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|NI FEATURE: THE EDITORIAL DEBATE V-- PROS AND CONS
|Year : 2018 | Volume
| Issue : 3 | Page : 678
Management of brain-stem hemangioblastomas: A bird's-eye view
Abhay K Varma
Department of Neurosurgery, Medical University of South Carolina, Charleston, USA
|Date of Web Publication||15-May-2018|
Dr. Abhay K Varma
Department of Neurosurgery, Medical University of South Carolina, Charleston
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Varma AK. Management of brain-stem hemangioblastomas: A bird's-eye view. Neurol India 2018;66:678
Joseph et al., report an impressive series of 27 patients, with brain stem hemangioblastoma (BH), managed surgically over 18 years. 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. 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. The role of preoperative embolization in the management of intracranial hemangioblastomas has not been unequivocally established and should be considered in select cases. 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. Patients requiring long term nasogastric tube feeding should be offered gastrostomy, to reduce the discomfort and potential complications of the former.
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|| |
Joseph J, Behari S, Gupta S, Bhaisora KS, Gandhi A, Srivastava A, et al
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