Clinical Neurology and Neurosurgery 115 (2013) 2200–2203
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Case report
Posterior fossa surgery in octogenarians: Special considerations Ricky H. Wong a,∗ , Anita P. Bhansali a , Andrew K. Wong b , Theera Rojanapremsuk c , Hamad I. Farhat b,2 a
Section of Neurosurgery, University of Chicago, 5841 S. Maryland Avenue MC3026, Chicago 60637, USA1 Department of Neurosurgery, North Shore Neurologic Institute, 2650 Ridge Avenue, Evanston, USA c Department of Pathology, North Shore University Health System, 2650 Ridge Avenue, Evanston, USA b
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Article history: Received 18 April 2013 Received in revised form 26 May 2013 Accepted 27 May 2013 Available online 24 June 2013 Keywords: Hemangioblastoma Elderly Surgical Complications
1. Introduction
2. Case report
In the present case, we describe a rare presentation of cerebellar hemangioblastoma, the management, considerations, and outcome, in an 89 year-old male. Hemangioblastomas are benign vascular tumors that occur most commonly in the cerebellum. They represent 1–2% of all intracranial tumors and typically affect males in their third to fifth decade of life. Most hemangioblastomas are cystic with a mural nodule and occur sporadically. Approximately 25% of hemangioblastomas occur in association with von Hippel–Lindau (VHL) disease. Neurosurgical intervention in the elderly is commonly associated with higher peri-operative and post-operative morbidity that can often deter multi-disciplinary teams from pursuing operative management. Thus far, there have been three reported cases of hemangioblastomas occurring in this age group (ages 81, 86, and 95) – this case represents the fourth [1,2].
Presentation: An 89 year-old high-functioning gentleman with a history of limited local melanoma of the ear and distant history of prostate cancer presented with several weeks of progressive gait instability. Neurologic exam was non-focal except for mild ataxia and left-sided dysmetria. Gadolinium-enhanced magnetic resonance imaging (MRI) demonstrated a solid, heterogeneously enhancing mass in the left cerebellar hemisphere with peri-lesional edema and effacement of the fourth ventricle (Fig. 1a). At the time, metastatic disease was believed to be the most likely diagnosis. Computed tomography (CT) scan of the chest, abdomen, and pelvis, however, did not reveal any primary oncologic disease. The patient underwent surgical resection. Surgical Management: In the supine position, abdominal fat was obtained for autologous fat grafting during closure. The patient was then placed in a lateral park-bench position (Fig. 2) with the lower arm free to hang off the top of the bed. A stack of blankets is placed anterior to the chest and abdomen, while the patient is secured to the table using heavy tape. The upper arm rests freely on the stack of blankets. The entire table is then placed in reverse Trendelenberg with the head fixed using Mayfield pins. The head is positioned with slight flexion, contralateral rotation, and contralateral bend. The upper shoulder is then taped to the foot of the bed. Intraoperative guidance is used to define the boundaries of the transverse and sigmoid sinus. A burr hole is placed safely away from the sinus junction and a small craniotomy is performed (Fig. 3a). A side-cutting drill is used to thin the bone overlying the edge of the venous sinuses. A diamond drill is then used to skeletonize the edge of the venous
∗ Corresponding author. Tel.: +1 773 702 2123. E-mail addresses:
[email protected] (R.H. Wong),
[email protected] (A.P. Bhansali),
[email protected] (A.K. Wong),
[email protected] (T. Rojanapremsuk),
[email protected] (H.I. Farhat). 1 Tel.: +1 773 702 2123. 2 Tel.: +1 847 570 1440. 0303-8467/$ – see front matter © 2013 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.clineuro.2013.05.027
R.H. Wong et al. / Clinical Neurology and Neurosurgery 115 (2013) 2200–2203
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Fig. 1. (a) Pre- and (b) post-operative axial images of a gadolinium-enhanced MRI scan of the head demonstrating enhancing mass in the left cerebellar hemisphere.
sinuses, which allows for direct visualization of this vital structure and safely maximizing surgical exposure. Upon visualization of the dura, no evidence of tumor infiltration was noted. A curvilinear dural incision was performed following the border of the transverse and sigmoid sinuses (Fig. 3b). Following microsurgical resection of the vascular tumor, the dura was closed primarily with Duragen® (Integra LifeSciences Corporation) and fat graft reinforcement. Sufficient fat graft was used to ensure elimination of all dead space and produce gentle pressure on the dura after titanium mesh was placed to reconstruct the craniectomy defect. Multi-layered fascial closure was followed by skin closure with a running, locked suture.
Post-operative course: Pathological results were consistent with hemangioblastoma (Fig. 4). The patient was admitted to intensive care for one night and transferred to a regular room on postoperation day 1. He was initiated on heparin thromboprophylaxis and aggressive physical therapy. The patient recovered well and was discharged home on post-operation day 2. At 2-month followup, he had no neurologic deficits and resumed full normal activity. 3. Discussion While metastatic disease remains the most likely etiology for a cerebellar mass presenting in the elderly, this case highlights
Fig. 2. Lateral, park bench, position with reverse Trendelenberg and both arms free and accessible. An arm board with foam padding (arrows) is placed on the Mayfield adaptor to support the lower arm. A stack of blankets (arrowheads) is placed anterior to the torso to stabilize the body and allow the upper arm to rest freely.
