February 03, 2015
Symptomatic cystic brainstem hemangioblastomas are quite satisfying to remove surgically. This is a case of a 46 year-old male who presented with progressive left-sided upper and lower extremity numbness. MRI evaluation revealed a cystic mass with a relatively homogeneously enhancing nodule along the posterior aspect of the inferior or caudal brainstem or medulla oblongata. This patient underwent a C1 laminectomy and minimal suboccipital craniectomy. You can see the fourth ventricle. CSF was drained via the ventricle. The lesion is clearly apparent. The dura was opened in the midline and the process of lesional resection is demonstrated. Because the neural structures in this area are so critical, I stay as close as possible to the nodule and drain the cyst early on. Here, you can see the thin membrane associated with the cyst. Now that the cyst is drained, I can better discern the borders of the hemangioblastoma, the inferior plane, or in this case, in the anatomical anterior plane, is immediately created by draining the cyst. Here's my attempt to stay as close to the border of the cyst as possible. Maximum amount of neural tissue is preserved. Bipolar coagulation is focused just at the level of the border. Most of the emphasized vessels on the surface of the brain stem are protected. Here, you can see disconnection of the apex of the tumor from the area of the cyst. The gliadic margin is apparent. Level of gentle blind dissection. The blunt dissection allows dissection on the nodule without the use of electrocautery. Small bleeding may be encountered. Here, you can see a small feeding vessel to the malformation that is being removed and disconnected. Now, the bleeding from the nidus can be readily controlled using low intensity focal bipolar coagulation. Obviously, indiscriminate coagulation of the neural tissue should be avoided. Let's go ahead and disconnect this coagulated part. Sharp dissection is the best method of dissection during transection of the peel attachments. Here, you can see the nodule is almost completely disconnected. Next, I inspect the cystic cavity to make sure that all the contents of the cyst are adequately drained. All the gliadic margins are left behind. Here, you can see the contents of the cyst. Obviously, the wall of the cyst is not affected by the tumor and should be left behind. And this patient made an excellent recovery with a resolution of his preoperative symptoms. Thank you.
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