alterations may strengthen formal grading schemes and lend themselves to treatment with targeted therapies.

Cerebellar hemangioblastoma during pregnancy: Management options and review of literature

Background:

Symptomatic cerebellar hemangioblastomas are extremely rare in pregnant women and the ideal management is not well established. In the present article, we aimed to report a case of large cerebellar hemangioblastoma complicated by pregnancy and managed successfully by surgical resection. In addition, we also discuss management options and review of the current literature pertaining to this pathology.

Case Description:

A 22-year-old female presented with a history of headache and vomiting for 4 weeks. She was carrying 28 weeks of pregnancy. She had left cerebellar signs, gait ataxia, and bilateral six nerve paresis. Fundus examination revealed bilateral papilledema. She was diagnosed to have large cerebellar hemangioblastoma with mass effect and obstructive hydrocephalus. She underwent suboccipital craniotomy and excision of lesion in lateral position. She recovered well postoperatively and delivered a healthy baby in the full term. Imaging at10- month follow-up demonstrates no residual lesion or another hemangioblastoma.

Conclusion:

Early diagnosis and direct surgery for excision of hemangioblastoma is a good option during pregnancy while avoiding CSF diversion procedures. The symptomatic hemangioblastoma during pregnancy can be safely operated during early pregnancy.

Stereotactic radiosurgery for central nervous system hemangioblastoma in von Hippel-Lindau disease: A systematic review and meta-analysis

Von Hippel-Lindau (VHL) disease is a dominantly inherited disorder marked by multiorgan tumors, such as central nervous system benign hemangioblastomas (CHB). Stereotactic radiosurgery (SRS) has also been used to treat CHB for a long time. The purpose of this meta-analysis is to provide a long-term outcome of SRS for VHL-associated CHB by reviewing published studies. We completed a Pubmed/Embase/SCOPUS/Cochrane Library literature search to get eligible studies published from January 1990 to December 2019 about using SRS to treat VHL-associated CHB. 15 studies met eligibility for qualitative systematic review, of which nine studies were ultimately eligible for quantity meta-analysis of 5-year tumor control rates (TCR), representing 170 subjects with a total of 660 lesions. Gamma Knife was the most published SRS method for VHL-associated CHB. The pooled 5-year TCR across the nine studies was 0.919 (95 %CI: 0.881-0.957). The pooled 5-year TCR for only intracranial lesions across eight studies was 0.917 (95 %CI: 0.876-0.957). Individual patient data were extracted from 9 studies, representing 298 lesions of 70 subjects. Sex, tumor volume, radiosurgery methods, marginal doses, maximum doses, the number of tumors for radiosurgery, age at the time of radiosurgery, tumor locations were not proven to be associated with tumor progression. SRS offered a satisfactory 5-year tumor control of CHB for VHL patients. Despite the paucity of randomized control trials, SRS is recommended to patients with limited surgical alternatives. However, the long-term outcomes and underlying factors associated with tumor progression remain to be investigated.

Spinal paraganglioma as unusual finding in von Hippel-Lindau disease

A 20-year-old patient with a history of von Hippel-Lindau disease reported on thoracic back pain radiating to the left shoulder for 10 weeks. Magnetic resonance imaging revealed a progressive contrast-enhancing tumor (14 × 21 × 28 mm) compressing the spinal cord and extending into the left neural foramen at T5/6. After embolization of supplying vessels, the tumor was completely resected via hemilaminectomy of T5. The postoperative course was uneventful without surgery related morbidity. The pathological examination disclosed a paraganglioma WHO grade I. We discuss the differential diagnoses and pitfalls of this unexpected finding in this patient with von Hippel-Lindau disease.

Safety and efficacy of surgical treatment for brainstem hemangioblastoma: a meta-analysis

