Clinical and surgical features of lower brain stem hemangioblastomas in von Hippel-Lindau disease

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.

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.

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.

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.

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.

Area Postrema: Fetal Maturation, Tumors, Vomiting Center, Growth, Role in Neuromyelitis Optica

INTRODUCTION

The area postrema in the caudal fourth ventricular floor is highly vascular without blood-brain or blood-cerebrospinal fluid barrier. In addition to its function as vomiting center, several others are part of the circumventricular organs for vasomotor/angiotensin II regulation, role in neuromyelitis optica related to aquaporin-4, and somatic growth and appetite regulation. Functions are immature at birth. The purpose was to demonstrate neuronal, synaptic, glial, or ependymal maturation in the area postrema of normal fetuses. We describe three area postrema tumors.

METHODS

Sections of caudal fourth ventricle of 12 normal human fetal brains at autopsy aged six to 40 weeks and three infants aged three to 18 months were examined. Immunocytochemical neuronal and glial markers were applied to paraffin sections. Two infants with area postrema tumors and another with neurocutaneous melanocytosis and pernicious vomiting also studied.

RESULTS

Area postrema neurons exhibited cytologic maturity and synaptic circuitry by 14 weeks'. Astrocytes coexpressed vimentin, glial fibrillary acidic protein, and S-100β protein. The ependyma is thin over area postrema, with fetal ependymocytic basal processes. A glial layer separates area postrema from medullary tegmentum. Melanocytes infiltrated area postrema in the toddler with pernicious vomiting; two children had primary area postrema pilocytic astrocytomas.

CONCLUSIONS

Although area postrema is cytologically mature by 14 weeks, growth increases and functions mature during postnatal months. We recommend neuroimaging for patients with unexplained vomiting and that area postrema neuropathology includes synaptophysin and microtubule-associated protein-2 in patients with suspected dysfunction.

Hemangioblastoma of Cerebral Aqueduct Removed via Sitting, Supracerebellar Intracollicular Approach

BACKGROUND

Tumors protruding into the cerebral aqueduct are rare, and tumors arising from within the cerebral aqueduct are rarer still.

CASE DESCRIPTION

In this report, we discuss the presentation and clinical outcome of a 65-year-old man who presented to us with symptoms of hydrocephalus. Prior imaging had revealed a small enhancing nodule within the cerebral aqueduct. In the 6 months between initial imaging and our seeing the patient, the tumor demonstrated substantial interval growth, so the patient was offered resection. The tumor was accessed using a sitting, supracerebellar, intracollicular approach, which allowed for gross total resection of the mass without complication. Histopathology later revealed the lesion to be a hemangioblastoma. Two years after surgery, the patient was doing well with no neurologic deficits.

CONCLUSIONS

We report the first case of an aqueductal hemangioblastoma and describe our use of a sitting, supracerebellar, intracollicular approach to access tumors occupying this cerebrospinal fluid space.

Intermittent Myokymia as a Pointer to Hemangioblastoma of the Cervical Spine: A Case Report

Hemangioblastomas represent 3% of all central nervous system (CNS) tumors. The majority of CNS hemangioblastomas are infratentorial, with the cerebellum being the most frequent location, while 13% are found in the brainstem. Symptoms of brainstem hemangioblastomas can be very subtle and might therefore be overlooked or misinterpreted. We report the case of a patient with a hemangioblastoma at the junction of the medulla oblongata and the cervical spine and provide a brief review of the literature.

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.

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.

Subarachnoid Hemorrhage after Surgery of the Medulla Oblongata Hemangioblastoma: A Case Report

Objectives

To discuss the bleeding mechanisms after removing a medulla oblongata hemangioblastoma.

Methods

A 42-year-old male patient was diagnosed with a medulla oblongata hemangioblastoma. Preoperative cranial magnetic resonance imaging, computed tomography angiography and post-surgery computed tomography were completed during clinical procedure. We also reviewed the related literatures.

Results

The preoperative computed tomography angiography did not demonstrate any intracranial aneurysm. But, the patient had a fatal subarachnoid hemorrhage with ventricular hemorrhage 4 hours after surgery following the post-surgery computed tomography.

Conclusions

Subarachnoid hemorrhage after surgery of the medulla oblongata hemangioblastoma is very rare. Delayed postoperative hemorrhage seems the most reasonable explanation of Subarachnoid hemorrhage in our case.

Surgical resection of medulla oblongata hemangioblastomas: outcome and complications

OBJECT

The purpose of this study was to analyze the surgical outcome and complications of a single-center series of medulla oblongata (MO) hemangioblastomas.

METHODS

We retrospectively reviewed the medical charts of all medulla oblongata hemangioblastomas operated on at our institution between 1996 and 2015. All patients had a pre- and postoperative MRI and a minimum follow-up of 6 months. Patients were scored according to the Karnofsky Performance Scale (KPS) and McCormick Scale at the moment of admission, discharge and the last follow-up.

