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Han J, Chung CK. Removal of a Large Laterally Located Spinal Cord Intramedullary Ependymoma Through a Lateral Myelotomy: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2023; 26:01787389-990000000-01009. [PMID: 38146940 PMCID: PMC11086959 DOI: 10.1227/ons.0000000000001035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 11/06/2023] [Indexed: 12/27/2023] Open
Affiliation(s)
- Junghoon Han
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Chun Kee Chung
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Republic of Korea
- Neuroscience Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
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Pantel T, Mende KC, Mohme T, Mohme M, Viezens L, Matschke J, Westphal M, Eicker SO. Cavernous Malformations and Hemangioblastomas of the Spinal Cord Show Distinct Differences in Clinical Course - A Retrospective Single-Center Analysis of 112 Patients. Global Spine J 2023:21925682231214363. [PMID: 37948580 DOI: 10.1177/21925682231214363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2023] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE Cavernous malformations (CMs) and hemangioblastomas (HBs) of the spinal cord exhibit distinct differences in histopathology but similarities in the neurological course. The aim of our study was to analyze the clinical differences between the vascular pathologies and a benign tumor of the spinal cord in a perioperative situation. METHODS We performed a retrospective analysis of patients who had undergone surgery for lesions in the spinal cord between 1984 and 2015. Patients were screened for CMs and HBs as the primary inclusion criteria. General patient information, surgical data, and disease-specific data were collected from the records. Cooper-Epstein scores for clinical symptoms were evaluated preoperatively, at discharge, and at the 6-month follow-up. RESULTS A total of 112 patients were included, of which 46 had been diagnosed with CMs and 66 with HBs. Patients with CMs often demonstrated more preoperative neurological deterioration compared to those with HBs (P < .05); accordingly, in took longer to diagnose HBs. Complete resection was possible for 96.8% of all patients with CMs and 90% of those with HBs. At the 6-month follow-up, patients with HBs more often presented with persisting neurologic impairment of the upper extremities compared to the CM patients (P < .001). CONCLUSION CMs and HBs of the spinal cord have similarities but also exhibit significant differences in neurological presentation and perioperative course. Surgical therapy is the treatment of choice for symptomatic lesions, and complete surgical resection is possible in the majority of cases for both entities. Neurologic outcomes are usually favorable, although patients with HBs retain neurologic deficits more often.
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Affiliation(s)
- Tobias Pantel
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Theresa Mohme
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Malte Mohme
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lennart Viezens
- Division of Spine Surgery, Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob Matschke
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sven Oliver Eicker
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Rauschenbach L, Santos AN, Engel A, Olbrich A, Benet A, Li Y, Schmidt B, Gembruch O, Özkan N, Jabbarli R, Wrede KH, Siegel A, Lawton MT, Sure U, Dammann P. Functional neurological outcome of spinal cavernous malformation surgery. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:1714-1720. [PMID: 36928489 DOI: 10.1007/s00586-023-07640-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 01/14/2023] [Accepted: 03/05/2023] [Indexed: 03/18/2023]
Abstract
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.
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Affiliation(s)
- Laurèl Rauschenbach
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.
- Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany.
| | - Alejandro N Santos
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
- Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
| | - Adrian Engel
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
- Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
| | - Angelina Olbrich
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
- Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
| | - Arnau Benet
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, USA
| | - Yen Li
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Börge Schmidt
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, Essen, Germany
| | - Oliver Gembruch
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
- Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
| | - Neriman Özkan
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
- Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
- Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
| | - Karsten H Wrede
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
- Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
| | - Adrian Siegel
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, USA
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
- Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
| | - Philipp Dammann
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
- Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Essen, Germany
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Liu T, Wang L, Zhang S, Han H, Du K, Chen X, Zhao Z, Zhao L, Xie J, Zhao L, Peng Z, Zhu T, Huang Q. Prediction of outcomes for symptomatic spinal cavernous malformation surgery: a multicenter prospective clinical study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:1326-1333. [PMID: 36829066 DOI: 10.1007/s00586-023-07585-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 01/23/2023] [Accepted: 02/04/2023] [Indexed: 02/26/2023]
Abstract
PURPOSE Clinical outcome of spinal cavernous malformation (SCM) varies because of its unclear natural history, and reliable prognostic prediction model for SCM patients is limited. The aim of the present study was to investigate potential factors that predict one-year neurological status in postoperative patients with SCM. METHODS This was a multicenter prospective observational study in consecutive patients with SCMs. SCMs treated microsurgically between January 2015 and January 2021 were included. Outcome was defined as the American Spinal Injury Association Impairment Scale (AIS) grade at one year after operation. Multivariable analyses were used to construct the best predictive model for patient outcomes. RESULTS We identified 268 eligible SCM patients. Neurological outcome had worsened from preoperative baseline in 51 patients (19.0%) at one year. In the multivariable logistic regression, the best predictive model for unfavorable outcome included symptom duration ≥ 26 months (95% CI 2.80-16.96, P < 0.001), size ≤ 5 mm (95% CI 1.43-13.50, P = 0.010), complete intramedullary (95% CI 1.69-8.14, P = 0.001), subarachnoid hemorrhage (95% CI 2.92-12.57, P < 0.001), AIS B (95% CI 1.91-40.93, P = 0.005) and AIS C (95% CI 1.12-14.54, P = 0.033). CONCLUSIONS Admission size of the lesion, morphology, symptom duration, AIS grade and the presence of subarachnoid hemorrhage were strong outcome predictors regarding prognostication of neurological outcome in postoperative patients with SCMs. A decision to surgically remove a symptomatic SCM should be justified by systematic analysis of all factors potentially affecting outcome.
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Affiliation(s)
- Tong Liu
- Department of Neurosurgery, Tianjin Institute of Neurology, Tianjin Medical University General Hospital, 154 Anshan Road in Heping District, Tianjin, 300052, China
| | - Lichao Wang
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Shizhong Zhang
- Department of Neurosurgery, The Affiliated Taian City Centeral Hospital of QingDao University, Qingdao, Shandong, China
| | - Hao Han
- Department of Neurosurgery, Jining No 1 People's Hospital, Neurosurgery, Jining, Shandong, China
| | - Kangjie Du
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Xin Chen
- Department of Neurosurgery, Tianjin Institute of Neurology, Tianjin Medical University General Hospital, 154 Anshan Road in Heping District, Tianjin, 300052, China
| | - Zilong Zhao
- Department of Neurosurgery, Tianjin Institute of Neurology, Tianjin Medical University General Hospital, 154 Anshan Road in Heping District, Tianjin, 300052, China
| | - Liwen Zhao
- Department of Neurosurgery, Tianjin Institute of Neurology, Tianjin Medical University General Hospital, 154 Anshan Road in Heping District, Tianjin, 300052, China
| | - Jiapeng Xie
- Department of Neurosurgery, Tianjin Institute of Neurology, Tianjin Medical University General Hospital, 154 Anshan Road in Heping District, Tianjin, 300052, China
| | - Lu Zhao
- Department of Radiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Zhijun Peng
- Department of Radiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Tao Zhu
- Department of Neurosurgery, Tianjin Institute of Neurology, Tianjin Medical University General Hospital, 154 Anshan Road in Heping District, Tianjin, 300052, China
| | - Qiang Huang
- Department of Neurosurgery, Tianjin Institute of Neurology, Tianjin Medical University General Hospital, 154 Anshan Road in Heping District, Tianjin, 300052, China.
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Liao D, Wang R, Shan B, Chen H. Surgical outcomes of spinal cavernous malformations: A retrospective study of 98 patients. Front Surg 2023; 9:1075276. [PMID: 36713668 PMCID: PMC9877401 DOI: 10.3389/fsurg.2022.1075276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 12/28/2022] [Indexed: 01/15/2023] Open
Abstract
Objective Spinal cord cavernous malformation (SCCM) is a rare vascular lesion, and the treatment strategy remains controversial at present. The goal of this retrospective study was to analyze the surgical outcomes of the SCCM and to find more appropriate treatment strategies for a better prognosis. Method A retrospective review of 98 patients with SCCM from 2009 to 2018 was conducted at the neurosurgical center of our hospital. Neurological function was assessed using the American Spinal Injury Association (ASIA) impairment scale. Clinical features were analyzed using the multivariable logistic regression. Results Ninety-eight patients with SCCM were included, of whom 36% were female and 64% male. The mean age was 41.6 years; and family history was reported in 8% of patients. Definite hemorrhage was found in 6%. Before surgery, the neurological status was Grade A in 2%, Grade B in 2%, Grade C in 12%, Grade D in 54%, and Grade E in 30% of the patients. 83% (81/98) patients had long-term follow-up, of whom, 42% had improved, 51% were stable and 7% had deteriorated. Patients with dorsal or superficial lesions showed better improvement than those with ventral or lateral deep lesions. Those with symptoms lasting less than three months had higher rates of improvement than those with symptoms lasting more than three months. However, there was no significant difference in prognosis between hemilaminectomy and laminectomy. Conclusion These results suggest that surgical strategies should be preferred for severe symptomatic SCCMs if total resection can be achieved, thereby avoiding the risk of severe complications with subsequent lesion hemorrhage. Earlier (usually within 3 months of symptom duration) surgical resection generally may lead to a better prognosis. For ventral or lateral deep SCCMs, the surgical strategy should be considered more carefully.
