Cervical intradural extramedullary cavernoma presenting with isolated intramedullary hemorrhage

Intradural extramedullary cervical cavernoma

Background

Spinal cavernomas (SCs) account for about 5% of all spinal vascular malformations. Intradural SCs occur in just 3% of cases and are typically intramedullary.

Case Description

A 58-year-old female presented with progressive left occipital neuralgia, left cervicobrachial neuralgia, and paresthesia of all four extremities. The magnetic resonance imaging (MRI) revealed an intradural extramedullary C2-C4 lesion causing significant spinal cord compression. Gross total tumor excision was accomplished through a midline laminectomy pathologically; the lesion proved to be a cavernoma. The postoperative follow-up MRI obtained 4 months postoperatively showed complete tumor resection.

Conclusion

A 58-year-old female successfully underwent gross total excision of a C2-C4 intradural extramedullary SC.

A rare case of cavernous malformation of the cauda equina a case report

INTRODUCTION

Cavernous malformation of the cauda equina is a rare neurosurgical condition. We sought to highlight one of these cases and its resultant diagnosis and management. Additionally, to recommend the need for raised clinical suspicion of these rare masses when an extramedullary lesion is noted on imaging.

PRESENTATION OF CASE

A 42-year-old female presented to our institution with a 9-month history of lower back pain. Her examination findings revealed a loss of right ankle jerk reflex. Magnetic resonance imaging (MRI) of her lumbosacral spine demonstrated an intradural, extramedullary tumor involving the cauda equina, at the L4/L5 level. The main differential diagnosis at this time was an ependymoma. An L4/5 laminectomy and resection of the cauda equina mass was scheduled. Intra-operatively, a mulberry - like mass was noted involving a single nerve root. A gross total resection was performed, with resolution of most of her symptoms. Histopathological diagnosis of a cavernous malformation was ascertained.

DISCUSSION

The accurate diagnosis of a cavernous malformation of the cauda equina was only suspected intra-operatively, following gross inspection. Cauda equina masses usually include myxopapillary ependymomas and schwannomas, making this vascular extramedullary lesion low on the possible differentials list. Very few cases have been published in modern literature.

CONCLUSION

Cavernous malformations of the cauda equina are an extremely uncommon, benign vascular malformation. These malformations have key characteristics on MRI that can aid its differentiation from other intradural lesions. However, because it is so rare, it does not usually make the list of differentials when considering likely extramedullary lesions.

Cervical intradural extramedullary cavernous malformation as a rare cause of subarachnoid hemorrhage without spinal dysfunction: illustrative case

BACKGROUND

Intradural extramedullary cavernoma is a very rare lesion of the spinal cord, especially of the cervical spine. Its clinical presentation can vary with symptoms of sensory or motor deficits and even with symptoms of subarachnoid hemorrhage (SAH).

OBSERVATIONS

The authors present a case of a 45-year-old man with SAH with prolonged neck pain and increasing headache confirmed by lumbar puncture. Head computed tomography revealed only discrete blood deposits in the right frontal and biparietal lobes. The finding of pan-cerebral angiography was negative for the cause of bleeding. Spinal magnetic resonance imaging revealed an intradural extramedullary mass lesion at cervical level C5–6. The finding of subsequent cervical angiography was negative. The diagnosis of a cavernous malformation was confirmed histopathologically after surgery. The cavernoma was completely removed, and full recovery of the initial symptoms was achieved.

LESSONS

Spinal lesions should be considered in the diagnostic work-up for SAH with excluded origin of bleeding in cranial neuroimaging. An intradural extramedullary cavernous malformation is an extremely rare entity in the differential diagnosis of SAH, and surgical resection is the treatment of choice to prevent further bleeding and neurological deficits.

Intradural extramedullary cavernous malformation with extensive superficial siderosis of the neuraxis: Case report and review of literature

Background:

Spinal cavernous malformations usually affect the vertebral bodies and are seldom intradural. Here, we report a rare spinal intradural-extramedullary cavernous malformation associated with extensive superficial siderosis along the neuraxis in a patient with radicular complaints.

Case Description:

A 60-year-old male presented with subacute headaches, intermittent fever, and acute back and radicular leg pain for 1–2 weeks. Magnetic resonance imaging revealed an intradural-extramedullary lesion just below the conus medullaris (at the L2 level). There was associated subarachnoid hemorrhage in the lumbar cistern and superficial siderosis along the entire spinal neuraxis. Following surgical resection, the patient's symptoms resolved. Histopathology of the lesion was of a cavernous malformation.