Brainstem hemangioblastomas are benign, highly vascular tumors located in the mesencephalon, pons, and medulla oblongata. Although surgical resection is currently considered the main therapeutic option for symptomatic lesions, evidence supporting the application of microsurgery has not been systematically assessed. This meta-analysis aims to evaluate the safety and efficacy of surgical treatment for brainstem hemangioblastomas. A comprehensive search of the PubMed, Embase, and Web of Science databases was performed to identify all English language publications reporting the outcomes of surgical treatment for brainstem hemangioblastomas. Studies from January 1990 to July 2019 with ≥ 10 cases were included. We analyzed the surgical outcomes, including gross total resection, mortality, neurological morbidity, and functional outcome according to the McCormick Scale or Karnofsky Performance Scale. Thirteen studies with 473 cases were included. The pooled proportion of gross total resection was 98% (95% confidence interval (CI), 94-100%). Overall mortality and neurological morbidity were 4 (95% CI, 2-6%) and 13% (95% CI, 7-20%), respectively. Favorable functional outcomes at the last follow-up were achieved in 85% (95% CI, 78-92%) of all patients. Improved or stable functional outcomes at long-term follow-up were achieved in 94% (95% CI, 89-97%) of patients. This meta-analysis revealed that surgical treatment for brainstem hemangioblastomas is technically feasible and effective with lasting patient benefits and cure.

Microsurgical resection of a radicular hemangioblastoma with subarachnoid hemorrhage: how I do it

BACKGROUND

Hemangioblastomas (HBL) are benign tumors occurring sporadically or associated with Von Hippel-Lindau syndrome (VHL).

METHOD

We present the pre-, per-, and postoperative course of a rare case with radicular HBL presenting with subarachnoid hemorrhage (SAH) in the frame of VHL. We describe the microsurgical approach.

CONCLUSION

Complete microsurgical in bloc resection has been performed. Postoperative course was uneventful.

Novel and recurrent germline mutations in the VHL gene in 5 Arab patients with Von Hippel-Lindau disease

Inherited germline mutations in the VHL gene cause predisposition to Von Hippel-Lindau (VHL) disease. Patients exhibit benign and cancerous lesions in multiple tissues, including hemangioblastomas, clear cell renal cell carcinoma, cysts in kidneys and pancreas, and pheochromocytomas. Although pathogenic germline mutations in the VHL gene have been widely described in different populations, only a single mutation was previously reported in a family from mixed Arab-Persian ethnicity. Here, we present five Arab patients with two new and two recurrent germline mutations in the VHL gene. These mutations include three in-frame deletions and a missense mutation. Infrequent in-frame deletions in previously described patients from other populations, as well as the presence of new mutations, suggests a distinct spectrum of VHL gene mutations in Arab patients. While pulmonary manifestation has been described rarely in VHL disease, we have identified two patients with a recurrent p.Phe76del in-frame deletion exhibiting multiple nodules in lungs. We also describe a first-ever in-frame deletion in the VHL gene in a patient with VHL type 2C disease, exhibiting bilateral pheochromocytoma. Overall, the study provides an insight into the genotype-phenotype relationship of VHL disease in Arab patients and provides a comparison with previously described patients from other ethnicities.

Case report: a synonymous VHL mutation (c.414A > G, p.Pro138Pro) causes pathogenic familial hemangioblastoma through dysregulated splicing

Background

von Hippel-Lindau (VHL) disease is a familial neoplasia syndrome that results from the germline mutation of VHL. Pathogenic VHL mutations include deletion, frameshift, nonsense and missense mutations. Synonymous mutations are expected to be phenotypically silent and their role in VHL disease remains poorly understood.

Case presentation

We report a Caucasian male with a family history of pheochromocytoma and the synonymous VHL mutation c.414A > G (p.Pro138Pro). At 47-years, MRI revealed pheochromocytoma in the left adrenal gland and hemangioblastomas in the spine and brain. Pheochromocytoma was treated by adrenalectomy. Radiotherapy, followed by craniotomy and resection were needed to reduce hemangioblastomas to residual lesions. Two of three of the proband’s children inherited the mutation and both presented with retinal hemangioblastomas without pheochromocytoma at age 7: one twin needed four laser treatments. Primary skin fibroblasts carrying the heterozygous mutation or wild type VHL were established from the family. Mutant fibroblasts downregulated full-length VHL mRNA and protein, and upregulated the short VHL mRNA isoform (a result of exon 2 skipping in splicing) at the mRNA level but not at the protein level.

Conclusions

Our study shows that the synonymous VHL mutation c.414A > G can within 7 years induce pediatric retinal hemangioblastoma in absence of pheochromocytoma. This highlights the need to include splicing-altering synonymous mutations into the screening for VHL disease. This is also the first report on detecting and validating a synonymous VHL mutation using patient-derived fibroblasts. The mutation c.414A > G translates to p.Pro138Pro, yet it is not functionally silent, because it causes aberrant splicing by skipping exon 2. The reduced but not completely abolished pVHL protein in a loss-of-heterozygosity genetic backdrop may underlie the etiology of VHL disease.

