Technical Note Complete preoperative embolization of hemangioblastoma vessels with Onyx 18 Denes B. Horvathy a,b , Erik F. Hauck a,b , Christopher S. Ogilvy a,b,c , L. Nelson Hopkins a,b , Elad I. Levy a,b , Adnan H. Siddiqui a,b,⇑ a Department of Neurosurgery and Toshiba Stroke Research Center, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, New York, USA b Department of Neurosurgery, Millard Fillmore Gates Hospital–Kaleida Health, 3 Gates Circle, Buffalo, New York 14209, USA c Neurovascular Service, Massachusetts General Hospital, Boston, Massachusetts, USA article info Article history: Received 23 April 2010 Accepted 14 June 2010 Keywords: Brain tumor Hemangioblastoma Onyx Preoperative embolization abstract The authors present a preliminary experience with ethyl-enevinylalcohol copolymer (Onyx) for heman- gioblastoma vessel embolization before surgical resection. The patient presented with neck pain, dizzi- ness, blurred vision, vomiting, and loss of balance. Diagnostic imaging revealed a posterior fossa cystic mass with a nodular component. Angiography demonstrated a significant vascular blush with arteriove- nous shunting that was characteristic of a hemangioblastoma. Tumor vessels originating off the left pos- terior inferior cerebellar artery were embolized before surgery using Onyx 18 (ev3, Covidien Vascular Therapies, Mansfield, MA, USA). This resulted in complete obliteration of all tumor vessels, transforming a highly vascular tumor into an avascular mass. A safe and uneventful surgical resection was performed the next day. Onyx is a valuable embolic agent for preoperative hemangioblastoma vessel embolization. Because of its low viscosity, Onyx penetrates deeply into the tumor vasculature and allows complete obliteration of tumor vessels. Risks of the intervention have to be carefully weighed against the benefits. If preoperative embolization is indicated, the use of Onyx should be strongly considered. Ó 2010 Elsevier Ltd. All rights reserved. 1. Introduction Hemangioblastomas are benign vascular tumors with low risk of spontaneous hemorrhage. 1 However, they frequently present as space-occupying lesions compressing adjacent neural structures with resultant symptoms. Excessive bleeding is a known potential complication of resection of these highly vascular lesions. More- over, obliteration of clear surgical planes by excessive and inces- sant blood loss increases the potential for inadvertent neural tissue injury during surgery. To minimize the possibility of these complications and facilitate surgical intervention, preoperative embolization can be performed. Previous reports have described the use of embolic agents in the management of hemangioblas- toma. 2–4 Additionally, partial embolization of hemangioblastomas using Onyx (ev3, Covidien Vascular Therapies, Mansfield, MA, USA) has been reported. 5 We report a patient in whom complete preoperative embolization of hemangioblastoma vessels with Onyx was achieved, which permitted a safe, uneventful resection on the following day. The novel use of Onyx for this indication is discussed in comparison with the current literature. 2. Case presentation 2.1. History and imaging A previously healthy patient presented to the emergency department with a 5-month history of worsening neck pain. Fur- ther, the patient complained of dizziness, blurred vision, vomiting, and loss of balance during the previous month. CT scans and MRI revealed hydrocephalus caused by a large posterior fossa mass. The mass contained a large cyst (5.6 cm by 3.7 cm) and an enhanc- ing mural nodule (2.6 cm by 1.6 cm). These findings were consis- tent with a hemangioblastoma causing hydrocephalus. 2.2. Treatment strategy Urgent resection of the lesion was planned to confirm the diag- nosis and treat the hydrocephalus. However, because of the risk of bleeding during hemangioblastoma resection, preoperative angi- ography and possible embolization were scheduled before surgery. A diagnostic cerebral angiogram demonstrated a significant vascu- lar blush supplied mostly from the left posterior inferior cerebellar artery (PICA). There was obvious arteriovenous (AV) shunting con- sistent with in a highly vascular lesion, consistent with a hemangi- oblastoma (Fig. 1A–C). The main vessel feeding the tumor, the PICA, seemed accessible with microcatheters. On the basis of these 0967-5868/$ - see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jocn.2010.06.016 ⇑ Corresponding author. Tel.: +1 716 887 5200x2112; fax: +1 716 887 4378. E-mail address: asiddiqui@ubns.com (A.H. Siddiqui). Journal of Clinical Neuroscience 18 (2011) 401–403 Contents lists available at ScienceDirect Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn