Primary hemangioblastomas are rare tumors of the central nervous, often slow growing and most commonly occurring in the cerebellum, brainstem, or spinal cord. Hemangioblastomas can arise sporadically; however, they are classically associated with von Hippel–Lindau (VHL) disease, with approximately 25% of hemangioblastomas being attributed to the disease [
1]. Multiple hemangioblastomas can be seen in at least 60% of VHL patients, and is one of the most common causes of demise in VHL patients, in addition to renal cell carcinoma. However, disseminated leptomeningeal involvement of hemangioblastomas is exceedingly rare in patients without a diagnosis of VHL disease, with only ~ 33 published cases [
2,
3].
Radiation therapy, either stereotactic radiosurgery or external beam radiotherapy, can be used as primary, adjuvant or a salvage treatment strategy for localized disease with excellent local control [
4‐
6] [16,18,19]. Local control is 98%, 88%, and 73% of intracranial hemangioblastomas at 1, 2, and 6 years, respectively, with marginal dose and fractions ranging from 10–32 Gy and 1–10 fractions, respectively [
7]. However, in patients with diffuse leptomeningeal involvement treated with palliative radiation, outcomes are poor [
8‐
10]. In reviewing all prior cases of diffuse leptomeningeal HB, a majority of patients had experienced disease progression or complications due to disease burden, with 79%, 47%, and 18% survival at 1, 2, and 5 years,respectively, in case reports with long-term follow-up. In addition to surgery and radiation, several other systemic therapies have been explored with disappointing results. Systemic therapies also have poor results in patients with metastatic disease [
11,
12]. With all reported cases of diffuse leptomeningeal HB, there are similar rates of overall survival in patients with 76%, 45%, and 18% survival at 1, 2, and 5 years, respectively, in patients with long-term follow-up. Our patient died shortly after palliative craniospinal radiation, with progression of disease and subsequent respiratory failure 6 months post-treatment. The clinical course of our patient closely aligns with prior case reports, with a quick declining following palliative radiation in patients with diffuse dissemination of HB in the brain and spine [
13‐
15]. In reported cases, dissemination occurred approximately 8.5 years after the primary hemangioblastoma. As a result, long-term follow-up of these tumors, particularly in multifocal and recurrent patients, may be necessary.
Systemic therapy has also been used for management of metastatic hemangioblastoma. Although anthracycline-based therapies are frequently used, limited data is available regarding its efficacy. Given the rich vascular characteristics of hemangioblastoma, antiangiogenic therapies have also been investigated, such as bevacizumab, imatinib, sorafenib, sunitinib, and pazopanib. However, further studies are needed to better define the optimal systemic therapeutic regimen.