May 12, 2015
This is demonstration of resection of a recurrent posterior brainstem hemangioblastoma. This is the case of a 15 year old male with Von-Hipple-Lindau disease, who presented with progressive lower cranial nerve dysfunction. He had previously undergone resection of a posterior fossa hemangioblastoma, five years earlier. MRI evaluation revealed recurrence of this hemangioblastoma, just along the posterior aspect of the brainstem, also involving the area of the vermis by the nodule. You can see the significant amount of mass effect caused by the cyst. Patient on the wind reopening of his incision. Here you can see the tonsils, the distal PICA, the area over the cyst. It's very important to isolate these perforating vessels from the PICA to the tumor, and coagulate and sharply cut them. Their avulsion should be obviously avoided. Here you can see a midline incision at the area of the previous operative corridor. This cyst has entered in the nodule, which is expected to be along this superior or cranial aspect of the cyst is identified. You can see the area of the gliosis which provides a nice trajectory to reach the cyst without any significant risks. Here you can see the wall of the cysts, which obviously are not manipulated, or the cyst wall is now removed. Now the nodule is quite apparent. It's a relatively large nodule. I continue to circumferentially disconnect the nodule. However, there are numerous operative blind spots. The most important one is situated superiorly. I have to avoid leaving any of the malformation behind there. Here, you can see the border of the tumor superiorly. Adequate exposure of the nodule is reached using fluorescein fluorescence, which is a nice tool to define the border of the nodule. Now I just work around the nodule. The nodule can be quite vascular. It's best to stay outside the nodule as much as possible. If you encounter bleeding, usually means that the nodule has been violated. There's obvious some bleeding from the feeding vessels at the border of the nodule, that each has to be carefully controlled and sharply transected. In my attempts to avoid removal of any functional neural tissue at the periphery of the tumor, I did get into the nodule a few times. However, I continued to redirect my attention around there or resolve the nodule. You can see the gliadic margin along the left aspect of the nodule. Feeding vessels are coagulated and cut. Fixer tractors are avoided as much as possible. Again the anterior wall of the cystic cavity is used for surgical orientation. The nodule is rolled in different directions, so the exact planes of dissection right at the border of the nodule are recognized. After the nodule is disconnected, it's removed. However, I have to very carefully inspect the resection cavity. As I suspected, some tumor could have been left behind. Here you can see a piece of tumor that was left behind. Here, a mobilization of this piece of the tumor into the resection cavity confirms the identity of the mass. The PICA is skeletonized as it appears to be very adherent to the surface of the residual nodule. And the residual nodule is located here. You can clearly see the residual nodule. It's really important to carefully inspect the operative resection cavity to minimize the risk of future recurrence. Sub bleeding was encountered. However, I continue to carefully circumferentially disconnect the tumor capsule. I avoid getting into the tumor and stay on the capsule of the tumor to assure its gross total removal. Here you can see the gliotic margins at the periphery of the malformation. Here's the gliotic margin. I cannot find any more residual tumor. Here's the entry into the fourth ventricle. All the blood is removed. Some choroid plexus may be apparent as well. Small amount of suspicious, coagulated tissue was also removed. Now you can clearly see through the ventricle. Here's the de magnified view of the operative space. And the post operative MRI demonstrated gross total removal of the nodule, adequate decompression of the cyst and no complicating features, thank you.
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