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Table of Contents    
NI FEATURE: THE EDITORIAL DEBATE V-- PROS AND CONS
Year : 2018  |  Volume : 66  |  Issue : 3  |  Page : 676-677

Management of brain-stem hemangioblastomas: Surgical skill versus technological advancements


Emory University, Saint Joseph's Hospital, 5560 Peachtree-Dunwood Road, Ste 350, Atlanta, GA, USA

Date of Web Publication15-May-2018

Correspondence Address:
Dr. Faiz Ahmad
Emory University, Saint Josephfs Hospital, 5560 Peachtree-Dunwood Road, Ste 350, Atlanta, GA
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.232322

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How to cite this article:
Deibert CP, Ahmad F. Management of brain-stem hemangioblastomas: Surgical skill versus technological advancements. Neurol India 2018;66:676-7

How to cite this URL:
Deibert CP, Ahmad F. Management of brain-stem hemangioblastomas: Surgical skill versus technological advancements. Neurol India [serial online] 2018 [cited 2018 Nov 20];66:676-7. Available from: http://www.neurologyindia.com/text.asp?2018/66/3/676/232322




In their paper entitled Brain-stem Hemangioblastomas: The Seemingly Innocuous Lesions in a Perilous Location, Joseph and colleagues describe a single institution experience on a variety of challenging hemangioblastomas located within the brainstem.[1] While benign histologically, when these lesions occur within the brainstem, they can lead to a myriad of symptoms ranging from headache to hydrocephalus, motor dysfunction, multiple cranial neuropathies and death. Complete surgical resection is curative but exceedingly difficult to achieve in many cases.

The authors describe 27 patients who underwent surgical resection of tumors of a variety of sizes and characteristics. Of these 27 patients, there were 3 peri-operative mortalities, three patients required re-operation for surgical site hematoma, seven transient neurological deficits and one new, permanent cranial neuropathy. 18 patients had the same or better score on Karnofsky Performance Status (KPS) scale on discharge. These results highlight the difficulty in treating these lesions, with a significant number of patients experiencing at least a temporary neurological decline. Other studies have shown similar experiences and were thoroughly reviewed in the present study.[2],[3],[4],[5],[6],[7]

The surgical principles guiding the resection of hemangioblastomas have been well established. The mural nodule of cystic hemangioblastomas should be completely resected when possible to provide a surgical cure in cases not related to von Hippel-Lindau disease. The cyst wall does not need to be resected unless there is convincing evidence of tumor invasion into the cyst.[8] Purely nodular lesions often present a more challenging surgical case. Nodular lesions can be highly vascular and so internal debulking is not advised as it can lead to catastrophic blood loss. A surgical approach similar to the treatment of arteriovenous malformations (AVMs) is, therefore, preferred. This includes extensive coagulation of the surface of the lesion and preservation of the venous outflow until the arterial feeders have been disconnected. Unfortunately, the plane between the lesion and the normal brain can be obscured and adherent. In the cases of brainstem hemangioblastomas, this leads to most of the neurological complications as the lesion is meticulously dissected.

Several technological advancements have the potential to improve surgical outcomes during these complex cases. Unfortunately, they are not easily accessible to many surgeons. Diffusion tensor imaging (DTI) and high definition fibertractography (HDFT) can show white matter tracts and their precise location relative to the lesion.[9] Using this detailed anatomical information, multiple surgical approaches can then be considered to minimize risk to the intricate brainstem anatomy. Intra-operative neurophysiological monitoring can also help to reduce risk during the resection. When combined with cortical and subcortical stimulation, this can help to guide dissection in properly selected cases. Finally, intra-operative fluorescence has been shown to be able to differentiate hemangioblastoma from normal brain and can provide critical intra-operative guidance in difficult cases.[10],[11]

Mass lesions of the brainstem are among the most challenging surgical lesions confronted by neurosurgeons. In the case of hemangioblastomas, the high vascularity adds a further degree of difficulty making them perilous surgical problems. The continued application of emerging technologies has attempted to address the initial problems of properly identifying lesional and normal anatomy but any manipulation of the brainstem can have lasting consequences. Non-invasive approaches, such as stereotactic radiosurgery, remain controversial [12],[13] making surgical resection the only proven treatment of hemangioblastomas. Joseph et al., should be commended for their honest report highlighting the difficulty in treating these patients.



