Rare intramedullary hemorrhage of a brainstem hemangioblastoma.

Object: Hemorrhages caused by hemangioblastomas are very rare and mostly located in the subarachnoid space. Intraparenchymal bleedings due to hemangioblastomas are even less frequent, and these hemorrhages are almost exclusively located in the supratentorial brain, cerebellum and spinal cord. We report the first case of a brainstem hemorrhage due to a hemangioblastoma of the medulla oblongata.

Case report: A 47-year-old woman presented with acute onset of headache, anarthria, inability to swallow, left-sided hemiparesis and hemidysesthesia with varying states of vigilance, finally developing acute respiratory failure. Cranial computed tomography (CT) scanning and magnetic resonance imaging (MRI) revealed a small hemangioblastoma of the posterior medulla oblongata causing intraparenchymal hemorrhage and acute occlusive hydrocephalus due to intraventricular hematoma extension.

Result: After implantation of an external ventricular catheter to treat acute hydrocephalus, the hemangioblastoma as well as its associated hemorrhage could be removed in toto via a microsurgical posterior median suboccipital approach with minimal foramen magnum enlargement. During the follow-up period of six months postoperatively the patient showed good recovery with only slight residual neurological deficits.

Conclusion: The most common causes of brainstem hemorrhages are arterial hypertension and cavernous hemangiomas. However, hemangioblastomas should not be ignored as a possible differential diagnosis for intraparenchymal brainstem hemorrhage. While the prognosis in hypertensive brainstem bleedings is mostly disastrous and surgery rarely indicated, an operative therapy should be considered in cases of hemorrhages caused by underlying tumors. Especially in the treatment of hemangioblastoma, the surgical management strategy is crucial for a successful result. Therefore, the authors recommend including the search for hemangioblastomas into the diagnostic workup in patients with brainstem hemorrhages.