Introduction: Intracranial hemangioblastomas are benign but hypervascular tumors, most commonly located in the cerebellum, which are difficult to resect without significant operative blood loss. While preoperative embolization may decrease the amount of operative bleeding, the vascular supply of cerebellar hemangioblastomas frequently precludes safe embolization by an endovascular route due to the risk of thromboembolic vertebrobasilar infarct. Direct puncture embolization overcomes many of the limitations of endovascular embolization but its safety and feasibility for intracranial tumors is unknown.

Methods: We report a case of a 48 year-old male who was diagnosed with a large cerebellar mass after presenting with headaches and gait ataxia. Based on diagnostic angiography, which demonstrated a highly vascular tumor supplied by the posterior inferior cerebellar and posterior meningeal arteries, we decided to embolize the tumor by a direct transcranial puncture approach.

Results: After trephinating the skull in a standard fashion, a catheter-needle construct, composed of an Echelon 10 microcatheter placed into a 21-gauge spinal needle, was inserted into the tumor under biplanar angiographic guidance. Using continuous angiographic monitoring, 9 cc of Onyx 34 was injected through the catheter resulting in 75% tumor devascularization without evidence of complications. The patient was taken directly to surgery where a gross total resection of the hemangioblastoma was achieved with an acceptable operative blood loss. At two year follow-up, the patient is neurologically intact without neuroimaging evidence of residual tumor.

Conclusions: We describe the first case of direct transcranial puncture for preoperative embolization of a cerebellar hemangioblastoma.

Patient Care: Hemangioblastomas are relatively common cerebellar tumors which are histologically benign but may be difficult to safely surgically resect due to the high degree of vascularity with which they are frequently associated. Therefore, a safe and effective method for preoperative embolization of these lesions may decrease surgical complication rates and perioperative morbidity and mortality.

Learning Objectives: By the conclusion of this session, participants should be able to 1) Describe the potential benefits of preoperative embolization for cerebellar hemangioblastomas, 2) Discuss, in small groups the advantages of direct transcranial puncture over endovascular access for delivery of permanent embolic agents, and 3) Identify an effective method for preoperative devascularization of cerebellar hemangioblastomas.

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