RESULTS

Thirty-one surgical procedures were performed on 27 patients (16 females and 11 males). The mean age was 33 years, and 93 % of patients had von Hippel Lindau (VHL) disease. Three patients experienced very complicated postoperative courses, with one case ending in the death of the patient. Two patients required tracheostomy. According to McCormick's classification, 7 (23 %) of the 31 operations resulted in aggravation and 23 (74 %) in no change. Considering the seven patients with aggravation at discharge, four patients (60 %) returned to their preoperative status, one (14 %) improved but remained below his preoperative McCormick grade and two (29 %) did not improve. At last follow-up, KPS was ameliorated in 53 %, stable in 40 % and worsened in 7 % of cases.

CONCLUSION

Surgery of medulla oblongata hemangioblastomas is a challenging procedure characterized by an acceptable morbidity. Transient morbidity is not negligible even if the long-term outcome is in most cases favorable. A compromised neurological condition seems to be the best predictor of unfavorable outcome.

Neurosurgical Management of Brainstem Hemangioblastomas: A Single-Institution Experience with 116 Patients

OBJECTIVE

Brainstem hemangioblastomas (HBs) are considered one of the most challenging lesions in surgical procedures. We present our institutional experience with 116 patients over a period of 20 years in the treatment of HBs.

METHODS

We evaluated the results of microsurgical treatment and highlighted the management strategies. There were 60 male and 56 female patients including 13 cases with clinical evidence of von Hippel-Lindau disease. Tumors were solid in 99 cases and cystic in 17 cases. Tumors were small (≤2 cm) in 43 cases, large (2-4 cm) in 45 cases, and giant (≥4 cm) in 28 cases.

RESULTS

Radical removal was achieved in 111 patients (95.7%), and incomplete removal was achieved in 5 cases (4.3%). The immediate postoperative mortality and morbidity were 7.8% and 17.2%, respectively. Detailed analyses of outcomes showed that surgical complications were related to some tumor characteristics. Follow-up study was available in 83 patients by Karnofsky performance scale scores. Most patients maintained their preoperative neurologic status. There were 17 patients with surgical disability who demonstrated a clear improvement with rehabilitation treatment. Worsening of neurologic deficits occurred in 2 patients. Ectopic recurrent lesions developed in 2 patients.

CONCLUSIONS

Based on our experience, microsurgery is safe and effective, and excellent outcomes can be obtained for cystic or small tumors. We advocate early surgical intervention for sporadic HBs; giant solid HBs remain a challenge, and meticulous microsurgical technique and perioperative management are vital. Long-term monitoring also is recommended.

Operative management of brainstem hemangioblastomas

Brainstem hemangioblastomas are technically challenging lesions. The authors retrospectively analyzed their experience in 24 patients with brainstem hemangioblastomas to evaluate the management strategies used over time and the results of microsurgical treatment. All patients were operated on between 2007 and 2012. The patients received postoperative follow-up by neuroradiological and neurological examinations. The maximum diameter of the tumors ranged from 2.0 to 4.5 cm (mean 3.6 cm). Gross total resection was achieved in 24 patients (100%). Two patients (8%) had new neurological deficits or worsening of pre-existing deficits. One patient (4%) died because of brain stem dysfunction after the operation. Radical en bloc surgical resection of brainstem hemangioblastomas in symptomatic patients is a safe and effective primary treatment. Preoperative embolization is not necessary. It is very important and necessary to differentiate and dissect precisely at the interface of the tumor surface and the brainstem with a meticulous microsurgical technique until the tumor is removed en bloc. The preoperative neurological status of the patient predicts the postoperative functional outcome. Asymptomatic patients with hemangioblastoma may be followed clinically with MRI surveillance at regular intervals.

Microneurosurgery in combination with endovascular embolisation in the treatment of solid haemangioblastoma in the dorsal medulla oblongata

OBJECTIVE

To investigate the treatment of solid haemangioblastomas in the dorsal medulla oblongata using microneurosurgery in combination with endovascular embolisation.

METHODS

Clinical data from 11 patients with solid haemangioblastomas in the dorsal medulla oblongata who were treated with endovascular embolisation followed by microneurosurgery were analysed retrospectively. Clinical results were evaluated using the modified Rankin scale. The patients were preoperatively evaluated by neuroimaging methods such as magnetic resonance imaging (MRI), contrast MRI and digital subtraction angiography (DSA). General anaesthesia was induced, the patients were tracheally intubated, and the abnormal vessels were embolised. Surgery to resect the haemangioblastoma was conducted after the blood-clotting index returned to normal levels (generally one month after the interventional treatment).

RESULTS

Embolisation was accomplished in all 11 patients. DSA analysis revealed that most of the tumour vessels and tumour stains disappeared without any complications. The haemangioblastomas were completely resected. None of the patients received blood transfusion or died during surgery. The neurological deficit was reduced or eliminated in 10 patients, but 1 patient died after experiencing an acute myocardial infarction on the tenth postoperative day. No recurrence occurred during follow-up in patients who underwent total tumour resection. Postoperative grades using the modified Rankin scale were improved in all 10 patients. However, several complications occurred, including communicating hydrocephalus, incision infection, pneumonia and cerebrospinal fluid leakage from the incision. Notably, normal perfusion pressure breakthrough (NPPB) did not develop during or after endovascular embolisation or surgery.

CONCLUSION

Preoperative endovascular embolisation is a safe and effective adjunct treatment. Employing this treatment, solid haemangioblastomas in the dorsal medulla oblongata can be safely and completely resected.