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Srinivasan VM, Karahalios K, Shlobin NA, Koester SW, Nguyen CL, Rumalla K, Rahmani R, Catapano JS, Labib MA, Mitha AP, Spetzler RF, Lawton MT. Residual and Recurrent Spinal Cord Cavernous Malformations: Outcomes and Techniques to Optimize Resection and a Systematic Review of the Literature. Oper Neurosurg (Hagerstown) 2023; 24:44-54. [PMID: 36519878 DOI: 10.1227/ons.0000000000000456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/04/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Intramedullary spinal cord cavernous malformations (SCCMs) account for only 5% of overall cavernous malformations (CMs). The occurrence of recurrent or residual SCCMs has not been well discussed, nor have the technical nuances of resection. OBJECTIVE To assess the characteristics of residual SCCMs and surgical outcomes and describe the techniques to avoid leaving lesion remnants during primary resection. METHODS Demographic, radiologic, intraoperative findings and surgical outcomes data for a cohort of surgically managed intramedullary SCCMs were obtained from an institutional database and retrospectively analyzed. A systematic literature review was performed using PRISMA guidelines. RESULTS Of 146 SCCM resections identified, 17 were for residual lesions (12%). Patients with residuals included 13 men and 4 women, with a mean age of 43 years (range 16-70). All patients with residual SCCMs had symptomatic presentations: sensory deficits, paraparesis, spasticity, and pain. Residuals occurred between 3 and 264 months after initial resection. Approaches for 136 cases included posterior midline myelotomy (28.7%, n = 39), pial surface entry (37.5%, n = 51), dorsal root entry zone (27.9%, n = 38), and lateral entry (5.9%, n = 8). Follow-up outcomes were similar for patients with primary and residual lesions, with the majority having no change in modified Rankin Scale score (63% [59/93] vs 75% [9/12], respectively, P = .98). CONCLUSION SCCMs may cause significant symptoms. During primary resection, care should be taken to avoid leaving residual lesion remnants, which can lead to future hemorrhagic events and neurological morbidity. However, satisfactory results are achievable even with secondary or tertiary resections.
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Affiliation(s)
- Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Katherine Karahalios
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Nathan A Shlobin
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Stefan W Koester
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Candice L Nguyen
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Kavelin Rumalla
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Redi Rahmani
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Mohamed A Labib
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Alim P Mitha
- Division of Neurosurgery, University of Calgary, Calgary, Alberta, Canada
| | - Robert F Spetzler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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Asimakidou E, Meszaros LT, Anestis DM, Tsitsopoulos PP. A systematic review on the outcome of intramedullary spinal cord cavernous malformations. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:3119-3129. [PMID: 35931791 DOI: 10.1007/s00586-022-07332-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 07/18/2022] [Accepted: 07/19/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE This study aimed to investigate the neurological outcome, trends and sequelae following surgical or conservative treatment of intramedullary spinal cord cavernous malformations (ISCCMs). METHODS A systematic review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. The primary outcome measure was the change in the neurological status after surgery or conservative management. A logistic regression analysis investigating prognostic factors related to outcome was also performed. RESULTS Twenty-one studies with 1091 patients in total were included, of which 1005 (92.1%) underwent surgical resection and 86 (7.9%) were treated conservatively. Gross total resection was achieved in 95.7% of the patients and partial resection in 4.3%. Most lesions (60.2%) were located in the thoracic spine and presented with motor (60.4%) and sensory deficits (59.7%). In the long term, surgical treatment resulted in an improved neurological status in 36.9% of the patients, in 55.8% it remained stable, and in 7.3% it deteriorated compared to the preoperative state. In the conservative cohort, 21.7% improved, 69.6% remained stable, and 8.7% deteriorated. Solitary lesions, duration of preoperative symptoms less than 3 months as well as an improved post-operative neurological status were predictors of a favourable long-term outcome. CONCLUSIONS Whenever feasible, symptomatic patients with ISCCM are recommended to undergo surgery within 3 months from symptom onset. Absence of multiple lesions and, most importantly, post-operative symptom improvement foresee a favourable long-term outcome. Further research is warranted to discern the role of conservative treatment in symptomatic patients.
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Affiliation(s)
- Evridiki Asimakidou
- Department of Neurosurgery, Hippokration General Hospital, Aristotle University School of Medicine, Thessaloniki, Greece.
| | | | - Dimitrios M Anestis
- Department of Neurosurgery, Hippokration General Hospital, Aristotle University School of Medicine, Thessaloniki, Greece
| | - Parmenion P Tsitsopoulos
- Department of Neurosurgery, Hippokration General Hospital, Aristotle University School of Medicine, Thessaloniki, Greece
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Santos AN, Rauschenbach L, Saban D, Chen B, Lenkeit A, Gull HH, Rieß C, Deuschl C, Schmidt B, Jabbarli R, Wrede KH, Zhu Y, Frank B, Sure U, Dammann P. Medication intake and hemorrhage risk in patients with familial cerebral cavernous malformations. J Neurosurg 2022; 137:1088-1094. [PMID: 35213840 DOI: 10.3171/2022.1.jns212724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 01/10/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this study was to analyze the impact of medication intake on hemorrhage risk in patients with familial cerebral cavernous malformation (FCCM). METHODS The authors' institutional database was screened for patients with FCCM who had been admitted to their department between 2003 and 2020. Patients with a complete magnetic resonance imaging (MRI) data set, evidence of multiple CCMs, clinical baseline characteristics, and follow-up (FU) examination were included in the study. The authors assessed the influence of medication intake on first or recurrent intracerebral hemorrhage (ICH) using univariate and multivariate logistic regression adjusted for age and sex. The longitudinal cumulative 5-year risk of hemorrhage was calculated by applying Kaplan-Meier and Cox regression analyses adjusted for age and sex. RESULTS Two hundred five patients with FCCMs were included in the study. Multivariate Cox regression analysis revealed ICH as a predictor for recurrent hemorrhage during the 5-year FU. The authors also noted a tendency toward a decreased association with ICH during FU in patients on statin medication (HR 0.22, 95% CI 0.03-1.68, p = 0.143), although the relationship was not statistically significant. No bleeding events were observed in patients on antithrombotic therapy. Kaplan-Meier analysis and log-rank test showed a tendency toward a low risk of ICH during FU in patients on antithrombotic therapy (p = 0.085), as well as those on statin therapy (p = 0.193). The cumulative 5-year risk of bleeding was 22.82% (95% CI 17.33%-29.38%) for the entire cohort, 31.41% (95% CI 23.26%-40.83%) for patients with a history of ICH, 26.54% (95% CI 11.13%-49.7%) for individuals on beta-blocker medication, 6.25% (95% CI 0.33%-32.29%) for patients on statin medication, and 0% (95% CI 0%-30.13%) for patients on antithrombotic medication. CONCLUSIONS ICH at diagnosis was identified as a risk factor for recurrent hemorrhage. Although the relationships were not statistically significant, statin and antithrombotic medication tended to be associated with decreased bleeding events.
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Affiliation(s)
- Alejandro N Santos
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
| | | | - Dino Saban
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
| | - Bixia Chen
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
| | - Annika Lenkeit
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
| | - Hanah Hadice Gull
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
| | - Christoph Rieß
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
| | - Cornelius Deuschl
- 2Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen
| | - Börge Schmidt
- 3Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen; and
| | - Ramazan Jabbarli
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
| | - Karsten H Wrede
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
| | - Yuan Zhu
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
| | - Benedikt Frank
- 4Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, Germany
| | - Ulrich Sure
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
| | - Philipp Dammann
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen
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9
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Duan Y, Mao R, Qin X, Liao Y, Li J, Chen G. The Long-Term Outcome in a Cohort of 52 Patients With Symptomatic Intramedullary Spinal Cavernous Hemangioma After Microsurgery and Emergency Rescue Surgery. Front Med (Lausanne) 2022; 9:872824. [PMID: 35547221 PMCID: PMC9084226 DOI: 10.3389/fmed.2022.872824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 03/14/2022] [Indexed: 11/13/2022] Open
Abstract
Background Surgery is the mainstay treatment for patients with symptomatic intramedullary spinal cavernous hemangioma (ISCH), however the time of surgical intervention remains controversial. In this study, we proposed emergency rescue surgery (ERS) for patients in deteriorative type. The prognostic factors of patients with ISCH after microsurgery and the clinical effect of ERS were analyzed. Methods From January 2013 to November 2019, 52 patients with symptomatic ISCH treated by microsurgical treatment were collected, ranging in age from 17 to 66 years old (mean: 45.8 ± 13.5 years). The course of the disease ranged from 2 days to 20 years. Of 52 lesions, 17 lesions were in the cervical segment, 25 in the thoracic segment, and 10 in the lumbosacral segment; while seven cases were at the ventral surface, 25 cases at the dorsal surface, and 20 cases at the central spinal cord. The sagittal diameter ranged from 1 to 58 mm (median: 17.3 mm). The transverse diameter ratio ranged from 20 to 80% (median: 50.7%). Thirty-two patients were diagnosed as deteriorative type and 22 were treated by ERS. Results At 12 months after surgery, all patients were followed up, and no residual or recurrence was found in all patients. Twenty-five patients (48.1%) showed spinal cord functional improvement after surgery; 25 (48.1%) had no functional change; 2 (3.8%) got worse. For deteriorative patients, ERS group had a significantly higher improvement rate than the non-ERS group (χ2 = 5.393, P = 0.02); For all 52 patients, the factors as a lesion at the ventral surface (Z = 10.453, P = 0.015), or lumbosacral segment (χ2 = 9.259, P = 0.010) and longer course of disease (Z = -2.021, P = 0.043) were potential risks in functional recovery in univariate analysis; and in multiple-factor analysis, the lesion at the lumbosacral segment (OR = 4.004, 95% CI: 1.341~11.961, P = 0.013) was the independent risk factors for the functional recovery. Conclusions Microsurgical resection is safe and effective for symptomatic ISCH. The ERS is an effective way to improve deteriorative patients' spinal cord function at long-term follow-up. The lesion at the lumbosacral segment is one of the poor prognostic factors.