Conclusions:

There are only 56 cases of spinal intradural-extramedullary cavernous malformations published in the literature; however, only 3 described superficial neuraxis siderosis as noted in this case. In the present case, slowly recurring hemorrhages of the lesion located at the conus likely contributed to the complete neuraxis superficial siderosis. Timely evaluation and treatment of these lesions is warranted to avoid further compressive and/or hemorrhagic complications.

Intradural spinal, extramedullary, T4-T5 cavernous hemangioma - case report

A very rare, purely intradural, spinal, extramedullary cavernous hemangioma was fortunately discovered in a 56 years old woman, presenting with bilateral brachial paresthesia. Using conventional spin-echo T1 proton density, T2-weighted magnetic resonance and gadolinium images an intradural spinal T4-T5, an extramedullary cavernous hemangioma was discovered. The patient underwent surgery, with laminectomy and microsurgical resection followed by an uneventful postoperative clinical course. Similar as in cerebral locations a mixed signal intensity in all sequences on magnetic resonance images might be indicative of cavernous hemangioma, rendering a presumptive preoperative diagnosis of the lesion and surgical planning for a good microsurgical resection.

Cervical spinal root cavernoma: case report and review

AIM

Cavernous malformations in the spinal canal are rare. We review previous reports and present our own case of a cervical intradural extramedullary cavernoma, associated with a ventral cervical rootlet.

METHODS

A 65 year old woman presented with radicular pain and paresthesias of the neck and right arm. PubMed search was used to compare her case to those previously published.

RESULTS

The cavernoma was successfully removed with excellent recovery and no deficits. Histopathology confirmed the diagnosis.

CONCLUSION

Gross total resection of symptomatic lesions continues to be the recommended approach, and resection outcomes have restored function in all cases but one, where the deficit persisted.

Intradural extramedullary cavernoma of a lumbar nerve root mimicking neurofibroma. A report of a rare case and the differential diagnosis

BACKGROUND CONTEXT

Intradural extramedullary (IDEM) cavernomas are rare vascular malformations. They are well-circumscribed dark berry-like lesions with a histologic appearance of sinusoidal vascular channels. Neurofibromas are the most common IDEM tumors, originating from all nerve elements and leading to firm enlargement of the affected nerve root. These lesions are completely different; however, they may involve the spinal nerve roots or the major nerve trunks. Any similarities in clinical findings are based on different pathophysiology.

PURPOSE

To present a rare resemblance of an IDEM cavernoma to a neurofibroma.

STUDY DESIGN

This is a case report with review of the literature focused on the differential diagnosis.

METHODS

A 79-year-old patient presented with acute sensorimotor disturbance from L2-S1 levels. The investigations showed an L2-L3 lesion occupying the canal. Findings resembled a neurofibroma and a surgical resection was decided.

RESULTS

The complete surgical resection revealed a vascular lesion originating from a nerve root. The histology confirmed an IDEM cavernoma. This is a unique case as such a clinical resemblance and a macroscopical appearance has not been reported for an IDEM cavernoma as yet. The patient showed full postoperative recovery from his initial symptoms.

CONCLUSIONS

Intradural extramedullary cavernoma is a rare cause of compression to spinal cord or nerve roots. Its manifestation characteristics are well defined and should always be part of the differential diagnosis. Intraoperative findings aid the diagnosis in nontypical cases before the final histology. The nontraumatic and nerve tissue sparing surgical resection warrants optimal postoperative results and excellent prognosis.

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.

Coexistence of multiple cavernous angiomas in the spinal cord and skin: a unique case of Cobb syndrome

Cobb syndrome is a rare, noninherited, neurocutaneous disease characterized by vascular abnormality of the spinal cord and is associated with vascular lesions in the skin at the same metamere. The majority of spinal vascular lesions are arteriovenous malformations, and skin lesions are mostly port-wine angiomas. The authors report the first case of multiple intramedullary cavernous angiomas (CAs) accompanied by skin CAs within the same metamere. A 42-year-old man presented with an acute onset of gait disturbance, low-back pain, and urinary incontinence. Magnetic resonance imaging of the thoracolumbar spine showed homogeneously enhanced lesions on a contrast-enhanced T1-weighted image and a hypointense area on a T2*-weighted image surrounding this enhanced lesion, between the T-12 and S-1 levels. Purple protruding skin lesions were detected on the left side of his gluteal region. The patient received a laminectomy followed by evacuation of a hematoma and partial removal of the tumor, which completely resolved his neurological symptoms. Pathological examinations showed that the spinal and skin lesions were CAs, suggesting that these vascular lesions developed congenitally. Cavernous angiomas associated with Cobb syndrome present with multiple lesions spanning more than 3 vertebral levels, making it difficult to completely resect these tumors. Although Cobb syndrome is an uncommon disease entity, it should be considered if a patient manifesting with neurological deficits has skin vascular lesions, including CAs.