 
  References Top

1.
Joseph J, Behari S, Gupta S, Bhaisora KS, Gandhi A, Srivastava A, Jaiswal AK. Brain-stem hemangioblastomas: The seemingly innocuous lesion in a perilous location. Neurol India 2018;66:779-96.  Back to cited text no. 1
  [Full text]  
2.
Chen LF, Yang Y, Yu XG, Bu B, Xu BN, Zhou DB. Operative management of brainstem hemangioblastomas. J Clin Neurosci 2013;20:1727-33.  Back to cited text no. 2
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3.
Zhou LF, Du G, Mao Y, Zhang R. Diagnosis and surgical treatment of brainstem hemangioblastomas. Surg Neurol 2005;63:307-16.  Back to cited text no. 3
[PUBMED]    
4.
Wang C, Zhang J, Liu A, Sun B. Surgical management of medullary hemangioblastoma: Report of 47 cases. Surg Neurol 2001;56:218-26.  Back to cited text no. 4
[PUBMED]    
5.
Liu X, Zhang Y, Hui X, You C, Yuan F, Chen W, et al. Surgical management of medulla oblongata hemangioblastomas in one institution: An analysis of 62 cases. Int J Clin Exp Med 2015;8:5576-90.  Back to cited text no. 5
[PUBMED]    
6.
Ma D, Wang Y, Du G, Zhou L. Neurosurgical management of brainstem hemangioblastomas: A single-institution experience with 116 patients. World Neurosurg 2015;84:1030-8.  Back to cited text no. 6
[PUBMED]    
7.
Yin L, Zhang L, Hao S, Zhang J, Wu Z. Medullary hemangioblastoma: 34 patients at a single institution. J Clin Neurosci 2014;21:250-5.  Back to cited text no. 7
[PUBMED]    
8.
Jagannathan J, Lonser RR, Smith R, DeVroom HL, Oldfield EH. Surgical management of cerebellar hemangioblastomas in patients with von Hippel–Lindau disease. J Neurosurg 2008;108:210-22.  Back to cited text no. 8
[PUBMED]    
9.
Li DC, Malcolm JG, Rindler RS, Baum GR, Rao A, Khurpad SN, Ahmad FU. The role of diffusion tensor imaging in spinal pathology: A review. Neurol India 2017;65:982-92.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Utsuki S, Kijima C, Hagiwara H, Oka H, Miyajima Y, Fujii K. Utility of intraoperative fluorescent diagnosis of residual hemangioblastoma using 5-aminolevulinic acid. Neurol India [Internet] 2011;59:612.  Back to cited text no. 10
    
11.
Moiyadi AV, Stummer W. δ-Aminolevulinic acid-induced fluorescence-guided resection of brain tumors. Neurol India 2015;63:155-65.  Back to cited text no. 11
[PUBMED]  [Full text]  
12.
Patrice SJ, Sneed PK, Flickinger JC, Shrieve DC, Pollock BE, Alexander E, et al. Radiosurgery for hemangioblastoma: Results of a multiinstitutional experience. Int J Radiat Oncol Biol Phys 1996;35:493-9.  Back to cited text no. 12
    
13.
Wang E-M, Pan L, Wang B-J, Zhang N, Zhou L-F, Dong Y-F, et al. The long-term results of gamma knife radiosurgery for hemangioblastomas of the brain. J Neurosurg 2005;102:225-9.  Back to cited text no. 13
    




 

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