Visualization of vascular structure of spinal hemangioblastoma using intraoperative indocyanine green videoangiography and temporary feeder occlusion.

BACKGROUND AND PURPOSE: To more safely resect pathological lesions during spinal vascular lesion surgery, it is most important to understand local abnormal hemodynamics in detail. New devices or techniques that make out intraoperative local hemodynamics have been awaited. To introduce a resourceful method, we present a case of spinal hemangioblastoma for which temporary arterial occlusion during near-infrared intraoperative indocyanine green (ICG) videoangiography gives useful assessment of the main and minor feeders easily. METHODS: A 36-year-old female suffered progressive paresthesia of both lower extremities for 12 months and gait disturbance for 2 weeks. A neurological examination revealed T10 myelopathy. Magnetic resonance imaging (MRI) of the thoracic spine showed an intramedullary tumor at the T8 level and severe spinal cord edema with a flow void in the extended dorsal spinal veins. Spinal angiography showed a hemangioblastoma at the T8 level, with two main feeders and minor feeders. RESULTS: She underwent total resection of the tumor by a posterior approach. During the intraoperative ICG videoangiography, temporary arterial occlusion of the two main feeders and FLOW(®)800 analysis enabled clear understanding of the vasculature, especially of the two minor feeders. At the 9-month follow-up, her neurological manifestation was partially resolved, and post-operative MRI showed total removal of the tumor and disappearance of the spinal cord edema. CONCLUSIONS: Temporary clipping of the main feeders during intraoperative ICG videoangiography is very useful for easily determining the minor feeding arteries, and helpful for maintaining normal perfusion of the spinal cord in spinal hemangioblastoma surgery. Furthermore, the FLOW 800 analysis, especially the false color-coded variation, increased our understanding of the hemodynamics.

MRI Characterization of Vascular Spinal Tumors.

STUDY DESIGN: Randomized trial. OBJECTIVE: This study described practical magnetic resonance imaging (MRI) characteristics to assist in the identification of these tumors including the corresponding statistics. SUMMARY OF BACKGROUND DATA: Identification of vascular spinal tumors using MRI allows the opportunity for angiography and preoperative embolization (PE) to improve outcomes and decrease hemorrhage. The MRI characterization reliability of these tumors has not been described. MATERIALS AND METHODS: A retrospective comparison of 40 patients, at a single institution, with known spinal tumors was conducted with 20 vascular versus 20 nonvascular cases (based on postoperative pathology). Randomized MRI T1 precontrast/postcontrast and T2 images of these tumors were blinded and reviewed by 7 spine surgeons and 5 musculoskeletal radiologists. Four criteria were reviewed: T2 hyperintensity, contrast enhancement, flow voids, and feeding vessels. The clinical relevance was evaluated by asking if the reviewer recommended PE. RESULTS: The specificity, sensitivity, and accuracy of each characteristic for surgeons were: T2 hyperintensity (65%, 85%, 75%), contrast enhancement (84%, 38%, 61%), flow voids (42%, 86%, 64%), and feeding vessels (35%, 90%, 63%). The results for the radiologists were: T2 hyperintensity (83%, 61%, 72%), contrast enhancement (87%, 32%, 60%), flow voids (44%, 93%, 69%), and feeding vessels (33%, 93%, 63%). Both the groups had low κ and intraclass correlation values. Review of angiography/PE recommendation showed that both surgeons and radiologists had a false-negative rate of 33%. CONCLUSIONS: Surgeons and radiologists have similar moderate accuracy of MRI vascularity identification. Radiologists have a higher sensitivity, but lower specificity. Even with simplified, straightforward criteria, the MRI characterization of vascular spinal tumors has low interobserver/intraobserver reliability with a false-negative rate for angiography/PE recommendation of 33%. Angiography may become more standard in the workup of spine tumors.

Use of near-infrared indocyanine videoangiography and Flow 800 in the resectioning of a spinal cord haemangioblastoma.

Haemangioblastomas are hypervascularized tumours. Their surgical management requires a complete resectioning and a prompt handling of the vascular inlets and outlets. The use of intraoperative indocyanine green video angiography (ICG-VAG) depicts the precise vascular pattern for the surgeon. Its use is safe and easy, and the procedure can be repeated during the operation. Here we present a case of spinal haemangioblastoma treated with the aid of intraoperative ICG-VAG and the Flow 800 software. The use of the Flow 800 allowed the surgeon to detect, at a glance, minimal changes in the vascular supply during the dissection. The colour-coded images generated by the Flow 800 increase the ICG-CAG sensitivity, improving the capability to detect changes in vascular patterns.