Spinal intradural extramedullary cavernous angioma presenting with superficial siderosis and hydrocephalus: a case report and review of the literature

A 36-year-old man with progressive hearing impairment visited our hospital complaining of a severe headache. A neurological examination revealed bilateral sensorineural hearing impairment, mild ataxia, hyperreflexia and mild cognitive dysfunction. Brain MRI demonstrated hydrocephalus and typical hypointensity rimming the brain surface on T2(*)-weighted images. The patient was diagnosed as having superficial siderosis. Spinal MRI disclosed the presence of a lumbar intradural extramedullary mass. The surgically resected tumor was histologically found to be a cavernous angioma. Superficial siderosis is an important cause of hearing loss. With respect to the detection of disorders underlying this pathological condition, MRI examinations, including those of the brain and whole spinal cord, are recommended.

Use of microscope-integrated near-infrared indocyanine green videoangiography in the surgical treatment of intramedullary cavernous malformations: report of 8 cases

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.

Spinal and paraspinal giant cervical cavernous malformation with postpartum presentation

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.

Treatment strategies in cavernomas of the brain and spine

The management of brain and spinal cavernomas includes two main options: (i) conservative treatment or (ii) surgical removal. Clinical experience related to cavernoma patients falls into four major categories: the surgical or conservative treatment of incidental or symptomatic cavernomas. In many patients, cavernomas exist as fairly benign lesions, frequently remaining clinically silent for life. This observation argues against the active treatment of all cavernoma patients; rather for the meticulous selection of only those more likely to benefit from surgery. Thus, the most crucial task in successful management of cavernomas is appropriate patient selection. In this review, we present our institutional experience on cavernoma management supplemented with data from the literature.

Spinal intradural extramedullary cavernoma presenting with intracranial superficial hemosiderosis

A case of intradural extramedullary cavernous angioma is presented with headache, dizziness, and bilateral sensorineural hearing loss caused by an intracranial superficial hemosiderosis. It was incidentally found in a patient with a 3-month history of sustained headache, dizziness and a 3-year history of hearing difficulty. The neurological examination was unremarkable in the lower extremity. MR images showed an intracranial superficial hemosiderosis mostly in the cerebellar region. Myelography and MR images of the thoracolumbar spine revealed an intradural extramedullary mass, which was pathologically proven to be a cavernous angioma. T12 total laminoplastic laminotomy and total tumor removal were performed without any neurologic deficits. The patient's symptoms, including headache and dizziness, have been absent for three years. Intradural extramedullary cavernous angioma can present with an intracranial superficial hemosiderosis as a result of chronic subarachnoid hemorrhage.

Cauda equina cavernous angioma presenting as acute low back pain and sciatica. A report of two cases and literature review

Spinal cavernous angiomas are rare vascular lesions occurring mainly in the vertebral bodies extending secondary into the extradural space. Only 3% of these lesions are intradural, usually localized within the spinal cord. Rarely, cavernous angioma has been reported to occur in the cauda equina. We describe clinical, diagnostic imaging, and surgical procedures of two cases of cavernous angioma of the cauda equina who presented with acute back pain and sciatica. The relevant literature is also reviewed.

Outcome after microsurgery in 14 patients with spinal cavernomas and review of the literature

Object

Spinal cavernomas are rare, but can cause significant neurological deficits due to mass effect and extralesional hemorrhage. The authors present their results of microsurgical treatment of 14 consecutive patients with spinal cavernoma, and review the literature.

Methods

Of the 376 patients with cavernomas of the CNS treated at Helsinki University Central Hospital (a catchment area close to 2 million inhabitants) between January 1980 and June 2009, 14 (4%) had a spinal cavernoma. The authors reexamined and analyzed the patient files and images retrospectively. Median patient age at presentation was 45 years (range 20–57 years). The female/male ratio was equal. Median duration of symptoms before admission to the department was 12 months (range 0.1–168 months). Patients suffered from sensorimotor paresis, radicular pain, or neurogenic micturition disorders in different combinations or separately. Hemorrhage had occurred in 7 patients (50%) before surgery. In 9 patients (64%) the cavernoma was intramedullary, in 4 (29%) extradural, and in 1 intradural extramedullary. On MR imaging, 6 patients (43%) had a cavernoma in the cervical region, 7 (50%) in the thoracic region, and 1 (7%) in the lumbar region.

