Surgical Management of Triple Sporadic Lumbar Intradural Hemangioblastomas with Atypical Imaging Presentations: A Case Report in a Patient without VHL Syndrome
Introduction and Importance: Hemangioblastomas of the cauda equina are particularly exceptional. Therefore, the management has not yet been established. This study reports on a very rare case of three hemangioblastomas arising from the cauda equina with a heterogeneous appearance of each lesion on MRI. This appearance is atypical and requires some reflection on the type of management. We chose to operate on the two lower lesions in order to obtain histology and treat symptoms by being as minimally invasive as possible. The upper lesion is under radio-clinical monitoring. Presentation of Case: A 72-year-old patient without Von Hippel-Lindau (VHL) disease presented a 1-year history of low back pain and 6 months of bilateral S1 radicular symptoms. MRI revealed three lumbar intradural extramedullary tumors with different types of contrast enhancement. Preoperative angiography rules out vascular malformation nests. The other results of the work-up are negative. Following multidisciplinary discussion, only two lower lesions were removed in order to have anatomopathological pieces, be less invasive, and try to heal leg symptoms. Tumors are well limited and hypervascular. The post-operative course is completely satisfactory, with complete resolution of neurological symptoms and no perioperative complications. The third lesion, the highest, is being monitored and will be treated on the basis of radio-clinical findings in the future. Clinical Discussion: This article reports a very rare case of three hemangioblastomas with different contrast enhancements. It shows that three extramedullary intradural hemangioblastomas on cauda equina are possible. Two of these were operated on, and the third is under observation. Conclusion: Surgical management of only part of the lesions is entirely feasible in the first instance in order to obtain histology, remain minimally invasive, and limit perioperative complications.
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