Quantitative assessment and clinical relevance of VEGFRs-positive tumor cells in refractory brain tumors

Vascular endothelial growth factor (VEGF)/VEGF receptor (VEGFR)1 and 2 signaling is a potent activator of tumor angiogenesis. Although the expressions of VEGFR1 and VEGFR2 were initially thought to be limited to the endothelial cells, it is now known that both the receptors are expressed in tumor cells. This is the first study wherein VEGFRs-positive tumor cells are quantitatively evaluated for brain tumors with upregulated VEGF/VEGFR signaling. The percentage of VEGFRs-positive tumor cells was quantitatively evaluated in various brain tumors (10 glioblastomas, 22 neurofibromatosis type 2 [NF2]-related schwannomas, 21 sporadic schwannomas, 27 chordomas, 36 meningiomas, 29 hemangioblastomas, 11 hemangiopericytoma, and 13 ependymomas) using immunohistochemistry. VEGF-A expression was also analyzed using quantitative real-time polymerase chain reaction. Double immunofluorescence staining using anti-PDGFR-β and anti-CD34 antibody, microvessel density, and vessel diameter were analyzed to evaluate the vascular characteristics. Chordomas demonstrated an extremely higher percentage of VEGFR1 and VEGFR2-positive tumor cells than other tumors. In contrast, meningiomas and hemangiopericytomas showed few VEGFRs-positive tumor cells. The percentage of positive tumor cells in chordomas, hemangioblastomas, and NF2 schwannomas was associated with clinical courses, such as shorter progression free survival, and growth speed. Glioblastomas and NF2 schwannomas showed larger tumor vessels without pericyte coverage. The present study is the first to quantitatively analyze VEGFR1- and VEGFR2- positive tumor cells in various types of refractory brain tumors. This novel parameter significantly correlated with the progressive clinical courses.

Surgical Management of Intramedullary Spinal Cord Tumors

Intramedullary spinal cord tumors (IMSCT) comprise a rare subset of CNS tumors that have distinct management strategies based on histopathology. These tumors often present challenges in regards to optimal timing for surgery, invasiveness, and recurrence. Advances in microsurgical techniques and technological adjuncts have improved extent of resection and outcomes with IMSCT. Furthermore, adjuvant therapies including targeted immunotherapies and image-guided radiation therapy have witnessed rapid development over the past decade, further improving survival for many of these patients. In this review, we provide an overview of types, epidemiology, imaging characteristics, surgical management strategies, and future areas of research for IMSCT.

A Large Solitary Hemangioblastoma of the Lateral Ventricles: A Case Report and Literature Review

Hemangioblastoma (HB) in the supratentorial region of the brain is rare and only a few cases are reported on intraventricular HB. HB of the lateral ventricles is even rarer. We present a case of a 30-year-old man with generalized tonic clonic seizures. The brain computed tomography showed a 5.5 cm heterogeneous mass extending into both lateral ventricles with partial enhancement. Based on the size and imaging features, we present the fourth documented case of a large solitary intraventricular HB. Our approach to this unique case and some treatment complexities are also described.

Considering the rarity of the case and the patient’s imaging features, the present study provides a better understanding of HB and recommends HB to be considered in the differential diagnosis of masses in the lateral ventricles. In addition, some preventable pitfalls in the treatment of such complex cases are described.

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.

Posterior Petrosal Transotic Approach for Cerebellopontine Angle Hemangioblastoma: Technical Case Report

BACKGROUND AND IMPORTANCE

Although posterior petrosal approaches are utilized less frequently in many practices today, they continue to provide distinct surgical advantages in carefully selected cases. Here, we report a case of a recurrent cerebellopontine angle (CPA) hemangioblastoma that had failed a prior, more conservative, surgical approach. We provide cadaveric dissections of variations of posterior petrosal approaches to illustrate the advantages of the selected approach.

CLINICAL PRESENTATION

A 70-yr-old female presented with a growing left CPA hemangioblastoma. The lesion had undergone a prior subtotal resection from a retrosigmoid approach and subsequent adjuvant radiation treatment. The patient had worsening left facial strength, progressive balance difficulty, and absent left auditory function. Preoperative angiogram demonstrated arterial blood supply from the left anterior inferior cerebellar artery (AICA) that was deemed unsafe for embolization due to significant arteriovenous shunting. A posterior petrosal transotic approach was performed in order to optimize the working angle to the anterior brainstem and afford the ability to occlude the vascular supply from AICA prior to surgical resection of the lesion.

