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Table of Contents    
NI FEATURE: THE EDITORIAL DEBATE V-- PROS AND CONS
Year : 2018  |  Volume : 66  |  Issue : 3  |  Page : 678

Management of brain-stem hemangioblastomas: A bird's-eye view


Department of Neurosurgery, Medical University of South Carolina, Charleston, USA

Date of Web Publication15-May-2018

Correspondence Address:
Dr. Abhay K Varma
Department of Neurosurgery, Medical University of South Carolina, Charleston
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.232321

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How to cite this article:
Varma AK. Management of brain-stem hemangioblastomas: A bird's-eye view. Neurol India 2018;66:678

How to cite this URL:
Varma AK. Management of brain-stem hemangioblastomas: A bird's-eye view. Neurol India [serial online] 2018 [cited 2018 Aug 20];66:678. Available from: http://www.neurologyindia.com/text.asp?2018/66/3/678/232321




Joseph et al., report an impressive series of 27 patients, with brain stem hemangioblastoma (BH), managed surgically over 18 years.[1] These are very challenging lesions to manage because of the location and vascularity of these tumors. Five (18.5%) patients harbored tumors less than 2.0 cm in size, and in 6 patients, the tumor was a manifestation of von-Hippel Lindau (VHL) disease. Gross total excision was achieved in 15 patients. The mortality of 11.1% (n = 3) in this series compares favorably with other contemporary large series of brainstem hemangioblastomas.[2] The authors' experience reiterates that small (<2 cm), subpial, dorsally placed tumors are most amenable to safe surgical resection; whereas larger solid tumors (>2 cm), that are purely intramedullary or ventrally placed are relatively difficult to resect safely. Tumors extending into the cerebellopontine (CP) angle tend to be more commonly solid.[3] The role of preoperative embolization in the management of intracranial hemangioblastomas has not been unequivocally established and should be considered in select cases.[4] Surgically, hemagioblastomas should be approached as vascular malformations, with the goal of en bloc resection. The exposure should be tailored to circumvent the entire lesion (especially for ventrally placed or CP angle tumors), and every attempt must be made to stay outside the tumor and identify the plane between tumor and surrounding brain. This can be particularly difficult in large and purely intramedullary tumors. As the tumor is circumferentially dissected out from the surrounding brain, it is shrunk with an irrigating bipolar cautery and the arterial supply should be targeted first. The blood supply is serially disrupted as the dissection moves along the tumor-brain interface. Venous drainage should be taken out last. In cystic hemangioblastomas, removal of the solid intramural nodule suffices. Experience with intraoperative monitoring (IOM) during resection of brainstem hemangioblastomas is not as extensive as with surgery of intramedullary spinal hemangioblastomas. Extrapolating the experience from spinal intramedullary tumors would suggest use of IOM can help facilitate safer resection of brainstem hemangioblastomas.[5] Patients requiring long term nasogastric tube feeding should be offered gastrostomy, to reduce the discomfort and potential complications of the former.[1]

The authors rightly point out that every patient with a brain or spinal cord hemangioblastoma must be evaluated for VHL disease. Patients with VHL disease require long term follow up because of a higher risk of recurrence at the same site or development of new lesions.



 
  References Top

1.
Joseph J, Behari S, Gupta S, Bhaisora KS, Gandhi A, Srivastava A, et al. 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.
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. 2
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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;103:248-56.  Back to cited text no. 3
    
4.
Ampie L, Choy W, Lamano JB, Kesavabhotla K, Kaur R, Parsa AT, Bloch O. Safety and outcomes of preoperative embolization of intracranial hemangioblastomas: A systematic review. Clin Neurol Neurosurg 2016;150:143-51.  Back to cited text no. 4
[PUBMED]    
5.
Muthukumar N. Multimodal intraoperative neuromonitoring during surgery for correction of spinal deformity: Standard of care or luxury? Neurol India 2017;65:80-2.  Back to cited text no. 5
[PUBMED]  [Full text]  




 

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