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

Lumbar Epidural Cavernous Hemangioma: A Case Report and Review of the Literature

Pure epidural cavernous hemangioma (ECH) of the spine are rare and account for only 4% of all epidural spinal lesions. We report a case of epidural cavernoma at L3/4 presenting with L4 radiculopathy. Radiological, intraoperative findings and histopathology are presented. We present the case of a 56-year-old man who was admitted with a right L4 radiculopathy including an M4 paresis of the right leg, hypoesthesia L4, and radicular pain. Magnetic resonance imaging (MRI) confirmed an extradural lesion L3/4 partially expanding into the right intervertebral foramen. The lesion had a heterogeneous signal, isointense on T1-weighted and hyperintense on proton density (PD) and T2-weighted images. At surgery, an epidural, ovoid, gray-red, soft mass, lightly adherent to the dura and extending to the right L4 foramen was observed. Findings in the histological examination indicated a cavernous hemangioma without signs of hemorrhage. Symptoms and paresis improved rapidly after surgery. The follow-up MRI showed complete resection of the lesion with no signs of radicular compression. Spinal ECH should be considered as a cause of chronic lumbar radiculopathy with atypical radiological findings. Early diagnosis and total removal of the spinal ECH might prevent hemorrhage and neurological deficits. Fewer than 50 cases of lumbar epidural spinal hemangioma have been reported until today, and our case report is adding valuable knowledge to the existing literature.

[Surgical treatment of spinal cord cavernous malformations]

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.

Epidural Hemangioma: A Clinical Series of Five Patients and Review of Literature for the Decade

Background

Since 1929, only 171 epidural hemangioma cases have been reported. We report five epidural hemangiomas and review cases reported over the past decade in terms of radiological features and clinical findings.

Methods

Among patients operated on for spinal tumors at our hospital between 2009 and 2020, five had epidural hemangiomas. We retrospectively examined patient records and images and reviewed relevant English literature in PubMed from 2009 to 2019. Eighty-seven epidural hemangioma cases were reported in the last 10 years.

Results

Among 87 cases, the average age was 49.58 years; 43 and 44 cases were male and female, respectively. The most common lesion level was thoracic (59.8%), while common symptoms were back pain (42.5%); numbness, hypoesthesia, or anesthesia (37.9%); paraparesis (34.5%); and radicular pain (20.7%). On magnetic resonance imaging (MRI), 77.1% showed hypo-isointensity on T1-weighted image (WI), hyperintensity on T2WI, and homogenous enhanced patterns with contrast. Total resection was performed in most cases, with good clinical outcomes. Preoperative embolization was performed in four cases, with good surgical outcomes. The median follow-up duration of postoperative MRI was 16 months, and no case had recurrence.

Conclusions

Epidural hemangiomas are extremely rare and may be difficult to diagnose preoperatively. They should be considered if a dumbbell-shaped or epidural hypervascular lesion is noted. The treatment of choice for epidural hemangioma is total resection, with most cases having good clinical outcomes. Preoperative embolization may be useful for reducing bleeding. Although there were almost no recurrences after resection, careful follow-up for longer periods is required.

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.

Pure spinal epidural cavernous hemangioma: A case series of seven cases

INTRODUCTION

Pure spinal epidural cavernous hemangiomas (PSECHs) are rare vascular lesions with about 100 cases reported. Herein, we present a case series of 7 PSECHs discussing their clinical presentation, radiological characteristics, surgical technique and intraoperative findings, pathological features, and functional outcome.

MATERIALS AND METHODS

We retrieved from the retrolective databases of the senior authors, patients with pathologically confirmed PSECH operated between January 2002 and November 2015. From their medical records, the patients' sociodemographic, clinical, radiological, surgical, and histopathological data were retrieved and analyzed.

RESULTS

The mean age of the seven cases was 50.3 years. Four were females. All the five cases (71.4%) in the thoracic spine had myelopathy and the 2 (28.6%) lumbar cases had sciatica. Local pain was present in all the cases. All the lesions were isointense on T1-weighted images, hyperintense on T2-weighted images, and in five cases there was strong homogeneous enhancement. In six cases (85.7%), classical laminectomy was done; lesions resected in one piece in five cases. Total excision was achieved in all the cases. Lesions were thin-walled dilated blood vessels, lined with endothelium, and engorged with blood and with scanty loose fibrous stroma. The median follow-up was 12 months (range: 1-144 months). All patients gradually improved neurologically and achieved a good outcome with no recurrence at the last follow-up.