CONCLUSION

The posterior petrosal transotic approach offers an improved surgical working angle to the anterior brainstem compared to the translabyrinthine approach. This advantage can be particularly important with vascular tumors that receive blood supply anteriorly, as in this case from AICA, and can improve the safety of the resection.

A Case of Sporadic Suprasellar Hemangioblastoma Mimicking Meningioma

Hemangioblastoma (HBL) in the suprasellar region is very rare and a few cases have been reported. Suprasellar HBL without von Hippel-Lindau disease is much rarer. A 76-year old male patient presented progressively deteriorating visual disturbance. MRI demonstrated solid suprasellar mass of 20 mm in diameter, broadly based to planum sphenoidale and diaphragm sella and dural tail sign after the administration of gadolinium diethylene triamine penta-acetic acid (Gd-DTPA). Preoperative diagnosis was meningioma. Total resection of the tumor was not accomplished because of massive hemorrhage, and the histopathologic examination revealed the tumor to be HBL. The visual disturbance of the patient was not improved. The authors reviewed the literature and considered a differential diagnosis of suprasellar tumors and treatment of suprasellar HBL.

Functional Outcome After Resection of Von Hippel-Lindau Disease-Associated Cauda Equina Hemangioblastomas: An Observational Cohort Study

BACKGROUND

Cauda equina hemangioblastomas in von Hippel-Lindau (VHL) disease can cause significant neurological signs and symptoms. Despite their associated morbidity, the management of these tumors remains incompletely defined.

OBJECTIVE

To determine optimal management, we analyzed the functional outcomes after resection of these tumors.

METHODS

VHL patients who underwent surgical resection of cauda equina hemangioblastomas at the National Institutes of Health and the University of Virginia were included. Clinical and radiological follow-up was performed at 6- to 12-month intervals after surgery.

RESULTS

Fifteen patients underwent 18 operations for 21 cauda equina hemangioblastomas (median follow-up 5.9 years). Patients often presented with multiple symptoms, including pain (67%), numbness (50%), urinary complaints (33%), and weakness (11%). Median preoperative tumor volume was 1.2 cm 3 . Four tumors at 3 operations were not resected due to a motor nerve root origin. Gross total resection was achieved in 14 surgeries (93% of operations when resection was attempted). New mild (non-function limiting) neurological symptoms were noted after 11 operations (61%), which most often (64%) resolved within 2 weeks of surgery. At 6-month follow-up, 15 patients (83%) were stable, 2 (11%) were improved, and 1 (6%) was worse. Histological analysis revealed that all tumors originated from within the involved nerve fascicle.

CONCLUSIONS

VHL-associated cauda equina hemangioblastomas have an intrafascicular origin and require interruption of the rootlet of origin for complete resection. Motor nerve root involvement may preclude complete resection but strategies including bony decompression and/or interruption of vascular supply may provide a therapeutic option. Nevertheless, most VHL patients with symptom-producing lesions improve with resection.

Retractorless interhemispheric transtentorial approach for large lesions in the posterior incisural space

Background:

Surgical resection of lesions in the posterior incisural space presents a significant surgical challenge, which may result in postoperative visual complications and other neurological deficits. We, therefore, describe a retractorless interhemispheric transtentorial approach that avoids surrounding brain structures with positive outcomes and no complications or visual damage.

Case Description:

We present four cases of lesions in the posterior incisural space that was treated with a retractorless interhemispheric transtentorial approach. Two patients were previously seen at another institution for a falcotentorial meningioma. We resected the meningiomas with a parietal-occipital interhemispheric transtentorial approach with no neurological deficits. A third patient presented with a large superior vermian hemangioblastoma with a steep angle of the tentorium. The fourth patient had a large upper vermian metastatic lesion with progressive enlargement, which was refractory to radiation treatments and chemotherapy, and we achieved partial resection. Postoperative visual function was completely preserved in all patients.

Conclusion:

A carefully executed retractorless interhemispheric approach in select cases is an effective option to reduce morbidity and prevent visual complications when removing lesions in the posterior tentorial incisure.

