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Solid Brainstem Hemangioblastoma and Distal PICA Aneurysm

April 29, 2016


Here's an interesting video regarding resection of a Solid Brainstem Hemangioblastoma Associated with a Distal PICA Aneurysm, which was floor related. This is a 58 year old male with Acute Intracerebral Hemorrhage. Location of the hemorrhage within the fourth ventricle is apparent. Mass was associated with the area of the tonsils and a questionable aneurysm related to the PICA. Here's the MRI evaluation related to this mass. Pre-operative Arteriogram demonstrated a hypervascular mass, most consistent with a Hemangioblastoma and a floor related aneurysm at the level of the distal PICA. you can see one of the vessels related to the aneurysm is primarily feeding this hypervascular tumor. Patient underwent a suboccipital craniotomy. Patient is in the lateral position in the ends here is a linear incision C one, and it's the laminar are exposed. Here's the critical cervical junction and the dura is open in a cushy fashion. The lesion is immediately apparent and here are the tonsils. My colleague initially attempted to dissect the lesion from this vessel whose identity was not clear at the beginning. Unfortunately, this led to premature entry into the lesion and excessive bleeding. Ultimately, this bleeding was controlled. Circumferential isolation of the lesion from the surrounding neural tissues continued. Here's the lesion. Here's the tonsil in close proximity to the capsule of the mass. Here's the vessel entering the tumor. I continue circumferential disconnection of the hemangioblastoma. I stay right on the capsule. Feeding vessels are coagulated and cut. Here's the more superior pole of the tumor. This vessel that I initially referred to as an unknown vessel is actually a vein that was coagulated. Superior pole of the tumor was covered by cap of the vermis. I stay right around the lesion. I don't enter into it. And the dissection remains relatively bloodless. Here's the clot leading me into the fourth ventricle as expected based on preoperative images. Then I continue the disconnection of the capsule from the right tonsil. Here's removal of the lesion. Additional clot is removed. So that entry into the fourth ventricle is apparent. The blood within the fourth ventricle is removed until CSF flow is restored decrease in the need for a postoperative shunting. Here's the fourth ventricle, the magnified view of our operative cavity. Hemangiomablastomas is completely removed. CSF flow is restored. You can see drainage of CSF through the aqueduct. Here is choroid plexus. Now I continue dissecting the PICAs from proximal to distal. So the aneurysm can be found. Here's the right PICA. Here was a vessel that led into the lesion directly that was sacrificed. So I suspect that the aneurysm would be located here. Here you can see the aneurysm very clearly apparent. Floor related aneurysm due to the hyper vascularity of the Hemangiomablastoma. Curve clip was placed across the neck. So the patent distal vessel besides the one that led to the malformation is spared. Here's the closure of the clip lights. Further inspection reveals that the distal vessels are patent. The neck is completely collapsed. Drop it if ICG angiogram reveals complete exclusion of aneurysm and patency of the distal vessels. And postoperative CT demonstrated complete removal of the mass. Without an evidence of ischemia, in this patient made an excellent recovery without a need for VP shunting. Thank you.

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