January 14, 2016
Recurrent hemangioblastomas within the cerebellum pose their unique challenges in resection. This is a 58 year-old female who presented with progressive gait dysfunction. Of note, she underwent resection of hemangioblastoma in the lateral cerebellum years prior. Repeat imaging demonstrated a relatively cystic hemangioblastoma within the cerebellar hemisphere, extending all the way to the level of the fourth ventricle. This hemangioma is not completely solid and therefore it's vascularity is not mostly likely as impressive as the purely solid hemangioblastomas. She underwent reopening of her previous incision. You can see the mastoid bone, the patient was placed in a lateral position. Here is the gliotic cerebellum over the lesion. Here's the transfer sinus located here. Here is the midline. I continued to stay outside of the lesion, dissect the gliotic cap of the cerebellum over the tumor. And again, respect gliotic margins of the mass without directly entering the tumor. Here is the tentorium. Again, the tumor is not a highly vascular. The margins of the lesion are quite clearly gliotic. I continue my circumferential dissection around the mass. Here's a portion of the tumor that is quite cystic that is being drained. Now, there's parts of this tumor were quite vascular. Again, I try to stay as much away from the tumor capsule to avoid bleeding. Respect the gliotic margins of the tumor. Here's the de-magnified view of our work around the superior pole of their mass. Some of the bleeding was very similar to the deep white matter feeders of arteriovenous malformation in the cerebellum. Now working along the more medial pole of the hemangioblastoma. Here is the more lateral pole of the lesion. And the gliotic cerebellum. Again, some of it bleeding from the deep white matter feeders, The mass is now more devascularized and appears decompressed. Here's the petra surface of the dura. You can see the floor of the fourth ventricle and the vicinity mass to the floor. Obviously any bleeding in this area should be avoided. Any injury to the floor of the fourth ventricle obviously is non-forgiving. The mass is more relaxed. Its capsule can be coagulated more effectively. I continue to shrink the mass away from the fourth ventricle, not manipulating the floor at all. Here's another view into the fourth ventricle with mobilization of the mass more medially. The white matter dissection is continued using the bipolar forceps like scissors. Here is persistent coagulation for some of the white matter feeders. The roof of the fourth ventricle was covered with a piece of Cottonoid to avoid bleeding into the ventricular cavities. The tumor is mostly disconnected now. Here's the final disconnection of the mass from the medial bands. Inferiorly, the tumor is also disconnected. Here is the extraction of the mass. Floor of the fourth ventricle through the resection cavity. Hemostasis is adequate. Postoperative MRI demonstrates gross total removal of the mass and this patient recovered nicely from her surgery without any untoward effect. Thank you.
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