Introduction: Restoring normal perfusion pressure to chronically hypoperfused brain tissue is thought to explain some types of brain hemorrhage seen after arteriovenous malformation (AVM) resection (Spetzler, et al 1978) and carotid endarterectomy for high grade stenosis (Bernstein, et al 1984). That hemorrhage may also immediately follow resection of highly vascular tumors such as Hemangioblastoma is not specifically addressed in detail or documented in even a single case in the literature.
Results: We present here the case of a highly vascular solitary cerebellar hemangioblastoma with preoperative imaging showing hypoperfusion at the margins. The entire tumor was unambiguously resected without difficulty using microsurgical technique preserving adjacent cerebellar vasculature. On inspecting the tumor resection cavity, there then developed bleeding from what appeared to be multifocal small vessels with evolving brain edema. The bleeding seemed to worsen with time despite increasingly frantic efforts at bipolar coagulation and application of hemostatic agents. This refractory bleeding from the cerebellar tissue at the margins of the resection cavity appeared identical to that experienced in cases of NPPB following AVM resection. Accordingly, the patient was treated intra-operatively by high dose barbiturate protocol together with induced hypotension following which the situation with hemostasis improved allowing wound closure. After 5 days of induced hypotension with barbiturate coma protocol, the patient emerged with a normal neurological exam. Postoperative imaging confirmed complete resection of the Hemangioblastoma and patient was discharged home without deficit soon after.
Conclusions: The case supports the NPPB concept as originally proposed because the phenomenon occurred even in the setting of an unambiguous total removal of a hypervascular tumor.
Patient Care: By understanding that NPPB bleeding can occur follow resection of a hypervascular brain tumor, neurosurgeons will be better able to anticipate and recognize the problem and start effective treatment intraoperatively.
Learning Objectives: To understand the relation of NPPB bleeding and resection of hypervascular brain tumors, in this case, Hemangioblastoma of cerebellum.
References: Bernstein, M., et al. (1984). "Cerebral hyperperfusion after carotid endarterectomy: a cause of cerebral hemorrhage." Neurosurgery 15(1): 50-56.
Spetzler, R. F., et al. (1978). "Normal perfusion pressure breakthrough theory." Clin Neurosurg 25: 651-672.