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Affiliation(s)
- Yu Duan
- Department of Neurosurgery, Huadong Hospital, Fudan University, Shanghai, China
| | - Renling Mao
- Department of Neurosurgery, Huadong Hospital, Fudan University, Shanghai, China
| | - Xuanfeng Qin
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Yujun Liao
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Jian Li
- Department of Neurosurgery, Huadong Hospital, Fudan University, Shanghai, China
| | - Gong Chen
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
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10
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Fredrickson VL, Hollon TC, Rennert RC, Mazur MD, Dailey AT, Couldwell WT. Laminectomy at T4 and T5 for Resection of Symptomatic Cavernous Malformation. World Neurosurg 2022; 163:3. [PMID: 35342024 DOI: 10.1016/j.wneu.2022.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 03/02/2022] [Accepted: 03/03/2022] [Indexed: 11/17/2022]
Abstract
Although rare, intramedullary spinal cavernous malformations have a 1.4%-6.8% annual hemorrhage risk and can cause significant morbidity.1 Prior hemorrhage and size >1 cm are risk factors for future hemorrhage that, in addition to notable or progressive symptoms, may justify early surgical intervention.1,2 In this video, we present key steps in surgical management of a large, symptomatic thoracic cavernous malformation. A 56-year-old woman presented with worsening lower extremity weakness, imbalance, and difficulty ambulating. Strength was 3/5 in her right lower extremity and 4/5 in her left lower extremity. She had an incomplete T4 sensory level and hyperreflexia. Magnetic resonance imaging demonstrated a heterogeneous "popcorn"-appearing expansile intradural intramedullary 2.2- × 1.2-cm lesion at T4-5, consistent with a cavernous malformation. Angiography was deferred given the characteristic magnetic resonance imaging appearance. Given her progressive symptoms (including weakness), lesion size, and good health, resection was recommended. Using neurological monitoring, a T4-5 laminectomy, midline myelotomy, and piecemeal microsurgical resection of the lesion was performed, clearly identifying the cavernoma-spinal cord interface and avoiding spinal cord retraction. Histopathology confirmed a cavernoma. Postoperatively, the patient had improved left lower extremity strength and stable right lower extremity strength but worsened dorsiflexion (1/5), which improved with rehabilitation. At 1-year follow-up, she had full strength in her left lower extremity and 4/5 in her right lower extremity, with mild paresthesias below T10. Consistent with prior series demonstrating low complication rates and good long-term neurological outcomes,2 microsurgical resection of selected symptomatic intramedullary spinal cavernous malformations can halt neurological decline and potentially improve neurological function.
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Affiliation(s)
- Vance L Fredrickson
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Todd C Hollon
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Robert C Rennert
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Marcus D Mazur
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Andrew T Dailey
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA.
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11
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Ren J, Jiang N, Bian L, Dmytriw AA, Zeng G, He C, Sun L, Li X, Ma Y, Yu J, Li G, Ye M, Hu P, Li J, Yang F, Li Q, Ling F, Zhang H, Hong T. Natural History of Spinal Cord Cavernous Malformations: A Multicenter Cohort Study. Neurosurgery 2022; 90:390-398. [PMID: 35049523 DOI: 10.1227/neu.0000000000001842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 10/04/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The natural history of spinal cord cavernous malformations (SCCMs) remains relatively unclear. OBJECTIVE To investigate the natural history for hemorrhagic risks and neurological outcomes, as well as relevant predicting factors, of SCCMs. METHODS All patients between 2002 and 2019 with diagnosis of SCCMs were identified retrospectively. An observational study of patients with conservative management was performed to reveal the natural history of SCCMs. RESULTS We identified 305 patients in the full cohort, including 126 patients who were conservatively treated for at least 6 months (median observational period, 24.0 months). Forty-five hemorrhage events occurred during 527 person-years of follow-up, yielding an annual hemorrhage rate of 8.5% per person-year. The 1-, 2-, and 5-year cumulative risks of hemorrhage were 13.9%, 26.1%, and 35.1%, respectively. Prior hemorrhage (hazard ratio [HR] = 12.948, P = .012) and pediatric patients (HR = 2.841, P = .031) were independent predictors of hemorrhage in the long-term follow-up. Familial form (adjusted odds ratio [OR] = 30.695, P = .010) and subsequent hemorrhage events (adjusted OR = 16.333, P = .000) were independent risk factors for worsening of neurological function, and baseline neurological status (adjusted OR = 78.984, P = .000) and presence of subsequent hemorrhage (adjusted OR = 9.611, P = .001) were significantly associated with neurological outcomes. CONCLUSION The natural history of SCCMs varies. Baseline characteristics, such as pediatric patients, familial form, and baseline neurological status, as well as prior and subsequent hemorrhagic events, significantly affect the natural history of the SCCMs, which prompts a differentiated treatment strategy.
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Affiliation(s)
- Jian Ren
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Nan Jiang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Lisong Bian
- Department of Neurosurgery, Beijing Haidian Hospital, Beijing, China
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gao Zeng
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Chuan He
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Liyong Sun
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Xiaoyu Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Yongjie Ma
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Jiaxing Yu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Guilin Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Ming Ye
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Peng Hu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Jingwei Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Fan Yang
- Department of Neurosurgery, Beijing United Family Hospital, Beijing, China
| | - Qianwen Li
- Department of Radiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Feng Ling
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Tao Hong
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
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12
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Abstract
The blood-spinal cord barrier (BSCB) has been long thought of as a functional equivalent to the blood-brain barrier (BBB), restricting blood flow into the spinal cord. The spinal cord is supported by various disc tissues that provide agility and has different local immune responses compared to the brain. Though physiologically, structural components of the BSCB and BBB share many similarities, the clinical landscape significantly differs. Thus, it is crucial to understand the composition of BSCB and also to establish the cause–effect relationship with aberrations and spinal cord dysfunctions. Here, we provide a descriptive analysis of the anatomy, current techniques to assess the impairment of BSCB, associated risk factors and impact of spinal disorders such as spinal cord injury (SCI), amyotrophic lateral sclerosis (ALS), peripheral nerve injury (PNI), ischemia reperfusion injury (IRI), degenerative cervical myelopathy (DCM), multiple sclerosis (MS), spinal cavernous malformations (SCM) and cancer on BSCB dysfunction. Along with diagnostic and mechanistic analyses, we also provide an up-to-date account of available therapeutic options for BSCB repair. We emphasize the need to address BSCB as an individual entity and direct future research towards it.
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13
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Santos AN, Rauschenbach L, Darkwah Oppong M, Gembruch O, Saban D, Chen B, Herten A, Schmidt B, Li Y, Özkan N, Jabbarli R, Wrede K, Sure U, Dammann P. Natural course of untreated spinal cord cavernous malformations: a follow-up study within the initial 5 years after diagnosis. J Neurosurg Spine 2021:1-5. [PMID: 34920423 DOI: 10.3171/2021.9.spine211052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 09/20/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cavernous spinal cord malformations (SCMs) are believed to have a high rate of bleeding. The risk of intramedullary hemorrhage (IMH) or recurrent IMH and the neurological impact of bleeding events are important for clinical decision-making and could impact current treatment strategies. METHODS The authors screened their institutional database for patients with cavernous SCM treated between 2003 and 2020. Patients with complete MRI data sets and clinical baseline characteristics were included. Surgically treated patients were censored after cavernous SCM removal. Neurological functional status was obtained using the modified McCormick (MMcC) scale at diagnosis, first IMH, and second IMH. Kaplan-Meier and Cox regression analyses were performed to determine the cumulative 5-year risk for hemorrhage or rehemorrhage. RESULTS Seventy-one patients with cavernous SCM were analyzed. Cox regression analysis identified previous IMH (hazard ratio 7.86, 95% confidence interval 1.01-61.47, p = 0.049) as an independent predictor for rehemorrhage during the 5-year follow-up. The cumulative 5-year risk of bleeding or rebleeding was 41.3% for cavernous SCM. The MMcC score significantly deteriorated in 75% of patients after recurrent hemorrhage (p = 0.012). CONCLUSIONS During untreated 5-year follow-up, a considerably increased risk for hemorrhage or rehemorrhage was found in cavernous malformations of the spinal cord compared to cerebral cavernous malformations. Neurological function significantly deteriorates after the second bleeding. The probability of recurrent IMH increased significantly after initial presentation with hemorrhage.
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Affiliation(s)
| | | | | | | | - Dino Saban
- 1Department of Neurosurgery and Spine Surgery
| | - Bixia Chen
- 1Department of Neurosurgery and Spine Surgery
| | | | - Börge Schmidt
- 2Institute for Medical Informatics, Biometry, and Epidemiology, and
| | - Yan Li
- 3Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Germany
| | | | | | | | - Ulrich Sure
- 1Department of Neurosurgery and Spine Surgery
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14
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Liu T, Li K, Wang Y, Zhao Z, Chen X, Li F, Zhao L, Peng Z, Zhu T, Zhang J. Treatment strategies and prognostic factors for spinal cavernous malformation: a single-center retrospective cohort study. J Neurosurg Spine 2021; 35:824-833. [PMID: 34665952 DOI: 10.3171/2021.2.spine201664] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 02/05/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors aimed to identify factors that influence neurological function after treatment in order to facilitate clinician decision-making during treatment of spinal cavernous malformation (SCM) and about when and whether to perform surgical intervention. METHODS The authors performed a retrospective observational cohort study of patients with SCM who were treated at their institution between January 2004 and December 2019. Multiple logistic and Cox regression analyses were performed to determine the prognostic predictors of clinical outcome. Neurological status was assessed according to Frankel grade. RESULTS A total of 112 patients met the inclusion criteria, and a minimum 24 months of follow-up was achieved by 73 surgically treated and 39 conservatively treated patients. The mean ± SD lesion size was 8.7 ± 5.2 mm. In the surgically treated group, preoperative lesion size ≤ 5 mm (OR 13.62, 95% CI 1.05-175.98, p = 0.045), complete intramedullary lesion (OR 7.48, 95% CI 1.39-40.15, p = 0.019), and subarachnoid hemorrhage (OR 6.26, 95% CI 1.13-34.85, p = 0.036) were independent predictors of worse outcome. In the conservative treatment group, lesion size ≥ 10 mm (HR 9.77, 95% CI 1.18-80.86, p = 0.034), ≥ 3 segments with hemosiderin deposition (HR 13.73, 95% CI 1.94-97.16, p = 0.009), and subarachnoid hemorrhage (HR 13.44, 95% CI 2.38-75.87, p = 0.003) were significant predictors of worse outcome. The annual hemorrhage rate of the conservatively treated patients was 4.3%. CONCLUSIONS Subarachnoid hemorrhage, lesion size, morphology, extent of hemosiderin involvement, and motor dysfunction were independent risk factors of prognosis. In clinical practice, these parameters may help to identify patients at high risk for worse outcome. The treatment strategy for patients with SCM should be based on these risk factors and balanced with clinical symptoms. ABBREVIATIONS SCM = spinal cavernous malformation.
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Affiliation(s)
- Tong Liu
- Department of Neurosurgery, Tianjin Institute of Neurology, Tianjin Medical University General Hospital, Tianjin
| | - Kai Li
- Department of Neurosurgery, Tianjin Institute of Neurology, Tianjin Medical University General Hospital, Tianjin
| | - Yongli Wang
- Department of Neurosurgery, Tianjin Institute of Neurology, Tianjin Medical University General Hospital, Tianjin
| | - Zilong Zhao
- Department of Neurosurgery, Tianjin Institute of Neurology, Tianjin Medical University General Hospital, Tianjin
| | - Xin Chen
- Department of Neurosurgery, Tianjin Institute of Neurology, Tianjin Medical University General Hospital, Tianjin
| | - Fanjian Li
- Department of Neurosurgery, Tianjin Institute of Neurology, Tianjin Medical University General Hospital, Tianjin
| | - Lu Zhao
- Department of Radiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Zhijun Peng
- Department of Radiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Tao Zhu
- Department of Neurosurgery, Tianjin Institute of Neurology, Tianjin Medical University General Hospital, Tianjin
| | - Jianning Zhang
- Department of Neurosurgery, Tianjin Institute of Neurology, Tianjin Medical University General Hospital, Tianjin
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15
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Spinal hemangioblastoma: surgical procedures, outcomes and review of the literature. Acta Neurol Belg 2021; 121:973-981. [PMID: 32638270 DOI: 10.1007/s13760-020-01420-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 06/29/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE total removal of spinal hemangioblastomas with satisfactory clinical outcomes remains a challenge. We aimed to evaluate the surgical outcomes of our spinal hemangioblastomas patients, summarize our experiences with this condition and review-related literature. METHODS records of 18 spinal hemangioblastoma patients who underwent microsurgical resection were analyzed retrospectively. Clinical features, surgical procedures and outcomes were reviewed to assess the prognosis of their spinal hemangioblastomas. The McCormick classification method was used to evaluate spinal function and MR scans used to assess location and features of the tumor pre-surgically, tumor recurrence and syringomyelia status post-surgically. RESULTS total resection of 37 tumors was achieved in all 18 cases. Of those patients, two (11%) were accompanied with von Hippel-Lindau (VHL). Of the 37 tumors, 3 (8.1%) were completely intramedullary, 16 (43.2%) intramedullary-extramedullary and 18 (48.6%) primarily extramedullary. Tumors accompanied with syringomyelia were present in 17 (94.4%) patients. Clinical symptoms such as pain were reduced within 48 h after surgery in 16 patients. Post-operative neurological functions improved in all cases at 3 months post-surgery. Over the subsequent 3-18 month follow-up period, pre-operative symptoms improved in all 18 patients and no tumor recurrence was present. Syringomyelia was reduced or absent within 3-6 months. CONCLUSIONS our results indicated that a complete microscopic resection was effective in eliminating symptoms in these spinal hemangioblastoma patients, who showed a good prognosis after surgery. These improvements in clinical symptoms may be associated with the blood flow changes, but not with reductions and/or eliminations of syrinx after surgery.
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16
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Zakirov BA, Konovalov NA, Belousova OB, Kaprovoy SV. [Surgical treatment of spinal cord cavernous malformations]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2021; 85:104-113. [PMID: 34156212 DOI: 10.17116/neiro202185031104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Cavernous malformations (CMs) of central nervous system are vascular malformations usually localized in the brain and rarely in the spinal cord. To date, these malformations are well studied. However, some problems of the management of this pathology are still unresolved. This is due to rare localization of intramedullary CMs in the spinal cord and difficult treatment of spinal pathology per se. To date, about 1000 cases of spinal CM are described in the literature. This review is devoted to natural course of disease and postoperative outcomes. These data allow getting a complete picture of modern concepts of the treatment of spinal CMs and formulating the questions requiring further discussion.
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Affiliation(s)
- B A Zakirov
- Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - N A Konovalov
- Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - O B Belousova
- Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - S V Kaprovoy
- Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
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17
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Long-term surgical outcomes and prognostic factors of adult symptomatic spinal cord cavernous malformations. J Clin Neurosci 2021; 90:171-177. [PMID: 34275545 DOI: 10.1016/j.jocn.2021.05.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 04/10/2021] [Accepted: 05/17/2021] [Indexed: 11/21/2022]
Abstract
Cervical and thoracic or lumbar intramedullary spinal cavernous malformations (ISCMs) may behave differently. We conducted this retrospective study by using data from adult ISCMs to compare their natural histories and explore prognostic factors for improved clinical outcomes. Neurological functions were assessed by using the Modified McCormick Scale (MMCS) and Aminoff-Logue Disability Scale. A total of 111 study-eligible adult patients were included in this study. Patients with cervical ISCMs mostly demonstrated a shorter duration of symptoms (P = 0.026), an acute onset pattern with some recovery (P = 0.026), and a larger lesion size (P = 0.033) than their thoracic or lumbar counterparts. Thoracic or lumbar lesions had a higher proportion of motor symptoms (P = 0.001) and sphincter problems (P = 0.005), and they were usually associated with an aggressive clinical course (P = 0.001, OR = 9.491, 95% CI = 2.555-35.262) in multivariate analysis. There was no difference in age, sex distribution, hemorrhage risk between the cervical and thoracic-lumbar groups. A better preoperative neurological status (P = 0.034, OR = 2.768, 95% CI = 1.081-7.177) and improvement immediately after surgery (P < 0.001, OR = 8.756, 95% CI = 4.837-72.731) were identified as indicators for long-term improvement by multivariate analysis. Cervical lesions had a high proportion for long-term improvement, but it was not a predictor for improvement in multivariate analysis. ISCMs in the thoracic or lumbar location should be considered for surgical removal more aggressively than those in the cervical location. Surgical removal of symptomatic ISCMs can avoid further neurological deterioration and usually result in satisfactory long-term outcomes.
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18
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Colombo E, Lanzino G, Brown RD, Elder BD. Clinical Reasoning: 63-Year-old woman with thoracic cavernous malformation and delayed worsening myelopathy. Neurology 2019; 93:1075-1078. [PMID: 31818994 DOI: 10.1212/wnl.0000000000008635] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Elisa Colombo
- From the Departments of Neurosurgery (E.C., G.L., B.D.E.) and Neurology (R.D.B.), Mayo Clinic, Rochester, MN
| | - Giuseppe Lanzino
- From the Departments of Neurosurgery (E.C., G.L., B.D.E.) and Neurology (R.D.B.), Mayo Clinic, Rochester, MN.
| | - Robert D Brown
- From the Departments of Neurosurgery (E.C., G.L., B.D.E.) and Neurology (R.D.B.), Mayo Clinic, Rochester, MN
| | - Benjamin D Elder
- From the Departments of Neurosurgery (E.C., G.L., B.D.E.) and Neurology (R.D.B.), Mayo Clinic, Rochester, MN
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19
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Ren J, Hong T, Zeng G, He C, Li X, Ma Y, Yu J, Ling F, Zhang H. Characteristics and Long-Term Outcome of 20 Children With Intramedullary Spinal Cord Cavernous Malformations. Neurosurgery 2019; 86:817-824. [DOI: 10.1093/neuros/nyz381] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 06/27/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
No prior reports have focused on the natural history and long-term outcomes of intramedullary spinal cord cavernous malformations (ISCCMs) in children.
OBJECTIVE
To investigate the clinical characteristics and long-term outcomes of pediatric ISCCMs and identify the risk of hemorrhage.
