Surgical Outcome of Large Solid Posterior Fossa Hemangioblastoma without Preoperative Embolization

Abstract

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

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

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

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

Keywords

solid hemangioblastoma - circumferential dissection - embolization

Statement of Ethics

All authors contributed equally to this work. All procedures performed in the study involving patients were following our institution's ethical standards, and any personal information and identity of patients were not disclosed in the study.

Publication History

Received: 12 October 2020

Accepted: 26 November 2020

Article published online:
25 August 2021

• References

• 1 Kuharic M, Jankovic D, Splavski B, Boop FA, Arnautovic KI. Hemangioblastomas of the posterior cranial fossa in adults: demographics, clinical, morphologic, pathologic, surgical features, and outcomes. A systematic review. World Neurosurg 2018; 110: e1049-e1062
• 2 Wan JQ, Cui H, Wang Y. Surgical management of large solid hemangioblastomas of the posterior fossa. J Clin Neurosci 2011; 18 (01) 39-42
• 3 Cheng J, Liu W, Zhang S, Lei D, Hui X. Clinical features and surgical outcomes in patients with cerebellopontine angle hemangioblastomas: retrospective series of 23 cases. World Neurosurg 2017; 103: 248-256
• 4 Cui H, Zou J, Bao Y-H, Wang M-S, Wang Y. Surgical treatment of solid hemangioblastomas of the posterior fossa: a report of 28 cases. Oncol Lett 2017; 13 (03) 1125-1130
• 5 Rachinger J, Buslei R, Prell J, Strauss C. Solid haemangioblastomas of the CNS: a review of 17 consecutive cases. Neurosurg Rev 2009; 32 (01) 37-47 , discussion 47–48
• 6 Staudt MD, Hebb MO. Staged multi-modality treatment approaches for giant cerebellopontine angle hemangioblastomas. J Clin Neurosci 2018; 53: 224-228
• 7 Kato M, Ohe N, Okumura A. et al. Hemangioblastomatosis of the central nervous system without von Hippel-Lindau disease: a case report. J Neurooncol 2005; 72 (03) 267-270
• 8 Moon BH, Park SK, Han Y-M. Large solid hemangioblastoma in the cerebellopontine angle: complete resection using the transcondylar fossa approach. Brain Tumor Res Treat 2014; 2 (02) 128-131
• 9 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 (04) 482-488
• 10 Ampie L, Choy W, Lamano JB. et al. Safety and outcomes of preoperative embolization of intracranial hemangioblastomas: a systematic review. Clin Neurol Neurosurg 2016; 150: 143-151
• 11 Sakamoto N, Ishikawa E, Nakai Y. et al. Preoperative endovascular embolization for hemangioblastoma in the posterior fossa. Neurol Med Chir (Tokyo) 2012; 52 (12) 878-884
• 12 de San Pedro JR, Rodríguez FA, Níguez BF. et al. Massive hemorrhage in hemangioblastomas literature review. Neurosurg Rev 2010; 33 (01) 11-26
• 13 van Leeuwaarde RS, Ahmad S, Links TP, Giles RH. Von Hippel-Lindau Syndrome. Bathesda, MD: National Library of Medicine; 2019
• 14 Young S, Richardson AE. Solid haemangioblastomas of the posterior fossa: radiological features and results of surgery. J Neurol Neurosurg Psychiatry 1987; 50 (02) 155-158
• 15 Okawara S-H. Solid cerebellar hemangioblastoma. J Neurosurg 1973; 39 (04) 514-518
• 16 Bush ML, Pritchett C, Packer M, Ray-Chaudhury A, Jacob A. Hemangioblastoma of the cerebellopontine angle. Arch Otolaryngol Head Neck Surg 2010; 136 (07) 734-738
• 17 Fukuda M, Takao T, Hiraishi T. et al. Clinical factors predicting outcomes after surgical resection for sporadic cerebellar hemangioblastomas. World Neurosurg 2014; 82 (05) 815-821
• 18 Liao C-C, Huang Y-H. Clinical features and surgical outcomes of sporadic cerebellar hemangioblastomas. Clin Neurol Neurosurg 2014; 125: 160-165
• 19 Tamura Y, Hirota Y, Miyata S, Yamada Y, Tucker A, Kuroiwa T. The use of intraoperative near-infrared indocyanine green videoangiography in the microscopic resection of hemangioblastomas. Acta Neurochir (Wien) 2012; 154 (08) 1407-1412 , discussion 1412
• 20 Hojo M, Arakawa Y, Funaki T. et al. Usefulness of tumor blood flow imaging by intraoperative indocyanine green videoangiography in hemangioblastoma surgery. World Neurosurg 2014; 82 (3–4): e495-e501
• 21 Shinya T, Nagamine H, Sugawara KI, Ishiuchi S. The usefulness of indocyanine green during surgery for hypervascular posterior fossa tumors. Surg Neurol Int 2018; 9 (01) 90
• 22 Liu A-H, Peng T-M, Wu Z. et al. Clinical effectiveness of preoperative embolization for cerebellar hemangioblastoma. Asian Pac J Cancer Prev 2013; 14 (09) 5179-5183
• 23 Cervio A, Villalonga JF, Mormandi R, Alcorta SC, Sevlever G, Salvat J. Surgical treatment of cerebellar hemangioblastomas. Surg Neurol Int 2017; 8 (01) 163