Results

Postoperatively, patients were followed up for a median of 3 years (range 1–10 years). At follow-up, 13 patients (93%) experienced significant improvement in motor ability after surgery, and all patients were able to walk with or without aid. Ten of the 11 patients with pain syndrome (91%) showed significant pain relief without recurrence. Micturition disorder was noted in 6 patients (43%) at follow-up, but in 5 the condition had existed before surgery. No patient improved in bladder function after surgery, and 1 patient developed micturition dysfunction postoperatively.

Conclusions

Microsurgical removal of spinal cavernomas alleviates sensorimotor deficits and pain caused by mass effect and hemorrhage. However, bladder dysfunction remains unchanged after surgery.

Intralesional hemorrhage and thrombosis without rupture in a pure spinal epidural cavernous angioma: a rare cause of acute lumbal radiculopathy

Pure spinal epidural cavernous angiomas are extremely rare lesions, and their normal shape is that of a fusiform mass in the dorsal aspects of the spinal canal. We report a case of a lumbo-sacral epidural cavernous vascular malformation presenting with acute onset of right-sided S1 radiculopathy. Clinical aspects, imaging, intraoperative findings, and histology are demonstrated. The patient, a 27-year-old man presented with acute onset of pain, paraesthesia, and numbness within the right leg corresponding to the S1 segment. An acute lumbosacral disc herniation was suspected, but MRI revealed a cystic lesion with the shape of a balloon, a fluid level and a thickened contrast-enhancing wall. Intraoperatively, a purple-blue tumor with fibrous adhesions was located between the right S1 and S2 nerve roots. Macroscopically, no signs of epidural bleedings could be denoted. After coagulation of a reticular venous feeder network and dissection of the adhesions the rubber ball-like lesion was resected in total. Histology revealed a prominent venous vessel with a pathologically thickened, amuscular wall surrounded by smaller, hyalinized, venous vessels arranged in a back-to-back position typical for the diagnosis of a cavernous angioma. Lumina were partially occluded by thrombi. The surrounding fibrotic tissue showed signs of recurrent bleedings. There was no obvious mass hemorrhage into the surrounding tissue. In this unique case, the pathologic mechanism was not the usual rupture of the cavernous angioma with subsequent intraspinal hemorrhage, but acute mass effect by intralesional bleedings and thrombosis with subsequent increase of volume leading to nerve root compression. Thus, even without a sudden intraspinal hemorrhage a spinal cavernous malformation can cause acute symptoms identical to the clinical features of a soft disc herniation.

Intraventricular cerebral cavernomas: a series of 12 patients and review of the literature

Object

Intraventricular cavernomas (IVCs) occur in only 2–10% of patients with cerebral cavernomas. Reports concerning IVC are scarce and are limited mostly to sporadic case reports. In this paper, the authors present a series of 12 patients with IVCs that were treated at a single neurosurgical department. In addition, the authors reviewed the literature.

Methods

All clinical data were analyzed retrospectively. Follow-up questionnaires were sent to all patients. Outcome was assessed using the Glasgow Outcome Scale. The authors also conducted a PubMed search and found 77 cases of IVC.

Results

The patients' median age was 47 years, and the male/female ratio was 2:1. A cavernoma occurred in the lateral ventricle in 6 patients, in another 5 it was in the fourth ventricle, and 1 had a lesion in the third ventricle. Almost all patients presented with acute headache on admission and in more than half, the symptoms were related to cavernoma bleeding. In total, 8 rebleedings occurred in 5 patients during a median of 0.4 years. Three patients with a cavernoma of the fourth ventricle presented with a cranial nerve deficit. In 8 cases, a cavernoma was surgically treated an average of 1.3 years after the diagnosis. Only 1 patient underwent surgery in the acute phase after a major intraventricular/intracerebral hemorrhage. The median follow-up time was 2 years. No patient was lost to follow-up, and no patient died. In total, on follow-up 9 patients improved and 3 had a persistent neurological deficit, of which 2 existed before surgery.

Conclusions

In the present series, the IVCs had a high tendency for rehemorrhage. Surgery is advocated when hemorrhages are frequent, and the mass effect causes progressive neurological deficits. Microsurgical removal of the IVC is safe, but in the fourth ventricle it can carry increased risk for cranial nerve deficits.