[Preoperative embolisation of spinal metastases]. / A spinális metasztázisok preoperatív embolizációja.

In the management of spinal metastases bringing about neurological symptoms and signs, palliative surgical treatment plays an important role. The goals of surgery are preservation of neurological function especially that of the mobility, pain relief and local tumor control. Many of spinal metastases are hypervascularised, accordingly, preoperative embolisation offers logically improvement in technical realisation of surgery by means of reduction of intraoperative profuse bleeding. To prove this working hypothesis a retrospective analysis was performed. Results of preoperative transarterial embolisation of hypervascularised spinal tumours were worked up from 2000 to 2012. By means of 2 case presentations - to our knowledge, first in the Hungarian literature - the techniques of transarterial spinal embolisation of spinal metastases are described. Indications, complications and effect on intraoperative bleeding events of the embolisation procedure in these oncological cases are presented on the basis of literature search and of our own experience. The case analyses, based mainly on qualitative retrospective data, support the notion that histologically known spinal hypervascularised metastases or those found to be hypervascularised by MRI can be treated effectively by means of preoperative superselective embolisation without major risks of morbidity or mortality.

Differentiation of localization of spinal hemangioblastomas based on imaging and pathological findings.

Intramedullary + extramedullary hemangioblastomas with largely extramedullary growth are rare and often incorrectly assigned as intradural-extramedullary tumors preoperatively. Preoperative evaluation of the precise tumor location is important for total resection of tumor and improving the surgical outcome. The aim of this study was to provide the first identification of the key differences among of preoperative MR images of hemangioblastomas in different locations and to correlate these with pathological findings. The subjects were 26 patients with surgery for spinal hemangioblastoma in our department, including 6 with an intramedullary tumor who were complicated with von Hippel Lindau disease. Intramedullary, intramedullary + extramedullary, and intradural-extramedullary tumors were present in 22, 3 and 1 cases, respectively. Sagittal MR images showed that intramedullary and intramedullary + extramedullary tumors gave intramedullary T2 high intensity areas (HIAs) spreading toward the craniocaudal sides of the tumor, whereas such findings were absent for the intradural-extramedullary tumor. All the tumors showed strong contrast on axial images, with focal enhancement of hemangioblastomas limited to the intramedullary region (focal type); smooth boundary lines between the spinal cord and the extramedullary tumor (smooth type); and a snowman sign for intramedullary + extramedullary tumors, which provided a key characteristic for differentiating intramedullary + extramedullary tumors from those limited to the extramedullary region. In pathological findings, the Ki67 activity was less than 1% for intramedullary and intradural-extramedullary tumors, but 18-25% in all cases with an intramedullary + extramedullary tumor. In conclusion, on preoperative MRI, a change in the intramedullary HIAs spreading the craniocaudal sides of the tumor on sagittal T2 weighted image (T2WI) and a snowman sign on contrast axial T1WI may be important for differentiation among spinal hemangioblastomas in different locations. Pathologically, we found that intramedullary + extramedullary hemangioblastoma has high cell proliferative activity, which may suggest that enlargement of this tumor occurs faster than that of intramedullary hemangioblastoma.

Multiple intradural extramedullary tumours presenting with paraplegia after trauma.

Intraspinal nerve-sheath tumours are generally slow growing and are diagnosed after causing symptoms such as back pain and progressive neurological symptoms. We present a rare example of multiple schwannomas located in the thoracolumbar spine in a previously asymptomatic patient who developed severe neurological deficits after a motor-vehicle accident. The exact mechanism of neurological compromise in this patient remains unclear. Circulatory instability in the early post-traumatic course could have contributed to pathogenesis.

Use of Intraoperative Indocyanine Green Angiography for Feeder Vessel Ligation and En Bloc Resection of Intramedullary Hemangioblastoma.

