Clinical presentation and surgical outcome of intramedullary spinal cord cavernous malformations

Cavernous Malformations and Hemangioblastomas of the Spinal Cord Show Distinct Differences in Clinical Course - A Retrospective Single-Center Analysis of 112 Patients

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.

Surgical Outcomes of Symptomatic Intramedullary Spinal Cord Cavernous Malformations: Analysis of Consecutive Cases in a Single Center

OBJECTIVE

Intramedullary spinal cavernous malformations (ISCMs) are rare vascular lesions of the spinal cord with unclear natural history and controversy over treatment. This study aimed to report a series of symptomatic ISCMs underwent microsurgical management to illustrate the natural history, clinical presentation, and surgical outcomes and to evaluate factors associated with hemorrhage events and neurological prognosis.

METHODS

This single-center retrospective study included 29 consecutive patients with whose demographic, symptomology, imaging, neurological, and surgical data were collected. The risk for hemorrhage events and factors affecting surgical outcomes were retrospectively analyzed.

RESULTS

There were 12 female (41.4%) and 17 male patients (58.6%), with an average age of 45.2 years (range, 17-69 years). The mean size of the lesion was 9.7 mm (range, 3-20 mm). Most patients had a bowel or/and bladder dysfunction symptom (n = 11, 37.9%), followed by sensory deficits (n = 5, 17.2%), gait disturbance (n = 5, 17.2%), pain (n = 4, 13.8%), and weakness (n = 4, 13.8%), most (n = 15, 51.7%) with a chronic onset. All patients received total resection without rehemorrhages after surgical resection in follow-up. Sixty-five point five percent patients (n = 19) improved, 13.8% (n = 4) remained stable, 20.7% (n = 6) got worsen. The overall annual hemorrhage risk was 2.1% per patient-year. A total of 27 hemorrhages occurred in the 18 patients, of which rehemorrhage rate increased to 50.0% (n = 9) with a previous history of hemorrhage. Patients with smaller lesion sizes were more likely to have hemorrhage or rehemorrhage events (p = 0.008). Recurrent hemorrhage of the lesions was a risk factor for neurological outcomes (p = 0.016).

CONCLUSION

The risk of rehemorrhage was significantly increased in symptomatic ISCM patients with a previous history of hemorrhage. Rehemorrhage was a risk factor for neurological outcomes. Patients can benefit from microsurgical treatment to avoid rehemorrhage and further neurological deterioration.

Functional neurological outcome of spinal cavernous malformation surgery

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Prediction of outcomes for symptomatic spinal cavernous malformation surgery: a multicenter prospective clinical study

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.

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

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.

The Long-Term Outcome in a Cohort of 52 Patients With Symptomatic Intramedullary Spinal Cavernous Hemangioma After Microsurgery and Emergency Rescue Surgery

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.

Treatment strategies and prognostic factors for spinal cavernous malformation: a single-center retrospective cohort study

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.

Conservative and Surgical Management of Spinal Cord Cavernous Malformations

Objectives

We present a case series of spinal cord cavernous malformations (SCCMs) to describe clinical presentation and outcomes of both surgical and conservative management.

Methods

The clinical courses of patients diagnosed with SCCMs at our institution were retrospectively reviewed. Neurologic symptoms were evaluated using the Modified McCormick Scale.

Results

A total of 18 patients were identified. Five patients (27.8%) presented with acute onset bleeding, 4 of whom underwent immediate surgical resection. Thirteen patients (72.2%) were initially managed conservatively. Eight patients (38.9%) developed a hemorrhage during follow-up, and 8 (38.9%) required surgical resection due to bleeding or neurological worsening. The mean (range) duration from primary symptoms to subsequent hemorrhage or deterioration of symptoms was 1.42 (range: 0.25–4.33) years. The mean duration from primary symptoms to surgery was 2.10 (range: 0.25–5.0) years. No patients experienced subsequent hemorrhage after surgical resection. Eleven patients (84.6%) in the surgery group showed improved neurological status, and 2 patients (15.4%) remained unchanged. The annualized subsequent hemorrhage risk was 3.7%. Patients in the immediate surgical group had a significantly larger lesion compared with those in the conservative group. There was significance between the worst Modified McCormick Scale grades at the time of debilitating symptoms and the length of hemorrhage, but not the size of the lesion.

Conclusions

Surgery for SCCMs resulted in no recurrence of hemorrhage or exacerbation of neurological symptoms, and should be considered for patients who experienced acute onset of hemorrhage or debilitating symptoms during follow-up.

Characteristics and Long-Term Outcome of 20 Children With Intramedullary Spinal Cord Cavernous Malformations

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.

