Spinal Hemangiopericytoma Which Needed Intraoperative Embolization due to Unexpected Bleeding

Abstract

Spinal intradural hemangiopericytoma is a very rare tumor and can be characterized by massive bleeding during surgeries, frequent recurrence, and metastasis. However, definite radiologic differential points of hemangiopericytoma are not known. We describe an unexpected hemangiopericytoma case with large bleeding and management of the tumor. A 21-year-old man visited complaining of progressive neck pain and tingling sensation in both hands. Magnetic resonance imaging of his spine revealed C1-2 ventral intradural mass. When the dura was opened, the intradural tumor was placed behind spinal accessary nerves. The tumor was partially exposed only after some accessary nerves had been cut. When internal debulking was performing, unexpected bleeding was noted and it was difficult to control because of narrow surgical field and hypervascularity. Intraoperative spinal angiography and embolization were performed. The tumor was completely removed after embolization. Pathological diagnosis was consistent with hemangiopericytoma. When surgeons meet a flesh-red tumor that bleeds unexpectedly during surgery, hemangiopericytoma may be considered. When feeder control is hard due to reciprocal location of spinal cord, the tumor, and feeders, intraoperative angiography and embolization may be a possible option.

Keywords: Angiography; Hemangiopericytoma; Intradural; Spine; Surgery.

Fig. 1

Preoperative sagittal (A) and axial (B) T2-weighted magnetic resonance images reveal a heterogeneous ventral intradural 2.5 cm diameter lesion in the C1-2 region. Sagittal T1-weighted images without enhancement (C) and with enhancement (D) reveal a well enhanced tumor with iso-signal intensity. The preoperative diagnosis was meningioma or schwannoma.

Fig. 2

Intraoperative microscopic finding. A paramedian incision of the dura mater reveal spinal accessory nerves and an oval, flesh-red tumor (asterisk) at the ventral side. The tumor had adhered to the ventral dura. The border between the tumor and the spinal cord is well defined.

Fig. 3

An anteroposterior (A) and lateral (B) conventional spinal angiogram demonstrates a hyper vascular tumor (arrow head) with feeding vessels (arrow). After embolization with titanium coil and particles, the tumor blush disappears on the anteroposterior (C) and lateral (D) angiogram.

Fig. 4

(A) Postcontrast sagittal T1-weighted image 6 months after the surgical resection demonstrates no recurred or residual tumor. Axial (B) and sagittal (C) T2-weighted images reveals that the spinal cord shifted anteriorly without the tumor. The cord is slightly diminished in caliber.

Fig. 5

(A) The tumor was somewhat firm and composed of cystic and nodular lesions. (B) Hematoxylin and eosin staining (original magnification, ×100) shows an irregular array of oval nuclei. The tumor is surrounded by many blood vessels resulting in the "staghorn" appearance typical of hemangiopericytoma. Upon immunostaining of the specimen, tumor cells are negative for CD34 (C) and EMA (D). EMA : epithelial membrane antigen.