Hemangioblastoma - late recurrence
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At the time the case was submitted for publication Bruno Di Muzio had no recorded disclosures.View Bruno Di Muzio's current disclosures
The patient was referred to this service due a cerebral mass found on CT scan. No further clinical data.
MRI Brain + MRA
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Technique: Pre and post contrast study including MRA and postcontrast brainlab sequence performed.
Findings: Irregular cystic lesion centered in the left cerebellar hemisphere measures 3.5 x 4.6 x 3.1 cm (AP x ML x SI). This demonstrates a 15 x 7 mm enhancing nodule at the anterior margin, abutting the pial surface, and contains a single thin internal septation. Thin margin of FLAIR hyperintensity with some subtle signal abnormality in the distorted left posterolateral medulla. Minimal appreciable rim enhancement. No evidence of hemorrhage.The lesion results in positive mass effect upon the medulla and fourth ventricle but without hydrocephalus.
The non-dominant left vertebral artery courses immediately inferior to the mass with the tortuous basilar artery lying anteriorly to and separate from the mass.
Scattered supratentorial white matter T2 hyperintensities are most consistent with moderate for age small vessel ischemic change. A few punctate foci are also noted within the pons. No other intra or extra-axial mass nor abnormal enhancement, in particular, no abnormal enhancement is seen in the upper cervical cord or retina.
Conclusion: Solitary cystic lesion left cerebellar hemisphere with enhancing mural nodule abutting the pial surface. Appearances are quite typical for hemangioblastoma, however metastasis remains an important differential.
The patient was submitted to a resection surgery that confirmed the diagnosis considered on the MRI study. After that surveillance MRI exams were proposed.
MRI Brain (4 years later)
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Technique: Multiplanar, multisequence imaging has been obtained through the brain including pre and post contrast sequences.
Findings: Left-sided occipital craniotomy with expected post-operative change and prominent gliosis of the cerebellar hemisphere is again noted, with an enhancing nodule nestled between the medulla and the left cerebral hemisphere. On today's examination the nodule measures 10 x 12 x 16 mm compared to 9 x 9 x 14 mm one year ago (remeasured).
Extensive patchy white matter T2 signal hyperintensity is similar, with no abnormal restricted diffusion. No abnormal enhancement elsewhere, with the remainder of the brain appearing unremarkable.
On T2 axial imaging there appears to be a right-sided middle cerebral artery trifurcation aneurysm (4 x 3 mm). No prior vascular imaging is available.
Conclusion: Enhancing left cerebellar medullary angle nodule continues to slowly growing consistent with recurrent/residual tumor.
Probable right middle cerebral artery bifurcated aneurysm. This does not appear to have altered when compared to imaging from 2011 but warrants dedicated vascular imaging (CTA / MRA) if clinically indicated.
This case illustrates a pathologically proven cerebellar hemangioblastoma that recurred after complete surgical resection (exams in between were not shown in this case). Recurrence in those tumors can be observed in up to a quarter of the cases.