Working Diagnosis:
Cerebellar hemangioblastoma with Obstructive hydrocephalus

Treatment:
He was admitted to the Neuro ICU on high-dose IV dexamethasone and IV levetiracetam for seizure prophylaxis. Neurosurgery performed a suboccipital craniotomy for mass resection and External Ventricular Drain (EVD) placement the following day; the EVD was removed 2 days later.

Outcome:
His hospital stay was complicated by hospital-acquired pneumonia, which was treated with piperacillin/tazobactam and azithromycin. He responded well to treatment and was discharged home on hospital day 10. He followed up with Neurosurgery after discharge, who assisted with guiding his return to sport.
At the time of discharge, he was ambulating without assistance, though with some subjective dizziness. He began balance training at 2 weeks post-op and was able to return to light aerobics and weight training by 4 weeks. A repeat MRI at 6 weeks revealed no residual tumor along with appropriate parenchymal filling of the cerebellar defect. Case Photo #3 Case Photo #4 He was able to progress his aerobic activity at 8 weeks. He received full clearance to return to practice and full weight training at 12 weeks. By 16 weeks, he had a full return to sport. A repeat MRI performed 6 months post-op revealed further parenchymal filling of the defect and no new masses.

Author's Comments:
This case highlights the often insidious onset of symptoms with a slow-growing central nervous system (CNS) neoplasm. Once the mass had grown large enough to obstruct CSF outflow, hydrocephalus developed, and symptoms rapidly progressed.


Hemangioblastomas are benign, slow-growing, highly vascularized neoplasms. They are the most common primary tumor of the cerebellum. They are commonly associated with von Hippel-Lindau disease, which causes hemangiomas in multiple organs, although 75 percent of cerebellar hemangioblastomas develop sporadically. Diagnosis is typically made with brain imaging, and it is later confirmed by pathology. The appearance of hemangioblastomas on imaging is similar to other CNS masses, particularly pilocytic astrocytoma. Definitive treatment is surgical resection. If complete resection is achieved, the relapse rate is zero. If resection is incomplete, then radiotherapy may be indicated. Patients with solid tumors tend to have worse outcomes compared to those with cystic tumors, which was the case with this patient.


As of this report, standardized Return to Play (RTP) protocol for patients with non-traumatic brain mass and craniotomy is currently being developed. Initial surveys suggest RTP is possible in a prolonged, stepwise fashion. At a minimum, the patient must be asymptomatic and several months post-op to allow for stabilization of the brain parenchyma as it fills the cavity left by resection of the mass. Some experts suggest resolution of blood/air on imaging prior to RTP.

Editor's Comments:
Hemangioblastomas are an uncommon, benign, slow-growing type of CNS tumor. They account for 7-10 percent of all posterior fossa tumors in adults, with 80 percent of these occurring in the cerebellar hemispheres. They can be sporadic or associated with von Hippel Lindau disease, a hereditary syndrome that can cause a variety of benign and malignant tumors affecting multiple organ systems. While benign, hemangioblastomas may grow to a size that causes mass effect symptoms, such as dizziness, cerebellar ataxia, oculomotor nerve dysfunction, dysphagia, motor weakness, or sensory deficits. MRI with gadolinium enhancement is the gold standard neuroimaging to make the diagnosis. Surgical resection is the recommended treatment for hemangioblastomas with an overall good prognosis.


There is very little evidence and standardization for RTP following craniotomy for a non-sports related brain lesion. While there are concerns for seizure risk, susceptibility to traumatic brain injury or infection following these procedures, the actual risks are currently unknown. Due to the lack of standardization, it is recommended to take an individualized approach when developing a RTP plan. The general neurosurgical consensus when considering RTP includes symptomatic recovery, resolution of blood or air on follow up imaging, and patient demand. RTP may take anywhere from 3 months to 1 year or longer, depending on the patient.

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