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May 2018

Review of the Neurological Implications of von Hippel–Lindau Disease

Author Affiliations
  • 1Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus
  • 2Otolaryngology Branch, National Institute on Deafness and Other Communication Disorders, National Institutes of Health, Bethesda, Maryland
  • 3Department of Otolaryngology–Head and Neck Surgery, Georgetown University Medical Center, Washington, District of Columbia
  • 4Neuroradiology Section, Diagnostic Radiology, Clinical Center, National Institutes of Health, Bethesda, Maryland
  • 5Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
JAMA Neurol. 2018;75(5):620-627. doi:10.1001/jamaneurol.2017.4469

Importance  von Hippel–Lindau (VHL) disease–associated central nervous system (CNS) lesions include hemangioblastomas and endolymphatic sac tumors (ELSTs), which are associated with significant neurological morbidity and mortality. Recent studies provide critical new biological, diagnostic, and management insights into these tumors.

Observations  Biological features, natural history, clinical findings, and management strategies of VHL disease–associated CNS tumors are reviewed. The VHL disease results from a germline mutation of the VHL gene (located on the short arm of chromosome 3), a tumor suppressor that encodes for the VHL protein. Whereas VHL disease is associated with visceral manifestations, CNS lesions are the most common source of morbidity and mortality. Craniospinal hemangioblastomas are almost entirely (99%) found in the cerebellum, brainstem, and spinal cord. These tumors arise from multipotent hemangioblasts. Peritumoral cysts frequently underlie the clinical findings associated with hemangioblastomas (>90% of symptomatic tumors). Prospective natural history studies demonstrate that CNS hemangioblastomas typically grow in a saltatory pattern. Due to this unpredictable growth pattern, surgical resection is reserved for symptomatic lesions, as many tumors do not become symptomatic. Recent studies indicate that VHL disease–associated ELSTs cause audiovestibular morbidity (hearing loss, tinnitus, and vertigo) via 3 mechanisms—otic capsule invasion, intralabyrinthine hemorrhage, and endolymphatic hydrops. Specialized magnetic resonance imaging techniques have been defined to elucidate each of these mechanisms, even when a tumor mass is not identified on imaging. Endolymphatic sac tumors cause audiovestibular morbidity unrelated to size or progression, and resection is now recommended at initial discovery of a tumor mass or a tumor-associated mechanism of morbidity.

Conclusions and Relevance  New insights into the development, pathobiological origin, natural history, and long-term outcomes of VHL disease–associated CNS tumors have redefined their management and treatment indications and potentially provide new targeted therapeutic strategies. Resection is reserved for symptomatic hemangioblastomas, but early resection of newly detected ELSTs is now recommended.

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