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Epithelioid hemangioendothelioma (EHE) is a rare vascular tumor, and develops infrequently in the central nervous system. To our knowledge, this is the first case of EHE of the spinal cord. An 85-year-old man presented with about 6-month progressive myelopathy. Magnetic resonance imaging (MRI) demonstrated an oval-shaped intradural extramedullary mass at T10 level with extensive intramedullary edema. A reddish tumor was removed via a total laminectomy of T9−T10. Histologically, the tumor cells with nuclear atypia and active mitoses were immunopositive for vascular tumor markers, and formed a lobular architecture associated with capillary-sized vessels lined with edematous endothelial cells. Although very rare, EHE should be considered in the differential diagnosis of a spinal intradural extramedullary tumor.

BACKGROUND AND IMPORTANCE:The treatment for large central disk herniation (LCDH) at upper lumbar spine is often challenging. Previous reports showed various surgical strategies, such as microdiscectomy with posterior fixation, endoscopic surgery, and microdiscectomy through transdural approach. However, there is no consensus regarding which surgical option is better for LCDH at upper lumbar spine. In this report, we describe the novel transdural epiarachnoid approach (TDEA), which uses the corridor of epiarachnoid space for microdiscectomy. Compared with classical transdural approaches, this novel approach may reduce risks of postoperative cerebrospinal fluid leakage and the development of arachnoiditis.CLINICAL PRESENTATION:A 69-yr-old man presented with progressive bilateral radiating leg pain, intermittent claudication, and low back pain. Magnetic resonance images and computed tomography scans revealed LCDH at L2/3 level. We performed microdiscectomy using the TDEA. Postoperative course was uneventful, and his symptoms were relieved after surgery.CONCLUSION:The novel TDEA for LCDH at upper lumbar spine is illustrated with a video. This novel approach has an advantage of the preservation of subarachnoid components compared with classical transdural approaches.

BACKGROUND The drug manufacturer recommends postponing initiation of bevacizumab for malignant gliomas at least 4 weeks later postoperatively. Malignant glioma patients with significant neurological deficits due to postoperative residual tumors are preferably needed earlier bevacizumab therapy that expecting improvement of neurological state and brain edema. There is a literature review indicating that the timing for administration of postoperative bevacizumab was at least 2 weeks. The authors assessed the safety,tolerability,efficacy for bevacizumab therapy less than 4 weeks later postoperatively. METHODS Six patients of malignant gliomas with residual tumors and neurological deficits were treated by bevacizumab (10mg /kg every 2 weeks) therapy 2–3 weeks later postoperatively with chemoradiotherapy. Patients included 31-year-old female with thalamic-midbrain glioblastoma (initial),11-year-old female with anaplastic ependymoma (recurrent),71-year-old female with initial cervical cord anaplastic astrocytoma (initial),88-year-old female bilateral frontal glioblastoma (initial),27-year-old female with thalamic midbrain glioblastoma (initial) and 3-year-old female with brain stem glioblastoma (initial). RESULTS All the patients did not experienced hemorrhage and impair wound healing. Every patient neurological state and perifocal brain edema following bevacizumab therapy demonstrated early improvement. Earlier bevacizumab therapy did not delay and cease postoperative chemoradiotherapy. CONCLUSIONS Initiation of bevacizumab therapy 2–3 weeks later postoperatively seems to be safe and effective for malignant glioma patients with worse neurological state due to residual tumor and perifocal edema. The optimal interval which balances the risk of complications and the risk of tumor progression should be considered.

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