CONCLUSION

PSECH although rare is increasing reported and ought to be included in the differential diagnosis of spinal epidural lesions. Early surgical treatment with total resection is recommended as would result in a good prognosis.

Primary spinal epidural cavernous hemangioma: clinical features and surgical outcome in 14 cases

OBJECT

The aim of this study was to investigate the clinical characteristics, imaging features, differential diagnosis, treatment options, and prognosis for primary spinal epidural cavernous hemangiomas.

METHODS

Fourteen patients with pathologically diagnosed non-vertebral origin cavernous hemangiomas who had undergone surgery at Beijing Tiantan Hospital between 2003 and 2012 were identified in the hospital's database. The patients' clinical data, imaging characteristics, surgical treatment, and postoperative follow-up were analyzed retrospectively.

RESULTS

There were 9 males and 5 females with an average age of 51.64 years. The primary epidural cavernous hemangiomas were located in the cervical spine (2 cases), cervicothoracic junction (2 cases), thoracic spine (8 cases), thoracolumbar junction (1 case), and lumbar spine (1 case). Hemorrhage was confirmed in 4 cases during surgery. Preoperatively 5 lesions were misdiagnosed as schwannoma, 1 was misdiagnosed as a meningioma, and 1 was misdiagnosed as an arachnoid cyst. Preoperative hemorrhages were identified in 2 cases. Three patients had recurrent cavernous hemangiomas. The initial presenting symptoms were local pain in 5 cases, radiculopathy in 6 cases, and myelopathy in 3 cases. Upon admission, 1 patient had radicular symptoms and 13 had myelopathic symptoms. The average symptom duration was 18 months. All patients underwent surgery; complete resection was achieved in 8 cases, subtotal resection in 4 cases, and partial resection in 2 cases. Postoperative follow-up was completed in 10 cases (average follow-up 34 months); 1 patient died, 5 patients showed clinical improvement, and 4 patients remained neurologically unchanged.

CONCLUSIONS

Total surgical removal of spine epidural cavernous hemangiomas with a chronic course is the optimum treatment and carries a good prognosis. Secondary surgery for recurrent epidural cavernous hemangioma is technically more challenging. In patients with profound myelopathy from acute hemorrhage, even prompt surgical decompression can rarely reverse all symptoms.

Pure spinal epidural cavernous hemangioma with intralesional hemorrhage: a rare cause of thoracic myelopathy

Although cavernous hemangiomas occur frequently in the intracranial structures, they are rare in the spine. Most of spinal hemangiomas are vertebral origin and "pure" epidural hemangiomas not originating from the vertebral bone are very rare. Our spinal hemangioma case is extremely rare because of its "pure" epidural involvement and intralesional hemorrhage. A 64-year-old man presented with progressive paraparesis from two months ago. His motor weakness was rated as grade 4/5 in bilateral lower extremities. He also complained of decreased sensation below the T4 sensory dermatome, which continuously progressed to the higher dermatome level. Magnetic resonance imaging demonstrated thoracic spinal tumor at T3-T4 level. The tumor was located epidural space compressing thoracic spinal cord ventrally. The tumor was not involved with the thoracic vertebral bone. We performed T3-5 laminectomy and removed the tumor completely. The tumor was not infiltrating into intradural space or vertebral bone. The histopathologic study confirmed the epidural tumor as cavernous hemangioma. Postoperatively, his weakness improved gradually. Four months later, his paraparesis recovered completely. Here, we present a case of pure spinal epidural cavernous hemangioma, which has intralesional hemorrhage. We believe cavernous hemangioma should be included in the differential diagnosis of the spinal epidural tumors.

Thoracic extraosseous, epidural, cavernous hemangioma: Case report and review of literature

A 40-year-old male presented with mid-thoracic backache and progressive, ascending, spastic, paraparesis for one year. Magnetic resonance imaging demonstrated an extraosseous, extradural mass, without any bone invasion at the T2-T4 vertebral levels, located dorsal to the thecal sac. The spinal cord was compressed ventrally. The lesion was totally excised after a T2-T4 laminectomy. Histopathological examination revealed a cavernous hemangioma. The authors reported this case and reviewed the literature, to explain why extraosseous, extradural, cavernous hemangiomas should be considered in the differential diagnosis of extradural thoracic compressive myelopathy.

