This 43 male presented with progressive headaches and neck pain over many months. He also described some visual obscuration over that time. He had a CT scan without contrast and was referred for assessment. An MRI scan was performed, showing a large, highly vascular left sided posterior fossa tumour, with obstructive hydrocephalus (figs 1 and 2).

Urgent treatment of the hydrocephalus was needed so he proceeded to an endoscopic 3rd ventriculostomy. This was uneventful and his headaches and visual problems were resolved.

The tumour was then assessed angiographically, and it was confirmed that it was highly vascular, fed by multiple arterial feeders (including from the external carotid and vertebral artery via the PICA and SCA) (figs 3, 4).

To improve the safety and ease of surgery, embolization was performed (fig 5).

This significantly reduced the vascularlity of the tumour, and surgical resection proceeded the day after embolization without incident (fig 6).

The histology was confirmed to be a Haemangioblastoma.

Haemangioblastomas are benign slow growing tumours of adults, typically occurring in the brain stem, cerebellum and spinal cord. They occur in sporadic forms (as in this case) and in association with von Hippel-Lindau syndrome. Most present as well circumscribed partially cystic and highly vascular lesions, but some are completely solid. Prognosis is excellent if surgical resection can be performed. To successfully achieve this, multimodal investigation is required, and preoperative embolization can aid in improving the safety of surgery, which can be technically demanding.

– By Prof. David Walker, Neurosurgeon and Spinal Surgeon