Clinical presentation, natural history and outcomes of intramedullary spinal cord cavernous malformations

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.

Surgical approaches and long-term outcomes of intramedullary spinal cord cavernous malformations: a single-center consecutive series of 219 patients

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.

Location, length, and enhancement: systematic approach to differentiating intramedullary spinal cord lesions

Purpose

Intramedullary spinal cord abnormalities are often challenging to diagnose. Spinal cord biopsy is a high-risk procedure with the potential to cause permanent neurological injury. Magnetic resonance imaging is the modality of choice for diagnosis and preoperative assessment of patients with spinal cord abnormalities. The radiologist’s ability to narrow the differential diagnosis of spinal cord abnormalities has the potential to save patients from invasive approaches for diagnosis and also guide appropriate management.

Approach/methods

This article will provide a systematic approach to the evaluation of intramedullary spinal cord lesions—with emphasis on location, length and segment distribution, and enhancement pattern—to help narrow the differential diagnosis. In doing so, we will review various spinal cord pathologies, including demyelinating and metabolic conditions, neoplasms, and vascular lesions.

Summary/conclusion

Although intramedullary spinal cord abnormalities can be a challenge for the radiologist, a systematic approach to the differential diagnosis with a focus on lesion location, cord length and segment involvement, as well as enhancement pattern, can greatly help narrow the differential diagnosis, if not synch the diagnosis. This strategy will potentially obviate the need for an invasive approach to diagnosis and help guide treatment.

Teaching points

• Imaging diagnosis of intramedullary spinal cord lesions could obviate cord biopsy.

• Evaluation of cord lesions should focus on location, length, and enhancement pattern.

• In demyelination, the degree of cross-sectional involvement is a distinguishing feature.

Clinical characteristics and surgical outcomes of solitary spinal epidural cavernous angiomas

The majority of spinal cavernous angiomas (CAs) originate from the vertebral bodies with or without epidural space extension. Solitary epidural CAs are rare. In the present study, we retrospectively reviewed the records of 12 patients who underwent microsurgery for solitary spinal epidural CAs. All patients had performed pre- and postoperative magnetic resonance imaging. The patients were 7 females and 5 males with the mean age of 52.1 years. Two tumors were located in the cervicothoracic spine, nine in the thoracic spine and one in the lumbar spine, respectively. Solitary epidural CAs generally exhibited isointensity on T1-weighted images and hyperintesity on T2-weighted images. Contrast-enhanced T1-weighted images showed homogeneous markedly enhancement. Gross total resection (GTR) was achieved in 11 cases, and subtotal resection (STR) was achieved in 1 case. During an average follow up of 35.9 months, neurological function was improved in 11 patients and in one patient, preoperative status was maintained. No patient experienced tumor recurrence. These findings suggest that CAs should be considered in the differential diagnosis of spinal epidural lesions. Early surgery is advocated to prevent irreversible neurological deficits. When aggravated by a large amount of acute hemorrhage, neurological deterioration is usually acute and prompt surgical decompression is the optimal choice. Because of the excessive vascularity of CAs, en bloc resection is recommended. In addition, a good clinical outcome after GTR can be expected, and the risk of long-term recurrence is low.

Spinal cavernous malformations

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.

Cavernous angiomas of the cauda equina: clinical characteristics and surgical outcomes

Cavernous angioma (CA) is a rare hamartomatous vascular lesion, consisting of abnormal, dilated, and packed sinusoidal vascular channels without interposed nervous tissue. CAs of the cauda equina are exceedingly rare and have been previously reported in the literature as case reports. The aim of this study was to discuss the clinical presentation and the outcomes of microsurgery for these rare lesions. We retrospectively reviewed the records of 10 patients who underwent microsurgery for CAs of the cauda equina. All patients had performed pre- and postoperative magnetic resonance imaging (MRI). CAs of the cauda equina generally exhibited mixed intensity on T₁- and T₂-weighted images. Contrast-enhanced T₁-weighted images showed heterogeneous enhancement. The hemosiderin ring which surrounded the cauda equina CA was rare. Gross total resection was achieved in all cases. All patients were followed up, with a mean duration of 41.1 months. Long-term neurological function was improved in nine patients and remained stable in one patient. No recurrence was observed on MRI. CAs should be considered in the differential diagnosis of cauda equina tumors. Because of the excessive vascularity of CAs, en bloc resection is recommended. For symptomatic patients, early surgery should be performed before neurological deficits deteriorate.

Surgical outcomes and natural history of intramedullary spinal cord cavernous malformations: a single-center series and meta-analysis of individual patient data

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.