METHODS
We retrospectively reviewed a series of 20 pediatric patients (<18 yr old) from a consecutive series of 254 patients with ISCCMs evaluated at a single institution.
RESULTS
Of the 20 pediatric patients, 9 (45.0%) presented with a severe neurological and disability status. The annual hemorrhagic rate in pediatric patients was 8.2%/patient/year. After initial overt hemorrhage events, the annual overt rehemorrhage rate increased to 30.7%/patient/year. In 234 adult patients, the respective rates were 2.8% and 7.4%. Thoracic or lumbar level lesions (P = .002, OR = 3.425, 95% CI = 1.588-7.387) and rehemorrhagic events (P = .005, OR = 3.209, 95% CI = 1.415-7.279) were more likely to follow an aggressive course. There were no significant differences in the sex distribution, location and size of lesions, types of symptoms, likelihood of a severe neurological and disability status, or immediate and long-term postoperative outcomes between pediatric and adult patients with ISCCMs
CONCLUSION
The annual overt hemorrhage rate and rehemorrhage rate of ISCCMs were higher in affected children than in affected adults. Surgical resection of pediatric ISCCMs remains the preferred therapeutic option and provides favorable outcomes.
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Affiliation(s)
- Jian Ren
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Tao Hong
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Gao Zeng
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Chuan He
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Xiaoyu Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Yongjie Ma
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Jiaxing Yu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Feng Ling
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
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20
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Enhanced recovery after surgery in intramedullary and extramedullary spinal cord lesions: perioperative considerations and recommendations. Spinal Cord 2019; 57:729-738. [PMID: 31358909 DOI: 10.1038/s41393-019-0335-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 07/08/2019] [Accepted: 07/09/2019] [Indexed: 01/16/2023]
Abstract
Enhanced recovery after surgery (ERAS) is an evidence-based approach developed to ameliorate the patient recovery process following surgical procedures. Employing a multimodal, multidisciplinary approach, ERAS implements strategies and treatment paradigms that have been shown to improve patient outcomes, reduce hospital length of stay, and ultimately reduce healthcare costs. With a substantial body of the literature supporting the implementation of ERAS in other surgical specialties, ERAS has only recently made its foray into spine surgery. Despite this, current studies are limited to spinal deformity and degenerative disease, with limited data regarding spinal cord surgery. This is due in part to the complex nature and rarity of spinal cord lesions, making the establishment of a formal ERAS protocol difficult. In developing an ERAS protocol, there must be a consensus on what factors are important to consider and implement. To address this, we reviewed the most recent advances in intramedullary and extramedullary spinal cord surgery in order to identify elements that influence patient outcomes. Using this information, the authors provide evidence-based recommendations with the intent of introducing a framework for future ERAS protocols with respect to treating spinal cord lesions.
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21
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Goyal A, Rinaldo L, Alkhataybeh R, Kerezoudis P, Alvi MA, Flemming KD, Williams L, Diehn F, Bydon M. Clinical presentation, natural history and outcomes of intramedullary spinal cord cavernous malformations. J Neurol Neurosurg Psychiatry 2019; 90:695-703. [PMID: 30760644 DOI: 10.1136/jnnp-2018-319553] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 01/20/2019] [Accepted: 01/21/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVE There is a paucity of literature investigating the clinical course of patients with spinal intramedullary cavernous malformations (ISCMs). We present a large case series of ISCMs to describe clinical presentation, natural history and outcomes of both surgical and conservative management. METHODS We retrospectively reviewed the clinical course of patients diagnosed with ISCMs at our institution between 1995 and 2016. Haemorrhage was defined as clinical worsening in tandem with imaging changes visualised on follow-up MRI. Outcomes assessed included neurological status and annual haemorrhage rates. RESULTS A total of 107 patients met inclusion criteria. Follow-up data were available for 85 patients. While 21 (24.7%) patients underwent immediate surgical resection, 64 (75.3%) were initially managed conservatively. Among this latter group, 16 (25.0%) suffered a haemorrhage during follow-up and 11 (17.2%) required surgical resection due to interval bleeding or neurological worsening. The overall annual risk of haemorrhage was 5.5% per person year. The rate among patients who were symptomatic and asymptomatic on presentation was 9.5% and 0.8%, respectively. Median time to haemorrhage was 2.3 years (0.1-12.3). Univariate analysis identified higher ISCM size (p=0.024), history of prior haemorrhage (p=0.013) and presence of symptoms (p=0.003) as risk factors for subsequent haemorrhage. Multivariable proportional hazards analysis revealed presence of symptoms to be independently associated with haemorrhage during follow-up (HR 9.39, CI 1.86 to 170.8, p=0.013). CONCLUSION Large, symptomatic ISCMs appear to be at increased risk for subsequent haemorrhage. Surgery may be considered in such lesions to prevent rebleeding and subsequent neurological worsening.
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Affiliation(s)
- Anshit Goyal
- Neurosurgery, Mayo Clinic, Rochester, New York, USA
| | | | | | | | | | | | | | - Felix Diehn
- Radiology, Mayo Clinic, Rochester, New York, USA
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22
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Nagoshi N, Tsuji O, Nakashima D, Takeuchi A, Kameyama K, Okada E, Fujita N, Yagi M, Matsumoto M, Nakamura M, Watanabe K. Clinical outcomes and prognostic factors for cavernous hemangiomas of the spinal cord: a retrospective cohort study. J Neurosurg Spine 2019; 31:271-278. [PMID: 31479221 DOI: 10.3171/2019.1.spine18854] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Intramedullary cavernous hemangioma (CH) is a rare vascular lesion that is mainly characterized by the sudden onset of hemorrhage in young, asymptomatic patients, who then experience serious neurological deterioration. Despite the severity of this condition, the therapeutic approach and timing of intervention for CH remain matters of debate. The aim of this study was to evaluate the clinical characteristics of CH patients before and after surgery and to identify prognostic indicators that affect neurological function in these patients. METHODS This single-center retrospective study included 66 patients who were treated for intramedullary CH. Among them, 57 underwent surgery and 9 patients received conservative treatment. The authors collected demographic, symptomology, imaging, neurological, and surgical data. Univariate and multivariate logistic regression analyses were performed to identify the prognostic indicators for neurological function. RESULTS When comparing patients with stable and unstable gait prior to surgery, patients with unstable gait had a higher frequency of hemorrhagic episodes (52.4% vs 19.4%, p = 0.010), as assessed by the modified McCormick Scale. The lesion was significantly smaller in patients who underwent conservative treatment compared with surgery (2.5 ± 1.5 mm vs 5.9 ± 4.1 mm, respectively; p = 0.024). Overall, the patients experienced significant neurological recovery after surgery, but a worse preoperative neurological status was identified as an indicator affecting surgical outcomes by multivariate analysis (OR 10.77, 95% CI 2.88–40.36, p < 0.001). In addition, a larger lesion size was significantly associated with poor functional recovery in patients who had an unstable gait prior to surgery (8.6 ± 4.5 mm vs 3.5 ± 1.6 mm, p = 0.011). CONCLUSIONS Once a hemorrhage occurs, surgical intervention should be considered to avoid recurrence of the bleeding and further neurological injury. In contrast, if the patients with larger lesion presented with worse preoperative functional status, surgical intervention could have a risk for aggravating the functional deficiencies by damaging the thinning cord parenchyma. Conservative treatment may be selected if the lesion is small, but regular neurological examination by MRI is needed for assessment of a change in lesion size and for detection of functional deterioration. ABBREVIATIONS AIS = ASIA Impairment Scale; ASIA = American Spinal Injury Association; CH = cavernous hemangioma; EBL = estimated blood loss; JOA = Japanese Orthopaedic Association; mMS = modified McCormick Scale.
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Affiliation(s)
| | | | | | - Ayano Takeuchi
- 2Preventive Medicine and Public Health, Keio University School of Medicine; and
| | - Kaori Kameyama
- 3Division of Diagnostic Pathology, Keio University Hospital, Tokyo, Japan
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Ren J, Hong T, He C, Li X, Ma Y, Yu J, Ling F, Zhang H. Surgical approaches and long-term outcomes of intramedullary spinal cord cavernous malformations: a single-center consecutive series of 219 patients. J Neurosurg Spine 2019; 31:123-132. [PMID: 30952112 DOI: 10.3171/2018.12.spine181263] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 12/28/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Optimal surgical strategies for intramedullary spinal cord cavernous malformations (ISCCMs) are not optimized and remain problematic. In this study the authors identify rational surgical strategies for ISCCMs and predictors of outcomes after resection. METHODS A single-center study was performed with 219 consecutive surgically treated patients who presented from 2002 to 2017 and were analyzed retrospectively. The American Spinal Injury Association (ASIA) Impairment Scale was used to evaluate neurological functions. Patient characteristics, surgical approaches, and immediate and long-term postoperative outcomes were identified. RESULTS The average ISCCM size was 10.5 mm. The spinal level affected was cervical in 24.8% of patients, thoracic in 73.4%, and lumbar in 1.8%. The locations of the lesions in the horizontal plane were 30.4% ventral, 41.6% dorsal, and 28.0% central. Of the 214 patients included in the cohort for operative evaluation, 62.6% had superficially located lesions, while 37.4% were embedded. Gross-total resection was achieved in 98.1% of patients. The immediate postoperative neurological condition worsened in 10.3% of the patients. Multivariate logistic regression identified mild preoperative function (p = 0.014, odds ratio [OR] 4.5, 95% confidence interval [CI] 1.4-14.8) and thoracolumbar-level lesions (p = 0.01, OR 15.7, 95% CI 1.9-130.2) as independent predictors of worsening. The mean follow-up duration in 187 patients was 45.9 months. Of these patients, 63.1% were stable, 33.2% improved, and 3.7% worsened. Favorable outcomes were observed in 86.1% of patients during long-term follow-up and were significantly associated with preoperative mild neurological and disability status (p = 0.000) and cervically located lesions (p = 0.009). The depths of the lesions were associated with worse long-term outcomes (p = 0.001), and performing myelotomy directly through a yellowish abnormal surface in moderate-depth lesions was an independent predictor of worsening (p = 0.023, OR 35.3, 95% CI 1.6-756.3). CONCLUSIONS Resection performed with an individualized surgical approach remains the primary therapeutic option in ISCCMs. Performing surgery in patients with mild symptoms at the thoracolumbar level and embedded located lesions requires more discretion.