Clinical and radiological presentation of spinal epidural haemangiomas: clinical series in a tertiary care centre during a 10-year period

PURPOSE

Haemangiomas are very frequent benign spinal tumours. However, pure epidural location is extremely rare. At present, only 52 cases have been reported in the literature during the last 10 years. We proposed to analyse clinical and radiological features of this rare entity treated in a tertiary care centre over the last 10 years.

METHODS

A study of a retrospective surgical series (2002-2012) was conducted. The clinic's electronic database was searched for "spinal" and/or "vertebral haemangiomas", which were treated by surgery and/or vertebroplasty. Clinical, radiological and histopathological data were analysed.

RESULTS

In total, the series comprised 30 spinal haemangiomas. There were 6 epidural (20 %), 17 vertebral (57 %) and 7 intradural lesions (23 %). There were four men and two women, mean age 28.3 years, with epidural lesions. One patient presented with localised back pain only, two with radiculopathy and focal neurological deficit, two with radiculopathy only and one with isolated focal neurological deficit, respectively. The onset of symptoms was progressive in four cases over weeks to months and sudden in two cases. Preoperative MRI imaging revealed features of meningioma, neurinoma or metastasis.

CONCLUSION

Epidural haemangiomas are extremely rare spinal lesions. They may mimic more common spinal tumours clinically and radiologically. The usual treatment is gross total resection confirming the diagnosis histologically.

Solitary spinal epidural cavernous angioma: report of nine surgically treated cases and review of the literature

PURPOSE

We intend to report the largest series of spinal epidural cavernomas (SEC), discuss their clinical features, imaging characteristics, surgical findings, outcome analysis and compare them with similar reports in the literature.

METHODS

Among the cases of spinal tumors treated surgically by the authors, there have been nine cases of SEC's. All the data were collected prospectively and the cases have been followed after surgery up to the time of this analysis.

RESULTS

There were six female and three male patients with the ages ranging between 13 and 74 years. The lesions were located in the thoracic spine (4 cases), lumbar spine (4 cases) and one at the sacral level. Clinical presentations included acute spinal pain and paraparesis in two, low back pain and radiculopathy in five, and slowly progressive myelopathy in the other two cases. The lesion was iso-intense with the spinal cord in T1W images and hyperintense in T2W images and showed strong homogeneous enhancement after contrast medium injection in most of our cases. In the presence of hemorrhage inside the lesion, it was hyperintense in both T1W and T2W MR sequences as in our case 6. In the single case presenting with acute hemorrhage, epidural hematoma was the only finding, our case 1. Complete surgical removal was achieved in all our cases, and confirmed by postoperative MRI.

CONCLUSION

SEC is hard to be differentiated from other epidural spinal lesions before intervention but should be considered in the list of differential diagnosis regarding its favorable outcome.

Pure spinal epidural cavernous hemangioma

BACKGROUND

Pure epidural cavernous hemangiomas without bony involvement are rare, representing 4% of all spinal epidural tumors. Most of these are case reports and are easily misdiagnosed.

METHODS

Herein nine patients (male:female, 5:4, average age: 51 years) with symptomatic pure epidural spinal cavernous hemangioma between 2005 and 2011 were treated, and the clinical, radiological, and pathological records, treatment, and prognosis were discussed.

RESULTS

All patients experienced a slowing progressive clinical course, except for one with intralesional hemorrhage. Clinical manifestations included back or radiating pain, sensorimotor deficits, and sphincters disturbance. Eight lesions were isointense on T1- and hyperintense on T2-weighted images with homogenously strongly enhancement and one was mixed signal with heterogeneous enhancement because of intratumoral hemorrhage. Hemilaminotomoy or laminotomy was performed and total resection was achieved. All patients experienced a gradual neurological improvement with no recurrence.

CONCLUSIONS

Spinal epidural cavernous hemangioma is a benign vascular malformation that should be excluded in the diagnosis of epidural lesion. Total surgical resection is recommended and usually results in a good prognosis.