A systematic review on the outcome of intramedullary spinal cord cavernous malformations

Treatment of Spinal Cavernous Malformations: A Single-Center Case Series

OBJECTIVE

Cavernous malformations (CMs) are benign vascular lesions composed of clusters of dilated, thin-walled, blood-filled vessels. The prevalence of CMs in the general population ranges from 0.4%-0.9%, with the majority located in the brain, while spinal cord CMs represent rare subtypes. Spinal CMs are clinically significant due to their potential for symptomatic hemorrhage, leading to neurological deficits. Although rare, they have attracted increasing attention in the literature. Thereby both, intramedullary hemorrhage and spinal cord surgery bear the risk of injury. This case series reports functional outcomes following surgical and conservative treatment of spinal CMs.

METHODS

In this retrospective case series, we analyzed all patients with spinal CMs from 2010-2023 at our tertiary center. Functional outcome was determined based on the modified Rankin and McCormick Scale.

RESULTS

Fifty-two patients with a median age of 54 (interquartile range: 43-60) years and a female-to-male ratio of 1:4 were included. Thirty-five (67.0%) of the patients received surgical treatment of the lesion via a posterior approach through (hemi-)laminectomy or laminoplasty with no mortality to report. The morbidity rate was 17.1%. Hereby, the patients report mainly surgery-related new sensitivity deficits. The univariate analysis revealed no independent risk factors concerning the occurrence of surgery-related morbidity. The surgically treated patients showed an improvement between preoperative and follow-up functional outcome.

CONCLUSIONS

Spinal CMs can be safely managed through surgical resection, with a relatively low morbidity rate and no reported mortality. Our results demonstrate that postoperative morbidity was predominantly characterized by sensory deficits, while motor deficits were less common.

Recent novelties in research and management of cerebrospinal cavernous malformations

In recent years, knowledge about cerebrospinal cavernomas has grown considerably, leading to the development of initial guidelines and treatment recommendations. However, due to the rarity and heterogeneity of the disease, the level of evidence remains limited, leaving many questions unanswered and subject to ongoing debate. Therefore, an up-to-date review of this field's latest developments and controversies is reasonable.

Presentation of lumbar intramedullary cavernous hemangioma by spindle-shaped hematoma sign on the spinal MRI: a case report

BACKGROUND

Cavernous hemangioma is a congenital insidious disease that can occur in any part of the central nervous system. In clinical practice, cavernous hemangioma is mostly found in the brain and rarely in the spinal cord. This study describes a case of a 34-year-old Chinese man of Han ethnicity with lumbar intramedullary cavernous hemangioma. On admission, lumbar intramedullary hemorrhage was observed in the patient, as well as a spindle-shaped hematoma sign was detected on the spinal magnetic resonance imaging. We suspected that the spinal hemorrhage could be associated with spinal cord cavernous hemangioma. The patient was started on dehydration and glucocorticoid therapy of mannitol on the day of admission and was diagnosed with cavernous hemangioma on the basis of his magnetic resonance imaging presentation and spinal cord histopathology results. However, there was no significant improvement in clinical manifestations following conservative treatment. It was exciting that the patient's condition improved after the surgical removal of hematomas.

CONCLUSION

Clinicians should consider lumbar intramedullary cavernous hemangioma in the differential diagnosis of early spinal cord hemorrhage with a spindle-shaped hematoma sign on the spinal magnetic resonance imaging.

Intraoperative changes in electrophysiological monitoring can be used to predict clinical outcomes in patients with spinal cavernous malformation

Aim

The study aimed to evaluate the sensitivity and specificity of these monitoring parameters in predicting postoperative neurological dysfunction.

Methods

In this study, a total of 85 patients with spinal cavernous malformations (SCMs) treated at Xuanwu Hospital, Capital Medical University, from November 2012 to August 2017 were included. During the surgical procedures, all patients underwent monitoring of motor evoked potentials (MEP) and somatosensory evoked potentials (SEP). The criteria for warning included a reduction of ≥80% in MEP amplitude and ≥50% in SEP amplitude.

Results

Among 85 patients, 40 (47.1%) had SCMs located in the thoracic segment, 35 (41.2%) in the cervical segment, 6 (7.1%) in the cervical thoracic segment, and 4 (4.7%) in the lumbar segment. MEP recordings were obtained from 81 patients, and the preoperative McCormick score was 1.53 ± 0.69. The sensitivity of multimodal monitoring combined with the criteria of 80% reduction in MEP amplitude and SEP was 83.9%, with a specificity of 69%, a positive predictive value of 69%, and a negative predictive value of 90.4%.

Conclusion

This study emphasizes the crucial role of electrophysiological monitoring, particularly MEP and SEP, during the surgical resection of SCMs. The findings demonstrate that this approach is effective in predicting and preventing postoperative neurological dysfunction, thereby improving patient outcomes.

Spinal Cord Cavernous Malformation: A Case Report

Spinal cord cavernous malformation is a rare and uncommon vascular malformation, it may remain asymptomatic for a long period or manifest as a sudden or gradual change in spinal cord functioning. The diagnosis relies essentially on magnetic resonance imaging (MRI). Surgery constitutes the majority of management with all the complications that can occur during and after surgery. We report a case of intramedullary cavernoma of a 12-year-old patient admitted for acute paraparesia with bowel and bladder dysfunction. MRI revealed 2 intramedullary cavernomas at T6-T7 and T11-T12. Through this case report, we discuss the clinical and radiological characteristics of this unusual intramedullary malformation.

Functional neurological outcome of spinal cavernous malformation surgery

PURPOSE

Spinal cavernous malformations (SCM) present a risk for intramedullary hemorrhage (IMH), which can cause severe neurologic deficits. Patient selection and time of surgery have not been clearly defined.

METHODS

This observational study included SCM patients who underwent surgery in our department between 2003 and 2021. Inclusion required baseline clinical factors, magnetic resonance imaging studies, and follow-up examination. Functional outcome was assessed using the Modified McCormick scale score.

RESULTS

Thirty-five patients met the inclusion criteria. The mean age was 44.7 ± 14.5 years, and 60% of the patients were male. In univariate analysis, the unfavorable outcome was significantly associated with multiple bleeding events (p = .031), ventral location of the SCM (p = .046), and incomplete resection (p = .028). The time between IMH and surgery correlated with postoperative outcomes (p = .004), and early surgery within 3 months from IMH was associated with favorable outcomes (p = .033). This association remained significant in multivariate logistic regression analysis (p = .041).

CONCLUSIONS

Removal of symptomatic SCM should be performed within 3 months after IMH when gross total resection is feasible. Patients with ventrally located lesions might be at increased risk for postoperative deficits.