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Winkler EA, Lu A, Rutledge WC, Tabani H, Rodriguez Rubio R, Mummaneni PV, Abla AA. A mini-open transspinous approach for resection of intramedullary spinal cavernous malformations. J Clin Neurosci 2018; 58:210-212. [DOI: 10.1016/j.jocn.2018.10.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 10/05/2018] [Indexed: 10/28/2022]
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Nagoshi N, Ishii K, Kameyama K, Tsuji O, Okada E, Fujita N, Yagi M, Matsumoto M, Nakamura M, Watanabe K. Total Resection of Cervical Ventral Intramedullary Cavernous Hemangiomas with an Anterior Corpectomy. Spine Surg Relat Res 2018; 2:331-334. [PMID: 31435543 PMCID: PMC6690108 DOI: 10.22603/ssrr.2017-0088] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 01/06/2018] [Indexed: 11/17/2022] Open
Abstract
Introduction Intramedullary lesions and tumors are generally accessed by a posterior approach. However, if the lesion is located on the ventral side of the spinal cord, a posterior resection with myelotomy poses technical difficulties. We report two cases of complete resection of a cervical ventral intramedullary cavernous hemangioma using an anterior approach. Case Report Two cases of intramedullary cavernous hemangioma located on the ventral side of the spinal cord were successfully treated by total resection with anterior cervical corpectomy followed by anterior spinal fusion with an autologous bone strut from the iliac crest. In both cases, the postoperative course was uneventful, and there was no neurological deficit. Bony fusion was achieved, and there was no recurrence or complication during a follow-up period of at least two years. Conclusions Here, we describe an anterior approach for total resection of cavernous hemangiomas on the ventral side of the cervical spinal cord. Outcomes were stable two years after the operations. Although the method should be assessed with more patients and a longer follow-up time, this anterior approach may be useful for the radical resection of a vascular malformation or tumor.
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Affiliation(s)
- Narihito Nagoshi
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Ken Ishii
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan.,Spine and Spinal Cord Center, International University of Health and Welfare, Mita Hospital, Tokyo, Japan.,Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, Chiba, Japan
| | - Kaori Kameyama
- Division of Diagnostic Pathology, Keio University School of Medicine, Tokyo, Japan
| | - Osahiko Tsuji
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Eijiro Okada
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Nobuyuki Fujita
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Mitsuru Yagi
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Morio Matsumoto
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Masaya Nakamura
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kota Watanabe
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
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Li J, Chen G, Gu S, Liu X, Shou J, Gu W, Gao X, Xu Q, Che X, Xie R. Surgical Outcomes of Spinal Cord Intramedullary Cavernous Malformation: A Retrospective Study of 83 Patients in a Single Center over a 12-Year Period. World Neurosurg 2018; 118:e105-e114. [DOI: 10.1016/j.wneu.2018.06.134] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 06/14/2018] [Accepted: 06/15/2018] [Indexed: 10/28/2022]
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Ghobrial GM, Liounakos J, Starke RM, Levi AD. Surgical Treatment of Vascular Intramedullary Spinal Cord Lesions. Cureus 2018; 10:e3154. [PMID: 30345209 PMCID: PMC6191006 DOI: 10.7759/cureus.3154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Vascular lesions represent a rare subset of intramedullary spinal cord pathology and consist of cavernous malformations (CM), hemangioblastomas, and arteriovenous malformations (AVM). These lesions are each unique and the literature pertaining to their surgical management is largely limited to retrospective case series and case reports. Objectives To evaluate the surgical management of each of these lesions with special attention to postoperative functional status. Methods A single-institution case series of intramedullary vascular lesions treated with surgery was retrospectively evaluated. The primary variables of interest included preoperative and postoperative McCormick grades. Other variables of interest included frequency and indication for conventional spinal angiography, rates of preoperative embolization, postprocedural complications, operative time, intraoperative blood loss, and length of hospital stay. Results Thirty-six patients were identified over the 17-year study period, including 20 with hemangioblastomas, 13 with CMs, and three with AVMs. The median preoperative McCormick grades were 2, 2, and 3 for hemangioblastomas, CMs, and AVMs, respectively. The median postoperative McCormick grades were 2, 2, and 2 for hemangioblastomas, CMs, and AVMs, respectively at the most recent follow-up. Preoperative angiography was performed in all AVM cases and 29% of hemangioblastomas. Preoperative embolization was performed in 40% of hemangioblastoma cases undergoing preoperative angiography. Operative times were similar between the three lesion groups. In three cases of hemangioblastoma resection and one case of CM resection, McCormick grade improved by one point following surgery. At a mean follow-up of 30.9 months for hemangioblastomas, 7.95 months for CMs, and 24 months for AVMs, all patients were at least at their discharge baseline, with no new neurologic complaints. Conclusion Intramedullary vascular lesions are rare and represent a complex surgical patient population. Surgical resection with or without preoperative angiography and embolization appears to be safe and to halt neurologic decline.
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Affiliation(s)
| | | | | | - Allan D Levi
- Neurosurgery, University of Miami Miller School of Medicine, Miami, USA
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Azad TD, Veeravagu A, Li A, Zhang M, Madhugiri V, Steinberg GK. Long-Term Effectiveness of Gross-Total Resection for Symptomatic Spinal Cord Cavernous Malformations. Neurosurgery 2018; 83:1201-1208. [DOI: 10.1093/neuros/nyx610] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 12/06/2017] [Indexed: 11/14/2022] Open
Affiliation(s)
- Tej D Azad
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Amy Li
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Michael Zhang
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Venkatesh Madhugiri
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Gary K Steinberg
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
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Otten M, Mccormick P. Natural history of spinal cavernous malformations. HANDBOOK OF CLINICAL NEUROLOGY 2017; 143:233-239. [PMID: 28552145 DOI: 10.1016/b978-0-444-63640-9.00022-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Spinal cavernous malformations are intramedullary vascular lesions. They have low pressure and flow, so they may take many years to present with clinical symptoms. Because of their relatively benign nature, surgical intervention is not always indicated. An understanding of the natural history of cavernous malformations helps make decisions about when and if to intervene. In patients who do not have surgery, 88.7% have stable or improved neurologic function, whereas 89.3% have these outcomes in the surgical group. Of note, 51.5% of patients were found to improve in the surgical group, compared to 30.2% in the nonsurgical group. Characteristics that correlated with better neurologic outcome were: resection within 3 months of the onset of symptoms, gross total resection, presentation with motor symptoms, and an acute course. Sensory symptoms correlated with worse outcome. Given the natural history of spinal cavernous malformations, surgery may be considered for symptomatic patients, when general medical health and lesion location permit safe resection. The severity of symptoms must also be considered, as the natural history of the disease can be benign.
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Affiliation(s)
- Marc Otten
- Department of Neurological Surgery, Columbia University Medical Center, Neurological Institute of New York, New York, NY, USA
| | - Paul Mccormick
- Department of Neurological Surgery, Columbia University Medical Center, Neurological Institute of New York, New York, NY, USA.
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Abstract
Spinal cavernous malformations are rare intramedullary vascular lesions of the central nervous system. Most are located in the thoracic spine. Patients present with either acute neurologic deficit or gradual deterioration. Weakness is the most common presenting symptom. The annual hemorrhage risk is 2.1%. Diagnosis is made by magnetic resonance imaging as these lesions are occult on angiography. Surgical removal is indicated in patients with hemorrhage and neurologic deficit. All lesions are approached posteriorly by laminectomy. Dorsal cavernous malformations are exposed by focused laminectomy of the level or levels overlying the lesion with minimally facet violation. Ventral and lateral lesions are approached by laminectomy including a level above and level below as well as unilateral radical facetectomy. After midline dural opening, the dentate ligament is divided and retracted to allow up to 90° of rotation of the spinal cord. Microsurgical treatment is associated with 42% symptom improvement and 50% symptom stabilization. Postoperative worsening is associated with longer preoperative duration of symptoms. Therefore we recommend consideration of early surgery for cavernous malformation removal in patients with symptoms attributable to the lesion.
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Affiliation(s)
- Aaron J Clark
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Doris D Wang
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Michael T Lawton
- Department of Neurological Surgery, University of California, San Francisco, CA, USA.
