Haemangioblastoma (central nervous system)
Haemangioblastomas are tumours of vascular origin and occur both sporadically and in patients with von Hippel Lindau (vHL). They are WHO grade I tumours that can occur in the central nervous system or elsewhere in the body, including kidneys, liver and pancreas.
These tumours generally present on imaging as sharply demarcated homogeneous masses composed of a cyst with non-enhancing walls, with a mural nodule which vividly enhances and often has prominent serpentine flow voids.
Haemangioblastomas typically occur in young to middle-aged adults, and although they are the most common primary posterior fossa mass in this demographic, they are nonetheless uncommon in absolute terms, accounting for only 1-2.5% of all intracranial tumours 3,4 and approximately 10% of all posterior fossa tumours 4:
- slight male predilection in adults with M:F ratio of 1.3-2.6:1 4
- peak incidence is around 30-60 years of age, but earlier in patients with vHL
- sporadic cases make up approximately 75-80%, with the remainder being found in patients with vHL
Most frequently present with symptoms relating to:
- headaches: 70% 4
- hydrocephalus and symptoms of raised intracranial pressure: 50 % 4
- cerebellar dysfunction: ~50-60% 3
- altered mental state: 10%
- polycythaemia due to erythropoietin production occurs in ~20% (range 5-40%) of cases 3,4
One study showed that in VHL patients, the onset of symptoms usually coincides with the development of cystic component, and they showed that solid cerebellar nodules were mostly well tolerated. They suggested repeat imaging at this stage to document the size of the cyst and to plan tumour excision 7.
Acute presentation due to significant haemorrhage is uncommon and tends to be seen in larger tumours (>1.5 cm) 5-6.
Haemangioblastoma is actually a capillary haemangioma and despite the name with the affix of "blastoma" it is a low grade (WHO grade I) lesion (note that the calvarial haemangioma is a cavernous haemangioma). The tumour is usually well circumscribed with a highly vascular mural nodule almost always abutting pial layer and a peripheral cyst which has similar contents as blood plasma. Hence it is suggested that the cystic component most likely arises by exudation from the solid nodule vascular component 4,9.
It has therefore also been suggested that resection of the cystic component need not be carried out. This has not been supported in a number of other studies however 8,9 (Note: a similar discussion is present in the pilocytic astrocytoma literature).
Cysts which are within the solid nodule, or have peripheral enhancement, are presumably part of the tumour and should, therefore, be resected. The fluid within the cyst is often xanthochromic due to frequent bleeding into the cyst 4.
Microscopy reveals a very vascular tumour composed of thin-walled vessels with surrounding stroma of connective tissue and polygonal lipid-laden 'stromal cells' 4.
- intracranial: 87-97% 4
- 95% in posterior fossa
- 85% in cerebellar hemisphere
- 10% in the cerebellar vermis
- 5% medulla
- only rarely do they extend beyond the cerebellum into the cerebellopontine angle 2
- 5% supratentorially (typically in the optic radiations)
- cerebral haemangioblastomas are only really seen in patients with vHL
- 95% in posterior fossa
- spinal: 3-13% 4
- multiple RCCs
von Hippel Lindau (vHL) disease
- ~45% of those with vHL develop haemangioblastomas
- ~20% of those with haemangioblastoma have vHL
- polycythaemia: due to secretion of erythropoietin from lesions
Typically haemangioblastomas (60% of cases) are sharply demarcated homogeneous masses composed of cyst with non-enhancing walls, except for a mural nodule which vividly enhances and often has prominent serpentine flow voids 2. Not infrequently the mural nodule itself has cystic spaces within it. The solid nodules are commonly seen abutting the pia mater.
In the remaining 40%, the tumour is solid with no cystic cavity 4.
- the mural nodule is isodense to brain on non-contrast scans with fluid density surrounding cyst
- bright enhancement of the nodule is demonstrated with contrast
- the cyst walls do not usually enhance
- calcification is not a feature
- hypointense to isointense mural nodule
- CSF signal cyst content
T1 C+ (Gd)
- mural nodule vividly enhances 2,4
- cyst wall does not enhance 4
- hyperintense mural nodule
- flow voids due to enlarged vessels may be evident especially at the periphery of the cyst, seen in 60-70% of cases 4
- fluid filled cyst, similar to CSF
- MR perfusion imaging: high rCBV ratios
Enlarged feeding arteries and often dilated draining veins are demonstrated, with a dense tumour blush centrally 4.
Treatment and prognosis
Surgical resection is usually curative, and with large lesions may be made easier by preoperative embolization. Simple cyst drainage appears to be insufficient for definitive management. Adjuvant radiotherapy may be used in patients with incomplete resections. Recurrence can be seen in up to 25% of patients 3.
General imaging differential considerations include:
- metastasis(es): although single posterior fossa metastases are uncommon they are still the most common diagnosis if the patient is middle-aged or older
- vascular lesions
- adult patients
- much more solid
- restricted diffusion (small round blue cell tumour)
- 1. Grossman RI, Yousem DM. Neuroradiology, the requisites. Mosby Inc. (2003) ISBN:032300508X. Read it at Google Books - Find it at Amazon
- 2. Bonneville F, Sarrazin JL, Marsot-Dupuch K et-al. Unusual lesions of the cerebellopontine angle: a segmental approach. Radiographics. 21 (2): 419-38. Radiographics (full text) - Pubmed citation
- 3. Farrukh HM. Cerebellar hemangioblastoma presenting as secondary erythrocytosis and aspiration pneumonia. West. J. Med. 1996;164 (2): 169-71. Free text at pubmed - Pubmed citation
- 4. Ho VB, Smirniotopoulos JG, Murphy FM et-al. Radiologic-pathologic correlation: hemangioblastoma. AJNR Am J Neuroradiol. 13 (5): 1343-52. AJNR Am J Neuroradiol (citation) - Pubmed citation
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- 6. De san pedro JR, Rodríguez FA, Níguez BF et-al. Massive hemorrhage in hemangioblastomas Literature review. Neurosurg Rev. 2010;33 (1): 11-26. doi:10.1007/s10143-009-0217-1 - Pubmed citation
- 7. Slater A, Moore NR, Huson SM. The natural history of cerebellar hemangioblastomas in von Hippel-Lindau disease. AJNR Am J Neuroradiol. 2003;24 (8): 1570-4. AJNR Am J Neuroradiol (full text) - Pubmed citation
- 8. Utsuki S, Oka H, Kijima C, Miyajima Y, Hagiwara H, Fujii K. Utility of intraoperative fluorescent diagnosis of residual hemangioblastoma using 5-aminolevulinic acid. Neurology India. 59 (4): 612-5. doi:10.4103/0028-3886.84349 - Pubmed
- 9. Raz E, Zagzag D, Saba L, Mannelli L, Di Paolo PL, D'Ambrosio F, Knopp E. Cyst with a mural nodule tumor of the brain. Cancer imaging : the official publication of the International Cancer Imaging Society. 12: 237-44. doi:10.1102/1470-7330.2012.0028 - Pubmed