Usefulness of posterior transpetrosal approach for the large solid cerebellopontine angle hemangioblastoma fed from multiple blood supplies: A technical case report
- Department of Neurosurgery, National Hospital Organization Yokohama Medical Center, Yokohama, Kanagawa, Japan.
Kosuke Miyahara, Department of Neurosurgery, National Hospital Organization Yokohama Medical Center, Yokohama, Kanagawa, Japan.
DOI:10.25259/SNI_38_2023Copyright: © 2023 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Kosuke Miyahara, Tomu Okada, Shin Tanino, Yasuhiro Uriu, Yusuke Tanaka, Koji Suzuki, Noriaki Sekiguchi, Naoyuki Noda, Teruo Ichikawa, Kazuhiko Fujitsu. Usefulness of posterior transpetrosal approach for the large solid cerebellopontine angle hemangioblastoma fed from multiple blood supplies: A technical case report. 02-Jun-2023;14:191
How to cite this URL: Kosuke Miyahara, Tomu Okada, Shin Tanino, Yasuhiro Uriu, Yusuke Tanaka, Koji Suzuki, Noriaki Sekiguchi, Naoyuki Noda, Teruo Ichikawa, Kazuhiko Fujitsu. Usefulness of posterior transpetrosal approach for the large solid cerebellopontine angle hemangioblastoma fed from multiple blood supplies: A technical case report. 02-Jun-2023;14:191. Available from: https://surgicalneurologyint.com/surgicalint-articles/12345/
Background: Extra-axial cerebellopontine angle (CPA) hemangioblastomas are rare clinical entity and surgical treatment is challenging due to the anatomical difficulties and multi-directional blood supplies. On the other hand, the risk of endovascular treatment for this disease has also been reported. Herein, we successfully applied a posterior transpetrosal approach to remove a large solid CPA hemangioblastoma without preoperative feeder embolization.
Case Description: A 65-year-old man presented with a complaint of diplopia during downward gaze. Magnetic resonance imaging revealed a solid tumor with homogeneous enhancement measuring about 35 mm at the left CPA, and the tumor compressed a left trochlear nerve. Cerebral angiography disclosed tumor-staining fed by both left superior cerebellar and left tentorial arteries. After the operation, the patient’s trochlear nerve palsy improved dramatically.
Conclusion: This approach offers more optimal surgical working angle to the anteromedial part compared to the lateral suboccipital approach. In addition, the devascularization from the cerebellar parenchyma can be performed more reliably than the anterior transpetrosal approach. After all, this approach can be particularly useful when vascular-rich tumors receive blood supplies from multiple directions.
Keywords: Cerebellopontine angle, Hemangioblastoma, Transpetrosal approach
Hemangioblastomas are typically intra-axial and highly vascular tumors occurring in the posterior fossa.[
A 65-year-old man presented with a complaint of diplopia during downward gaze. He was diagnosed with left trochlear nerve palsy at admission. He had no family history of VHL disease. Magnetic resonance (MR) imaging showed a well-enhancing solid mass (maximum diameter of 35 mm) in the left CPA extending superiorly to the tentorial notch [
Preoperative magnetic resonance axial (a) and coronal (b) T1-weighted gadolinium images showing a 35 mm homogeneously enhancing solid mass in the left cerebellopontine angle. Left vertebral angiogram lateral view showing the vascular tumor fed by the left superior cerebellar artery (c) and left common carotid angiogram lateral view also showing the vascular tumor fed by the left tentorial artery (d).
After administering general anesthesia, we inserted a lumbar cerebrospinal fluid drain to minimize brain retraction. In the lateral park-bench position, the patient’s head was turned 30° inferiorly from the vertical plane. A horseshoe-shaped skin incision and temporo-suboccipital craniotomy were made with a splitting mastoidectomy [
(a) Photograph demonstrating the scalp incision and craniotomy range. (b) The incision of the tentorium (asterisk) toward the free edge revealed a reddish extra-axial tumor (double asterisk) between the cerebellum (triple asterisk) and the tentorium. After confirming the presence of displaced trochlear nerve (arrow) in the deep part (c), the tumor (double asterisk) was detached while the feeding arteries from the cerebellar parenchyma (arrowheads) were coagulated (d), and the tumor was completely removed as a mass (e).
The postoperative course was uneventful and the pathology was confirmed as hemangioblastoma. He was discharged without any new complication, and his left trochlear nerve palsy improved after a few months. Postoperative MR imaging confirmed total excision of the tumor [
Except for the cases originating from cranial nerves, 15 cases (including the present case) of CPA hemangioblastoma have been reported with MR findings [
Surgical strategies for CPA hemangioblastomas should be determined while considering several parameters, such as tumor’s size, location, solid or cystic forms, and the number of feeders. In particular, the treatment of large solid type is difficult because of multiple feeders entering the tumor from various directions, for which a preoperative feeder embolization or a skull base approach is needed. Our report indicates the usefulness of a PTPA for large solid CPA hemangioblastomas.
The authors certify that they have obtained all appropriate patient consent.
There are no conflicts of interest.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.
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