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Endo T, Takahashi Y, Nakagawa A, Niizuma K, Fujimura M, Tominaga T. Use of Actuator-Driven Pulsed Water Jet in Brain and Spinal Cord Cavernous Malformations Resection. Neurosurgery 2016; 11 Suppl 3:394-403; discussion 403. [PMID: 26284350 DOI: 10.1227/neu.0000000000000867] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND A piezo actuator-driven pulsed water jet (ADPJ) system is a novel surgical instrument that enables dissection of tissue without thermal damage. It can potentially resect intra-axial lesions while preserving neurological function. OBJECTIVE To report our first experience of applying an ADPJ system to brain and spinal cord cavernous malformations. METHODS Four patients (2 women and 2 men, mean age 44.5 years) with brain (n = 3) and spinal cord (n = 1) cavernous malformations were enrolled in the study. All surgeries were performed with the aid of the ADPJ system. Postoperative neurological function and radiological findings were evaluated. RESULTS The ADPJ system was useful in dissecting boundaries between the lesion and surrounding brain/spinal cord tissues. The pulsed water jet provided a clear surgical view and helped surgeons follow the margins. Water jet dissection peeled off the brain and spinal cord tissues from the lesion wall. Surrounding gliotic tissue was preserved. As a consequence, the cavernous malformations were successfully removed. Postoperative magnetic resonance imaging confirmed total removal of lesions in all cases. Preoperative neurological symptoms completely resolved in 2 patients. The others experienced partial recovery. No patients developed new postoperative neurological deficits; facial palsy temporarily worsened in 1 patient who underwent a suprafacial colliculus approach for the brainstem lesion. CONCLUSION The ADPJ provided a clear surgical field and enabled surgeons to dissect boundaries between lesions and surrounding brain and spinal cord gliotic tissue. The ADPJ system is a feasible option for cavernous malformation surgery, enabling successful tumor removal and preservation of neurological function.
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Affiliation(s)
- Toshiki Endo
- Department of Neurosurgery, Tohoku University, Graduate School of Medicine, Sendai, Japan
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Zhang L, Yang W, Jia W, Kong D, Yang J, Wang G, Xu Y. Comparison of Outcome Between Surgical and Conservative Management of Symptomatic Spinal Cord Cavernous Malformations. Neurosurgery 2015; 78:552-61. [DOI: 10.1227/neu.0000000000001075] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Intramedullary cavernous malformations (CMs) are rare lesions with unclear natural history.
OBJECTIVE:
To compare the functional outcomes of spinal CMs managed surgically and conservatively.
METHODS:
We performed a retrospective study of patients diagnosed with intramedullary CMs seen at our institution from 2006 to 2013. Functional outcomes of patients were assessed by treatment modality with the Modified McCormick Scale and Karnofsky Performance Status.
RESULTS:
We identified a total of 85 study-eligible patients; 51 (60.0%) were male. Mean age of patients was 40.5 years. Fifty-eight patients underwent microsurgical removal, and 27 patients underwent conservative management. All patients except 1 harbored a single symptomatic intramedullary CM. Mean follow-up time was 42.8 months. For the surgical group (n = 58), 51 CMs were completely resected. During the follow-up period, 40 patients (69.0%) within the surgical group had improvement in neurological state, 16 patients (27.6%) remained unchanged, and 2 patients (3.4%) experienced deteriorated functional status. In the conservative group, 4 patients (14.8%) had improvement of their symptoms, 19 patients (70.4%) remained in baseline, and 4 patients (14.8%) deteriorated. No significant statistical difference was observed in follow-up Karnofsky Performance Status assessment (odds ratio = 0.89; 95% confidence interval = 0.73-1.08; P = .15) or Modified McCormick Scale assessment (odds ratio = 0.90; 95% confidence interval = 0.74-1.10; P = .30) after adjustment for preoperative lesion size and location. Annual hemorrhagic risk was 3.9% in conservatively managed patients. In contrast, no patients experienced subsequent hemorrhages after surgical resection.
CONCLUSION:
Surgical resection of intramedullary CMs eliminates the risk of subsequent hemorrhagic and may achieve satisfactory outcome when patients are carefully selected. Although conservative management is recommended in patients at high surgical risk, they should be closely monitored because of persistent hemorrhagic risk.
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Affiliation(s)
- Liang Zhang
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wuyang Yang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Wenqing Jia
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Desheng Kong
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jun Yang
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guihuai Wang
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yulun Xu
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Reitz M, Burkhardt T, Vettorazzi E, Raimund F, Fritzsche E, Schmidt NO, Regelsberger J, Westphal M, Eicker SO. Intramedullary spinal cavernoma: clinical presentation, microsurgical approach, and long-term outcome in a cohort of 48 patients. Neurosurg Focus 2015; 39:E19. [PMID: 26235017 DOI: 10.3171/2015.5.focus15153] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Intramedullary spinal cavernoma (ISC) is a rare entity and accounts for approximately 5%-12% of all spinal vascular pathologies. The purpose of the present study was to examine the influence of clinical presentation, localization, and different surgical approaches on long-term outcome in patients treated for ISC. METHODS The authors performed a retrospective single-center study of 48 cases of ISC treated microsurgically over the past 28 years. Analyzed factors included preoperative clinical history, microsurgical strategies, neurological outcome (American Spinal Injury Association [ASIA] grade, Epstein and Cooper grade), and the occurrence of postoperative spinal ataxia. Univariate analysis was performed to identify factors influencing long-term outcome. RESULTS Preoperatively, 18.8% of all patients experienced a slow, progressive decline in neurological function and 33.3% suffered repetitive episodes of acute neurological deterioration over a time frame of months to years. Moreover, 16.7% noted the sudden onset of a severe neurological deficit, whereas 25% experienced the sudden onset of symptoms with a subsequent gradually progressive decline in neurological function. On long-term follow-up after treatment (mean ± SD, 79.3 ± 35.2 months), 70.8% of patients showed no change in neurological function, 6.3% suffered from a decline, and 22.9% improved neurologically. Thoracolumbar localization (p = 0.043), low preoperative Epstein and Cooper grade for the lower extremities (p < 0.001), and a low preoperative ASIA grade (p < 0.001) were identified as factors associated with an unfavorable outcome (ASIA Grade A-C). The rate of spinal ataxia related to surgical approach was 16.7%. CONCLUSION Postoperative neurological function in ISC patients is determined by the preoperative neurological status. On long-term follow-up after microsurgical treatment, 93.7% of patients presented with a stable or improved condition (ASIA grade); thus, definite microsurgical treatment should be considered as long as patients present with only mild symptoms after the diagnosis of symptomatic ISC.
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Affiliation(s)
| | | | - Eik Vettorazzi
- Institute of Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf; and
| | - Frank Raimund
- Department of Spinal Surgery, Asklepios Hospital Wandsbek, Hamburg, Germany
| | - Erik Fritzsche
- Department of Spinal Surgery, Asklepios Hospital Wandsbek, Hamburg, Germany
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Badhiwala JH, Farrokhyar F, Alhazzani W, Yarascavitch B, Aref M, Algird A, Murty N, Kachur E, Cenic A, Reddy K, Almenawer SA. Surgical outcomes and natural history of intramedullary spinal cord cavernous malformations: a single-center series and meta-analysis of individual patient data. J Neurosurg Spine 2014; 21:662-76. [DOI: 10.3171/2014.6.spine13949] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Information pertaining to the natural history of intramedullary spinal cord cavernous malformations (ISCCMs) and patient outcomes after surgery is scarce. To evaluate factors associated with favorable outcomes for patients with surgically and conservatively managed ISCCMs, the authors performed a systematic review and metaanalysis of the literature. In addition, they included their single-center series of ISCCMs.
Methods
The authors searched MEDLINE, EMBASE, CINAHL, Google Scholar, and The Cochrane Library for studies published through June 2013 that reported cases of ISCCMs. Data from all eligible studies were used to examine the epidemiology, clinical features, and neurological outcomes of patients with surgically managed and conservatively treated ISCCMs. To evaluate several variables as predictors of favorable neurological outcomes, the authors conducted a meta-analysis of individual patient data and performed univariate and multivariate logistic regression analyses. Variables included patient age, patient sex, lesion spinal level, lesion size, cerebral cavernomas, family history of cavernous malformations, clinical course, presenting symptoms, treatment strategy (operative or conservative), symptom duration, surgical approach, spinal location, and extent of resection. In addition, they performed a meta-analysis to determine a pooled estimate of the annual hemorrhage rate of ISCCMs.
Results
Eligibility criteria were met by 40 studies, totaling 632 patients, including the authors' institutional series of 24 patients. Mean patient age was 39.1 years (range 2–80 years), and the male-to-female ratio was 1.1:1. Spinal levels of cavernomas were cervical (38%), cervicothoracic (2.4%), thoracic (55.2%), thoracolumbar (0.6%), lumbar (2.1%), and conus medullaris (1.7%). Average cavernoma size was 9.2 mm. Associated cerebral cavernomas occurred in 16.5% of patients, and a family history of cavernous malformation was found for 11.9% of evaluated patients. Clinical course was acute with stepwise progression for 45.4% of patients and slowly progressive for 54.6%. Symptoms were motor (60.5%), sensory (57.8%), pain (33.8%), bladder and/or bowel (23.6%), respiratory distress (0.5%), or absent (asymptomatic; 0.9%). The calculated pooled annual rate of hemorrhage was 2.1% (95% CI 1.3%–3.3%). Most (89.9%) patients underwent resection, and 10.1% underwent conservative management (observation). Outcomes were better for those who underwent resection than for those who underwent conservative management (OR 2.79, 95% CI 1.46–5.33, p = 0.002). A positive correlation with improved neurological outcomes was found for resection within 3 months of symptom onset (OR 2.11, 95% CI 1.31–3.41, p = 0.002), hemilaminectomy approach (OR 3.20, 95% CI 1.16–8.86, p = 0.03), and gross-total resection (OR 3.61, 95% CI 1.24–10.52, p = 0.02). Better outcomes were predicted by an acute clinical course (OR 1.72, 95% CI 1.10–2.68, p = 0.02) and motor symptoms (OR 1.76, 95% CI 1.08–2.86, p = 0.02); poor neurological recovery was predicted by sensory symptoms (OR 0.58, 95% CI 0.35–0.98, p = 0.04). Rates of neurological improvement after resection were no higher for patients with superficial ISCCMs than for those with deep-seated ISCCMs (OR 1.36, 95% CI 0.71–2.60, p = 0.36).
