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Hemangioblastoma, case 1

CLINICAL HISTORY:
This 64-year old man complains of 2 months of gait disturbances with a tendency to fall to the right and disequilibrium. He notes bifrontal headache.

NEUROLOGICAL EXAMINATION shows gait instability with deviation to the right and tendency to fall to the right on Romberg test. There is left dysmetria and dysdiadochokinesia.

CONTRAST-ENHANCED CT (IMAGE 1) shows an intensely contrast enhancing lesion in the left cerebellar hemisphere with accompanying edema and displacement of brainstem and fourth ventricle (arrowhead) to the right.

MRI:
a) TRANSAXIAL T2-WEIGHTED (2500/90/1) SPIN-ECHO SEQUENCE (IMAGES 2 AND 3): A mass is seen within the left cerebellar hemisphere with surrounding edema and compression and deviation of brainstem and fourth ventricle. Within the tumor several linear structures with signal voids (arrowheads) can be seen.

b) CORONAL T1-WEIGHTED (380/15/1) SPIN-ECHO SEQUENCE (IMAGE 4): The tumor is recognized in the left cerebellar hemisphere with an overall signal isointense to grey matter. Again within the tumor streaky areas of signal voids (arrowheads) can be recognized.

c) CORONAL) GADOLINIUM-ENHANCED SPIN-ECHO SEQUENCES (IMAGES 5 AND 6): There is intense contrast enhancement of the tumor. At the most inferior aspect a small cyst is seen. Within the tumor diffuse signal voids (arrowheads) can again be seen.

ANGIOGRAPHY: Selective injection of the left vertebral artery in the anteroposterior (IMAGE 7) and the lateral (IMAGE 8) projection: The tumor is markedly hypervascular.

RADIOLOGICAL DIFFERENTIAL DIAGNOSIS includes hypervascular metastasis and hemangioblastoma.

SURGICAL FINDINGS: At surgery, a highly vascularized tumor was seen in the left cerebellar hemisphere, well-delineated from the surrounding white matter. There was extension into the middle cerebellar peduncle. In the craniocaudal direction the tumor reached the surface of the tentorium. Resection was total.

ANATOMOPATHOLOGY was consistent with capillary hemangioblastoma Grade I.

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Fig. 1

Hemangioblastoma, case 1, Fig. 1
Hemangioblastoma, case 1, Fig. 2
Hemangioblastoma, case 1, Fig. 3
Hemangioblastoma, case 1, Fig. 4
Hemangioblastoma, case 1, Fig. 5
Hemangioblastoma, case 1, Fig. 6
Hemangioblastoma, case 1, Fig. 7
Hemangioblastoma, case 1, Fig. 8