BACKGROUND: As vascular tumors, intramedullary hemangioblastomas are associated with significant intraoperative blood loss, making them particularly challenging clinical entities. The use of intraoperative indocyanine green or other fluorescent dyes has previously been described to avoid breaching the tumor capsule, but improved surgical outcomes may result from identifying and ligating the feeder arteries and arterialized draining veins. OBJECTIVE: To describe the use of combined preoperative angiography and intraoperative indocyanine green use for the identification of feeder arteries and arterialized draining veins to decrease blood loss in the resection of intramedullary hemangioblastomas. METHODS: A patient with cervical myelopathy secondary to a large C3 hemangioblastoma and cervicothoracic syrinx underwent a C2-3 laminoplasty with resection of the lesion. To reduce intraoperative blood loss and facilitate safe lesion resection, the vascular architecture of the lesion was defined via preoperative digital subtraction angiography and intraoperative use of indocyanine green. The latter permitted ligation of the major and minor feeding arteries and arterialized veins prior to tumor breach, allowing for facile en bloc resection of the lesion. RESULTS: The lesion was resected en bloc with minimal blood loss (approximately 100 mL) and without intraoperative neuromonitoring signal changes. The patient remained at neurological baseline throughout their stay. CONCLUSION: We present a written and media illustration of a technique for intraoperative indocyanine green use in the en bloc resection of intramedullary hemangioblastoma.

Advanced reactive astrogliosis associated with hemangioblastoma versus astroglial-vascular neoplasm ("angioglioma").

Hemangioblastomas of the central nervous system are often accompanied by a cyst exhibiting an extensive astroglial reaction. The cyst's wall might be composed of various astroglial elements including reactive pilocytic or gemistocytic and hypertrophic astrocytes. The small tissue samples composed of compact gliotic tissue are sometimes nonrepresentative for primary hemangioblastoma tumour and might be confused with both pilocytic and diffuse infiltrative astrocytoma. Moreover, vascular anomalies of hemangioblastoma-like pattern could be combined with true neoplastic glial proliferation. Such association of glioma with certain types of vascular anomalies has been designated as angioglioma. In the current study we evaluated a series of hemangioblastomas accompanied by advanced astrogliosis of adjacent brain tissue. In some cases the histopathological features of pilocytic gliosis with numerous Rosenthal fibres and eosinophilic granular bodies strongly suggest the diagnosis of pilocytic astrocytoma. One tumour was identified as an angioglioma exhibiting a combination of hemangioblastoma-like tissue and pilocytic astrocytoma. The recognition of such an entity is important in differential tumour diagnosis and prognosis.

Acute paraparesis from hemorrhagic spinal ependymoma: diagnostic dilemma and surgical management. Report of two cases and review of the literature.

Spinal ependymomas are a common type of primary spinal cord neoplasm that frequently occurs in the lumbar spine. The authors report on two patients who presented with acute neurological decline after hemorrhage into ependymomas of the filum terminale. Both were transferred to the authors' institution because of diagnostic uncertainty and a concern about possible intradural vascular abnormalities. Both patients underwent lumbar laminectomies for tumor resection. The pathological finding in each case was myxopapillary ependymoma. Both patients made a significant recovery and were ambulatory and continent at follow-up review. These cases illustrate the rare but clinically significant incidence of acute neurological decline caused by hemorrhagic cauda equina ependymomas, including the potential for delayed diagnosis and treatment.

Rosette-forming glioneuronal tumour (RGNT) of the fourth ventricle: a highly aggressive case.

BACKGROUND: The rosette-forming glioneuronal tumour (RGNT) is a rarely encountered tumour that has been included as a new entity in the 2007 edition of the "World Health Organization (WHO) Classification of Tumours of the Central Nervous System". We describe a rather unusual case of multifocal cerebellar RGNT, located in the spinal cord and displaying leptomeningeal spread. CLINICAL PRESENTATION: Twenty-four-year-old male with history of long-lasting headaches. A magnetic resonance scan revealed three heterogeneous lesions located within both cerebellar hemispheres and the left cerebellopontine angle, in addition to a spinal cord lesion at the level of the cervical region, and images of leptomeningeal spread. Interventions were performed in two stages; these involved resection of two cerebellar lesions, with a histopathological diagnosis of RGNT with atypical microvascular proliferation and focal necrosis. Although these tumours appear to be benign, our case debuted in an aggressive form, both from the radiological point of view and with respect to its histopathological characteristics. For this reason, the patient received adjuvant therapy with chemotherapy and radiotherapy. CONCLUSIONS: Experience of RGNT is limited. The prognostic significance of the histological findings of vascular proliferation and necrosis is still unknown. The clinical improvement in our patient endorses our decision to perform aggressive treatment.