Conclusions
Intramedullary spinal cord cavernous malformations tend to be clinically progressive. The authors' findings support an operative management plan for patients with a symptomatic ISCCM. Surgical goals include gross-total resection through a more minimally invasive hemilaminectomy approach within 3 months of presentation.
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Affiliation(s)
| | - Forough Farrokhyar
- 2Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Waleed Alhazzani
- 2Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | | | - Mohammed Aref
- 1Division of Neurosurgery, Department of Surgery, and
| | | | - Naresh Murty
- 1Division of Neurosurgery, Department of Surgery, and
| | - Edward Kachur
- 1Division of Neurosurgery, Department of Surgery, and
| | - Aleksa Cenic
- 1Division of Neurosurgery, Department of Surgery, and
| | - Kesava Reddy
- 1Division of Neurosurgery, Department of Surgery, and
| | - Saleh A. Almenawer
- 1Division of Neurosurgery, Department of Surgery, and
- 2Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
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Straus D, Moftakhar R, Fink Y, Patel D, Byrne RW. Application of Novel CO2 Laser-Suction Device. J Neurol Surg B Skull Base 2014; 74:358-63. [PMID: 24436938 DOI: 10.1055/s-0033-1347373] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2012] [Accepted: 03/04/2013] [Indexed: 10/26/2022] Open
Abstract
Background Development of the flexible CO2 fiber has presented new opportunities for the use of precision laser cutting in cranial procedures. The efficacy of the CO2 scalpel is further enhanced by combining it with a fluid removal suction capability. Objectives We report our experience with a novel CO2 laser-suction device. Methods The novel laser-suction device was designed in conjunction with OmniGuide Inc. (Cambridge, Massachusetts, USA). We performed a case review of its use in firm tumors that were resistant to resection by bipolar, suction, and ultrasonic aspirator. Results The laser-suction device was applied in three tumors where resection with ultrasonic aspiration failed. Tumor resection using the laser-suction device was successful in all three cases. There were no complications related to the laser-suction device. There were no instances of intraoperative device malfunction. Discussion The CO2 laser combined with suction is a useful instrument for resection of firm tumors that prove to be resistant to ultrasonic aspiration. We also find it to be useful in settings where precise tissue incisions are desired with minimal manipulation. In our experience, the surgical efficiency of the CO2 laser is improved by the laser-suction device. This device allows the surgeon to utilize a suction device and laser in a single hand and enables concurrent use of bipolar electrocautery without repeated instrument changes.
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Affiliation(s)
- David Straus
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois, United States
| | - Roham Moftakhar
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois, United States
| | - Yoel Fink
- Massachusetts Institute of Technology, Cambridge, Massachusetts, United States
| | - Deval Patel
- St. Louis University, St. Louis, Missouri, United States
| | - Richard W Byrne
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois, United States
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Takami T, Yamagata T, Ohata K. Posterolateral sulcus approach for spinal intramedullary tumor of lateral location: technical note. Neurol Med Chir (Tokyo) 2013; 53:920-7. [PMID: 24172592 PMCID: PMC4508739 DOI: 10.2176/nmc.tn2012-0419] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Posterolateral sulcus (PLS) approach of the spinal cord, being equivalent to the dorsal root entry zone myelotomy, may offer the satisfactory exposure of the spinal intramedullary tumor if applied appropriately. Eight consecutive patients with spinal intramedullary tumors of lateral location underwent the surgery of PLS approach in our institute. There were 6 male and 2 female patients, ranging in age from 34 to 72 years (mean, 57 years). PLS approach was indicated for the intramedullary tumor situated laterally in the spinal cord and that do not contact the posterior or lateral surfaces on magnetic resonance (MR) images before surgery. Total removal of the tumor was achieved in 6 cases except of 2 cases of anaplastic astrocytoma. All 6 patients with total removal of the tumor demonstrated the modest or mild deterioration of motor function on the approach side early after surgery, which resolved within 1 month after surgery. Average grade of the modified McCormick functional schema was 3.5 before surgery and improved to 3.0 at 3 months after surgery. These 6 patients demonstrated satisfactory pain relief early after surgery. Average grade of the sensory pain scale was 2.7 before surgery and improved to 1.7 at 3 months after surgery. PLS approach can be one of the surgical choices to the spinal intramedullary tumors, if applied appropriately. Better indication for PLS approach may be the tumors of the uneven location within the spinal cord associated with moderate or severe local pain.
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Affiliation(s)
- Toshihiro Takami
- Department of Neurosurgery, Osaka City University Graduate School of Medicine
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Abstract
Vascular disease affecting the spinal can cause substantial neurologic morbidity. Several vascular spinal cord ailments present as neurologic emergencies, and should thus be recognizable to the practicing neurologist. We review the epidemiology, presentation, management strategies, and prognosis of various pathologies, including infarction, dural arteriovenous fistula, arteriovenous malformation, cavernous malformation, compressive epidural hematoma, vasculitis, and genetic abnormalities.
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Affiliation(s)
- Mark N Rubin
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA
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Consiglieri GD, Killory BD, Germain RS, Spetzler RF. Utility of the CO Laser in the Microsurgical Resection of Cavernous Malformations. World Neurosurg 2013; 79:714-8. [PMID: 22381271 DOI: 10.1016/j.wneu.2011.12.088] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Revised: 11/03/2011] [Accepted: 12/20/2011] [Indexed: 12/19/2022]
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Endo T, Aizawa-Kohama M, Nagamatsu K, Murakami K, Takahashi A, Tominaga T. Use of microscope-integrated near-infrared indocyanine green videoangiography in the surgical treatment of intramedullary cavernous malformations: report of 8 cases. J Neurosurg Spine 2013; 18:443-9. [PMID: 23473269 DOI: 10.3171/2013.1.spine12482] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The characteristics and efficacy of indocyanine green (ICG) videoangiography in cavernous malformation (CM) have not been fully elucidated. The purpose of this paper is to examine the potential utility of ICG videoangiography in the surgical treatment of intramedullary CMs. METHODS The authors conducted a retrospective review of 8 cases involving 5 men and 3 women who had undergone surgery for intramedullary CM between January 2008 and July 2011. All patients were evaluated by means of MRI. The MRI findings and clinical history in all cases suggested intramedullary CM as a preoperative diagnosis. In 2 of 8 cases, dilated venous structures associated with CMs were demonstrated. In one of these cases, there were coexisting extramedullary CMs. Intraoperatively, ICG fluorescence was observed for 5 minutes using microscope-integrated videoangiography. RESULTS In all 8 cases, intra- and extramedullary CMs were seen as avascular areas on ICG videoangiography. Indocyanine green videoangiography helped surgeons to localize and predict margins of the lesions before performing myelotomy. Importantly, in the cases with associated venous anomalies, ICG videoangiography was useful in delineating and preserving the venous structures. In extramedullary CMs located dorsal to the spinal cord, gradual ICG infiltration was seen, starting at 110 seconds and maximal at 210 seconds after injection. Postoperative MRI confirmed total removal of the lesions in all cases, and subsequent recovery of all patients was uneventful. CONCLUSIONS Indocyanine green videoangiography provided useful information with regard to the detection of lesion margins by demonstrating intramedullary CMs as avascular areas. In cases associated with venous anomalies, ICG contributed to safe and complete removal of the CMs by visualizing the venous structure. In extramedullary CMs, ICG videoangiography demonstrated the characteristic of slow blood flow within CMs.
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Affiliation(s)
- Toshiki Endo
- Department of Neurosurgery, Graduate School of Medicine, Tohoku University, Sendai, Japan.
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Batra S, Rigamonti K, Rigamonti D. Management of Hemorrhage from Cavernous Malformations. Curr Atheroscler Rep 2012; 14:360-5. [DOI: 10.1007/s11883-012-0261-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Oppenlander ME, Kalani MYS, Dickman CA. Spinal and paraspinal giant cervical cavernous malformation with postpartum presentation. J Neurosurg Spine 2012; 16:447-51. [PMID: 22360563 DOI: 10.3171/2012.1.spine11630] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Cavernous malformations (CMs) are found throughout the CNS but are relatively uncommon in the spine. In this report, the authors describe a giant CM with the imaging appearance of an aggressive, invasive, expansive tumor in the cervical spine. The intradural extramedullary portion of the tumor originated from a cervical nerve root; histologically, the lesion was identified as an intraneural CM. Most of the tumor extended into the paraspinal tissues. The tumor was also epidural, intraosseous, and osteolytic and had completely encased cervical nerve roots, peripheral nerves, branches of the brachial plexus, and the vertebral artery on the right side. It became symptomatic during the puerperal period. Gross-total resection was achieved using staged operative procedures, complex dural reconstruction, spinal fixation, and fusion. Clinical, radiographic, and histological details, as well as a discussion of the relevant literature, are provided.
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Affiliation(s)
- Mark E Oppenlander
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
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