Feasibility and Risks of Preoperative Embolization for CNS Hemangioblastoma Surgery at a National VHL Referral Center

ABSTRACT Introduction Preoperative embolization is used selectively for central nervous system hemangioblastomas (CNS-HBLs), but anatomical feasibility and procedural risk remain important uncertainties. Research question How feasible is embolization in selected CNS-HBL cases? Material and Methods We retrospectively reviewed a prospectively maintained von Hippel-Lindau (VHL)/HBL registry (1997–2025), including operations preceded by angiography with intent to embolize. Feasibility, operator-reported devascularization, complications, and perioperative outcomes were assessed. Devascularization was categorized into “non-feasible”, <50%, 50–75%, and >75%. Comparisons were exploratory. Results We identified 237 individuals, 565 operations, and 804 CNS-HBLs. 27 (4.8%) procedures met inclusion criteria. Embolization was performed in 21/27 cases (77.8%; 95% CI 57.7–91.4%), with >75% devascularization in 13/21 (61.9%). Prohibitive vascular anatomy prevented embolization in six cases. Four angiography-related complications occurred (4/27 overall: 14.8%, 95% CI 4.2–33.7%; 4/21 embolization: 19.0%, 95% CI 5.4–41.9%), including two with permanent neurological deficits. In embolized versus non-feasible cases, median surgery duration was 271 versus 372 minutes, median blood loss was 425 versus 600 mL, median hemoglobin decrease was 2.6 versus 4.1 g/dL, and functional status improved/remained unchanged/worsened in 10/9/2 versus 0/3/3 cases, respectively. Qualitative bleeding assessments did not differ. Conclusions Only a small proportion of CNS-HBLs were considered for preoperative embolization. Embolization was feasible in most selected cases but carried relevant procedural risk. The small cohort, and potential confounding prevent attribution of outcome differences to embolization. Careful multidisciplinary selection in high-volume VHL/HBL centers remains essential. Future studies would benefit from standardized angiographic scoring systems and uniform criteria for assessing embolization success.