Dural-Based Frontal Lobe Hemangioblastoma

BACKGROUND

Hemangioblastomas are benign vascular neoplasms that may be associated with von Hippel-Lindau disease. They are more common in men, with a mean age of 36 years, and rarely affect the supratentorial region and, when present in this topography, do not have meningeal impairment. Diagnosis by the radiologic and histopathologic study is difficult, since they are rare and, therefore, forgotten diagnosis, besides they are differential diagnoses with other supratentorial neoplasms.

CASE DESCRIPTION

The present report describes a case of a frontal hemangioblastoma in a 64-year-old woman who presented with seizures. Our imaging studies had as a main hypothesis a frontal meningioma because of dural tail sign, lack of edema, contrast enhancement pattern, and extra-axial location in the supratentorial region, in the frontal lobe, which is uncommon for a hemangioblastoma. The patient underwent microneurosurgery for tumor resection, and the excised tissue was submitted for anatomopathologic evaluation. This study clarified the diagnosis as hemangioblastoma. We followed up the patient at the outpatient clinic for 2 years, with clinical improvement, without tumor recurrence. We also compared the clinical, radiologic, epidemiologic, and anatomopathologic data of the reported case with data from a literature review conducted through the PubMed portal.

CONCLUSIONS

Definitive treatment for these lesions is surgical resection. Physicians should be aware that supratentorial meningeal hemangioblastomas can be developed in a patient without von Hippel-Lindau disease and regular follow-up is mandatory.

Optic Nerve Hemangioblastoma: Review

BACKGROUND

Hemangioblastomas of the optic nerve are very rare tumors. They occur in association with Von Hippel-Lindau (VHL) syndrome; however, sporadic occurrences have been reported. We describe here a case of optic nerve hemangioblastoma in the absence of VHL and review the pertinent literature.

CASE DESCRIPTION

A 33-year-old woman presented with gradually progressive vision loss in the right eye. On examination, the visual acuity on the right was hand movement close to face in all quadrants. Color discrimination was impaired. Fundoscopy revealed optic atrophy and no other retinal pathology. There was relative afferent pupillary defect in the right eye. No neurocutaneous markers were found. Imaging revealed lesion isointense on T1, hyperintense on T2/fluid-attenuated inversion recovery, and showing relatively homogenous enhancement on postcontrast study. Multiple flow voids were seen in the intracranial part of the lesion. The proximal part of the intraorbital right optic nerve was enlarged and tortuous with distended optic nerve sheath. A right single-piece fronto-orbital craniotomy was done. A reddish lesion seen involving the right optic nerve just proximal to the chiasm with multiple vessels and a distinct feeding vessel was seen supplying the tumor. The lesion was excised and the optic nerve was sacrificed approximately 1 cm proximal to the chiasm. The postoperative course was uneventful.

CONCLUSIONS

Conclusions: Optic nerve hemangioblastoma is a rare occurrence and a high level of suspicion is required preoperatively in the absence of VHL syndrome.

Gamma Knife Stereotactic Radiosurgery favorably changes the clinical course of hemangioblastoma growth in von Hippel-Lindau and sporadic patients

PURPOSE

This is the first single-institution study of its size to characterize the treatment impact and to address the question of whether hemangioblastoma treatment with Gamma Knife Stereotactic Radiosurgery (GKRS) in both sporadic and VHL patients changes the characteristic saltatory hemangioblastoma growth pattern.

METHODS

The authors reviewed a single-institution tumor registry to identify patients who had received GKRS for hemangioblastomas between January 1st, 1999, and December 31st, 2017.

RESULTS

15 patients with 101 lesions met search criteria with a median age of first GKRS of 39.2 years (interquartile range [IQR] of 25.7-57.4 years), including 96 VHL and 5 sporadic lesions. The median time from GKRS to last follow-up was 5.4 years (IQR 2.3-11.5 years). 4 lesions (4%) and 3 patients (20%) experienced a local failure. The 1-year, 3-year, and 5-year freedom from new hemangioblastoma formation rates were 97%, 80%, and 46% respectively. Multivariate analysis revealed a reduction in tumor volume after GKRS. Several variables associated with a greater percent reduction in volume from GKRS to last follow-up: non-cystic status (p = .01), no prior craniotomy (p = .04), and follow-up time from GKRS (p < .0001).

CONCLUSIONS

GKRS is a successful long-term treatment option for hemangioblastomas changing the clinical course from saltatory growth to reduction in tumor volume. Non-cystic tumors and those without prior craniotomy were associated with a greater percent reduction in volume from GKRS at last follow-up.