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Large solid hemangioblastoma in the cerebellopontine angle: complete resection using the transcondylar fossa approach.

Moon BH, Park SK, Han YM - Brain Tumor Res Treat (2014)

Bottom Line: Therefore, differential diagnosis is important for the safe treatment of the lesion.Similar to AVM surgery, the tumor was widely opened and removed en bloc without a new neurological complication using the modified transcondylar fossa approach without resection of the jugular tubercle.Accurate diagnosis, pre-operative embolization, and a tailored approach were essential for the safe treatment of the HBM in the CPA.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, Incheon St. Mary's Hospital, The Catholic University of Korea College of Medicine, Incheon, Korea.

ABSTRACT
Hemangioblastomas (HBMs) in the cerebellopontine angle (CPA) have rarely been reported. When they are within the CPA, they may be misdiagnosed as vestibular schwannoma (VS) or cystic meningioma. Therefore, differential diagnosis is important for the safe treatment of the lesion. Large solid HBMs, similar to intracranial arteriovenous malformations (AVMs), are difficult to surgically remove from an eloquent area because of their location and hypervascularity. We report a case of an HBM in the CPA, which manifested as a hearing impairment or VS. Similar to AVM surgery, the tumor was widely opened and removed en bloc without a new neurological complication using the modified transcondylar fossa approach without resection of the jugular tubercle. Accurate diagnosis, pre-operative embolization, and a tailored approach were essential for the safe treatment of the HBM in the CPA.

No MeSH data available.


Related in: MedlinePlus

Preoperative angiographic imaging showing the angio-arcitecture of the tumor. A: Left vertebral artery angiogram anterior-posterior views of the tumor (large arrow) fed by the superior cerebellar artery (small arrow) and the anterior inferior cerebellar artery (small double arrow). B: After the embolization, angiogram showing a 90% reduction in the tumor vascularity (arrow).
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Figure 2: Preoperative angiographic imaging showing the angio-arcitecture of the tumor. A: Left vertebral artery angiogram anterior-posterior views of the tumor (large arrow) fed by the superior cerebellar artery (small arrow) and the anterior inferior cerebellar artery (small double arrow). B: After the embolization, angiogram showing a 90% reduction in the tumor vascularity (arrow).

Mentions: A 31-year-old male was admitted to our hospital with headache and hearing difficulty in his left ear. His neurological examination upon his admission revealed no symptoms and signs of cerebellar dysfunction and other cranial nerve dysfunctions. His neuro-otological test showed no serviceable hearing in the affected ear. The magnetic resonance imaging (MRI) showed a well-enhancing lesion in the left CPA with a peritumoral cyst on the medial portion of the lesion (Fig. 1). The cerebral angiogram (Fig. 2A) showed the lesion fed by the left superior cerebellar artery (SCA) and the anterior inferior cerebellar artery (AICA). They were superselected with flow-directed microcatheters (Marathon™, EV3, Irvine, CA, USA), and the distal feeders were embolized with N-butyl cyanoacrylate (0.4 cc in the SCA and 0.6 cc in the AICA). The angiogram after the embolization revealed a 90% reduction in the tumor vascularity (Fig. 2B). Five days after the embolization, surgical resection was performed. The patient was positioned lateral to the head that was turned towards the contralateral side. After a curvilinear skin incision was made, TCFA was performed under navigation guided with electrophysiological monitoring. The tumor was bright red and was associated with intense vascularity (Fig. 3A). Intra-operative indocyanine green video angiography was performed to identify the feeders (Fig. 3B). A peritumoral cyst with a brownish fluid was observed on the medial portion of the tumor, at the prepontine cistern. The tumor was dissected while the draining vein was circumferentially preserved, and then en bloc resection was achieved (Fig. 3C). Intra-operative indocyanine green videoangiography was used to confirm the angio-architecture of the tumor. The MRI obtained a day post-operatively showed complete resection of the tumor (Fig. 4). The post-operative neurological examination did not reveal a neurological complication, such as facial palsy or auditory function and lower cranial nerve symptoms. The pathological examination revealed a highly vascular neoplasm composed of atypical stromal cells that consisted of HBMs (Fig. 5). The index of the Ki-67 protein was low-approximately 3%.