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R.H. Wong et al. / Clinical Neurology and Neurosurgery 115 (2013) 2200–2203
Fig. 3. Posterolateral view of the skull base with demonstration of the transverse and sigmoid venous sinuses (arrows). (a) Initial burr hole is placed a safe distance away from the sinus junction that is followed by a small craniotomy. (b) After achieving direct visualization of the sinus edge, a curvilinear dural opening is performed (asterisk). This can be extended into C-shaped flap if additional exposure is needed.
the possibility of other, more benign, causes with significant prognostic consequences. In addition, general anesthesia and surgery in the elderly is often associated with higher peri-operative and post-operative morbidity, which often results in non-surgical management in this population. Advanced age has been found to be associated with increased lengths of hospital stay after craniotomy, as well as an independent risk factor for the development of venous thromboembolism [3,4]. In a large series of craniotomies for intraparenchymal tumors, Sawaya et al. found advanced age and infratentorial location of tumor resections to be independent risk factors for regional complications such as wound infection, cerebrospinal fluid leak (CSF), hematoma, and meningitis [5]. In the same study, however, they also found pre-operative Karnofsky Performance Status scores to be a significant predictor of post-operative recovery in the elderly. Recently, in a study of 424 patients comparing awake craniotomies in young patients to elderly patients, no statistically significant higher rate of mortality or complications were found in the elderly group [4]. Thus, in carefully selected cases, surgical management offers the potential for diagnosis, symptomatic improvement, and cure. Successful neurosurgical intervention in this age group, however, requires several considerations. At our institution, all patients undergo rigorous pre-operative medical evaluation and multidisciplinary consultation with neuro-oncology. Prior to surgery, we discuss with the anesthesiologist regarding the potential risk
of air embolism and, in particular, request special attention to end-tidal CO2 levels, blood pressure, and the use of precordial Doppler ultrasound in cases with especially high risk. In addition, we typically request the anesthesiologist to be judicious with intraoperative fluid replacement as patients of this age group typically have reduced cardiopulmonary reserve and are more susceptible to fluid overload. For non-midline infratentorial lesions, we prefer to use the park-bench positioning over prone positioning to reduce intra-abdominal pressure and improve venous return. We also prefer a special modification to the park-bench position that allows for both arms to be easily accessible in order to improve intra-operative monitoring and manipulation by anesthesiology. We utilize mild reverse Trendelenberg and optimal head positioning to further enhance venous return and operative exposure. Intraoperative image guidance allows us to minimize the incision, craniectomy, and risk of venous sinus injury. We prefer a curvilinear dural opening over the common cruciate opening to improve the strength of primary closure, because watertight closure of the intersection point in a cruciate opening is often difficult and suboptimal. In the event of tumor infiltration of the dura, we resect the affected portion and use dural substitutes to repair the defect. We prefer suturable dural substitutes over onlay substitutes for defect repair, because it allows for the graft to be primarily sutured into the dural defect for improved CSF leak prevention. To further minimize the risk of CSF leak, dural closure of infratentorial craniotomies are
Fig. 4. (a) High-powered magnification of a hematoxylin and eosin stain that demonstrates thin-walled capillary spaces with vacuolated stromal cells. (b) The stromal cells were strongly and diffusely positive on inhibin staining.
R.H. Wong et al. / Clinical Neurology and Neurosurgery 115 (2013) 2200–2203
also reinforced with autologous fat graft and Duragen. We repair the craniectomy with mesh in order to provide gentle pressure on the fat graft and Duragen to enhance the seal of the dura. Postoperation, patients are placed on heparin for thromboprophylaxis on day one and entered into aggressive, scheduled physical therapy immediately. This is to address the risks of deep vein thromboses and post-operative cardiopulmonary complications such as atelectasis and pneumonia. In the three reported cases of hemangioblastomas in the elderly in the literature, all three underwent total resection. Two of the three had good functional outcome at long-term follow-up. The third developed a fatal respiratory infection 3 weeks after surgery. The present case demonstrates an instance of a hemangioblastoma in an 89 year-old gentleman who underwent successful surgical management for presumptive cure and demonstrated good neurologic recovery at follow-up. 4. Conclusion While metastatic tumors are the most common infratentorial tumors presenting in the elderly, hemangioblastoma represents
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a possible and benign differential. Despite reported peri- and post-operative morbidities in elderly neurosurgical patients, with careful patient selection and attention to the special considerations of neurosurgical intervention in this group, surgical intervention is not only possible, but can also allow for rapid neurologic recovery and cure. References [1] Gnanalingham KK, Apostolopoulos V, Chopra I, Mendoza N, Peterson D. Haemangioblastoma: a rare cause of a cerebellar mass in the elderly. British Journal of Neurosurgery 2003;17:461–4. [2] Laborde G, Gilsbach J, Harders A. Successful treatment of a haemangioblastoma in a 95 year-old patient. Case report. Acta Neurochirurgica 1991;110: 193–4. [3] Chaichana KL, Pendleton C, Jackson C, Martinez-Gutierrez JC, Diaz-Stransky A, Aguayo J, et al. Deep venous thrombosis and pulmonary embolisms in adult patients undergoing craniotomy for brain tumors. Neurological Research 2013;35:206–11. [4] Grossman R, Nossek E, Sitt R, Hayat D, Shahar T, Barzilai O, et al. Outcome of elderly patients undergoing awake-craniotomy for tumor resection. Annals of Surgical Oncology 2013;20:1722–8. [5] Sawaya R, Hammoud M, Schoppa D, Hess KR, Wu SZ, Shi WM, et al. Neurosurgical outcomes in a modern series of 400 craniotomies for treatment of parenchymal tumors. Neurosurgery 1998;42:1044–55 (discussion 1055–1046).