Large solid hemangioblastoma in the cerebellopontine angle: complete resection using the transcondylar fossa approach.

Moon BH, Park SK, Han YM - Brain Tumor Res Treat (2014)

Preoperative angiographic imaging showing the angio-arcitecture of the tumor. A: Left vertebral artery angiogram anterior-posterior views of the tumor (large arrow) fed by the superior cerebellar artery (small arrow) and the anterior inferior cerebellar artery (small double arrow). B: After the embolization, angiogram showing a 90% reduction in the tumor vascularity (arrow).
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4231628&req=5

Figure 2: Preoperative angiographic imaging showing the angio-arcitecture of the tumor. A: Left vertebral artery angiogram anterior-posterior views of the tumor (large arrow) fed by the superior cerebellar artery (small arrow) and the anterior inferior cerebellar artery (small double arrow). B: After the embolization, angiogram showing a 90% reduction in the tumor vascularity (arrow).
Mentions: A 31-year-old male was admitted to our hospital with headache and hearing difficulty in his left ear. His neurological examination upon his admission revealed no symptoms and signs of cerebellar dysfunction and other cranial nerve dysfunctions. His neuro-otological test showed no serviceable hearing in the affected ear. The magnetic resonance imaging (MRI) showed a well-enhancing lesion in the left CPA with a peritumoral cyst on the medial portion of the lesion (Fig. 1). The cerebral angiogram (Fig. 2A) showed the lesion fed by the left superior cerebellar artery (SCA) and the anterior inferior cerebellar artery (AICA). They were superselected with flow-directed microcatheters (Marathon™, EV3, Irvine, CA, USA), and the distal feeders were embolized with N-butyl cyanoacrylate (0.4 cc in the SCA and 0.6 cc in the AICA). The angiogram after the embolization revealed a 90% reduction in the tumor vascularity (Fig. 2B). Five days after the embolization, surgical resection was performed. The patient was positioned lateral to the head that was turned towards the contralateral side. After a curvilinear skin incision was made, TCFA was performed under navigation guided with electrophysiological monitoring. The tumor was bright red and was associated with intense vascularity (Fig. 3A). Intra-operative indocyanine green video angiography was performed to identify the feeders (Fig. 3B). A peritumoral cyst with a brownish fluid was observed on the medial portion of the tumor, at the prepontine cistern. The tumor was dissected while the draining vein was circumferentially preserved, and then en bloc resection was achieved (Fig. 3C). Intra-operative indocyanine green videoangiography was used to confirm the angio-architecture of the tumor. The MRI obtained a day post-operatively showed complete resection of the tumor (Fig. 4). The post-operative neurological examination did not reveal a neurological complication, such as facial palsy or auditory function and lower cranial nerve symptoms. The pathological examination revealed a highly vascular neoplasm composed of atypical stromal cells that consisted of HBMs (Fig. 5). The index of the Ki-67 protein was low-approximately 3%.

Bottom Line: Therefore, differential diagnosis is important for the safe treatment of the lesion.Similar to AVM surgery, the tumor was widely opened and removed en bloc without a new neurological complication using the modified transcondylar fossa approach without resection of the jugular tubercle.Accurate diagnosis, pre-operative embolization, and a tailored approach were essential for the safe treatment of the HBM in the CPA.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, Incheon St. Mary's Hospital, The Catholic University of Korea College of Medicine, Incheon, Korea.

ABSTRACT
Hemangioblastomas (HBMs) in the cerebellopontine angle (CPA) have rarely been reported. When they are within the CPA, they may be misdiagnosed as vestibular schwannoma (VS) or cystic meningioma. Therefore, differential diagnosis is important for the safe treatment of the lesion. Large solid HBMs, similar to intracranial arteriovenous malformations (AVMs), are difficult to surgically remove from an eloquent area because of their location and hypervascularity. We report a case of an HBM in the CPA, which manifested as a hearing impairment or VS. Similar to AVM surgery, the tumor was widely opened and removed en bloc without a new neurological complication using the modified transcondylar fossa approach without resection of the jugular tubercle. Accurate diagnosis, pre-operative embolization, and a tailored approach were essential for the safe treatment of the HBM in the CPA.

No MeSH data available.


Related in: MedlinePlus