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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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Sakashita K, Koda M, Takahashi H, Funayama T, Yamazaki M. Acute Neurological Aggravation Caused by Intratumoral Hemorrhage of a Cervical Dumbbell Schwannoma: Report of a Rare Case and Literature Review. Cureus 2023; 15:e34682. [PMID: 36909029 PMCID: PMC9994380 DOI: 10.7759/cureus.34682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2023] [Indexed: 02/09/2023] Open
Abstract
Schwannomas are one of the most common types of primary intraspinal tumors. We report a rare case of neurological aggravation due to the intratumoral hemorrhage of a cervical schwannoma. A 65-year-old man presented with lower extremity weakness developing gradually. Tumor resection was performed one week after neurological aggravation occurred. After surgery, he recovered dramatically. There are vascular and mechanical hypotheses for the etiology of intratumoral hemorrhage of schwannoma. In the present case, falling and antiplatelet drugs may have caused the intratumoral hemorrhage. Optimal surgical timing remains controversial. Some reports reveal patients recovered well after urgent surgery. However, even if urgent surgery is performed, some have neurological sequelae. Others reveal patients recovered well after elective surgery without any sequelae. Because previous reports reveal the surgical procedure may damage the spinal cord, urgent surgery may not be compulsory and elective surgery may be a better treatment option. Further investigation is needed to clarify the etiology and optimal timing for surgical treatment of intratumoral hemorrhage.
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Affiliation(s)
- Kotaro Sakashita
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, JPN
| | - Masao Koda
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, JPN
| | - Hiroshi Takahashi
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, JPN
| | - Toru Funayama
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, JPN
| | - Masashi Yamazaki
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, JPN
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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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Intradural Extramedullary Cavernous Malformation of the Spinal Cord with Hemorrhagic Transformation and Rapid Expansion. Case Rep Neurol Med 2022; 2022:8677298. [PMID: 35992225 PMCID: PMC9391149 DOI: 10.1155/2022/8677298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 07/30/2022] [Indexed: 11/18/2022] Open
Abstract
Intradural extramedullary cavernous malformations in the spinal cord are rarely occurring vascular lesions. Mostly they are clinically silent unless the hemorrhagic transformation causes subarachnoid hemorrhage or neurologic deficits. We report the case of a 51-year-old man who developed a headache and weakness of the lower limb. Spinal cord magnetic resonance imaging revealed that the cause of his symptoms was a spinal intradural and extramedullary cavernous malformation with hemorrhagic transformation causing subarachnoid hemorrhage and compression of the thoracic spinal cord. Surgical decompression of the spinal cord followed by the resection of the lesion resulted in significant neurological improvement. Early diagnosis and early surgical extirpation of the lesion should be done to prevent recurrent hemorrhagic transformation and development of neurological symptoms.
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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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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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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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Lotfinia I, Mahdkhah A. Spinal epidural cavernous hemangioma of spine, a case report and review of literature. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2020.101071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Fotakopoulos G, Kivelev J, Andrade-Barazarte H, Tjahjadi M, Goehre F, Hernesniemi J. Outcome in Patients with Spinal Cavernomas Presenting with Symptoms Due to Mass Effect and/or Hemorrhage: Conservative versus Surgical Management: Meta-analysis of Direct Comparison of Approach-Related Complications. World Neurosurg 2021; 152:6-18. [PMID: 34062296 DOI: 10.1016/j.wneu.2021.05.094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/20/2021] [Accepted: 05/21/2021] [Indexed: 01/11/2023]
Abstract
OBJECTIVE We sought to examine the conservative treatment of symptomatic spinal cavernomas and evaluate the efficacy and safety of surgical management of spinal cord cavernous malformations. METHODS This meta-analysis included articles comparing outcomes of conservative treatment and surgical management of spinal cavernomas, published in the full-text form (from 2000 to June 31, 2020). Collected variables included first author name, country, covered study period, publication year, the total number of patients and at follow-up, bleeding, motor weakness, pain, bladder and/or bowel dysfunction neurologic improvement or deterioration after discharge, and the need for reintervention after subtotal surgical resection or hemorrhage. RESULTS After the initial searching and applying all exclusion and inclusion criteria, there were 9 articles left in the final article pool. The total number of patients was 396 with 264 (66.6%) undergoing surgical resection and 132 (33.4%) electing conservative management. Regarding motor weakness, bladder/bowel dysfunction, deterioration, and reintervention, the final results demonstrated no potential significant difference between the 2 groups. In regard to the subgroup of patients with bleeding, improvement, and pain, the results of the analysis showed a statistically significant difference between the 2 groups. CONCLUSIONS Patients who have experienced a hemorrhagic episode should consider surgical intervention, which decreases the risk of recurrent hemorrhage and further neurologic deterioration. In addition, surgical decompression obtained by resection of the hemorrhage and cavernoma seems to lead to slight neurologic improvement in some patients. In nonhemorrhagic cavernomas, conservative treatment might be optimal due to surgery-related morbidity risks.
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Affiliation(s)
- George Fotakopoulos
- Department of Neurosurgery, University Hospital of Thessaly, University Hospital of Larissa, Biopolis, Thessaly, Greece.
| | - Juri Kivelev
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland
| | - Hugo Andrade-Barazarte
- International Center for Neurosurgery, Henan Provincial People's Hospital, Zhengzhou, China
| | - Mardjono Tjahjadi
- Department of Surgery, Faculty of Medicine, Atma Jaya Catholic University of Medicine, Jakarta, Indonesia
| | - Felix Goehre
- Department of Neurosurgery, Stroke Center, Bergmannstrost Hospital Halle, Halle, Germany
| | - Juha Hernesniemi
- International Center for Neurosurgery, Henan Provincial People's Hospital, Zhengzhou, China
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Ohnishi YI, Nakajima N, Takenaka T, Fujiwara S, Miura S, Terada E, Yamada S, Kishima H. Conservative and Surgical Management of Spinal Cord Cavernous Malformations. World Neurosurg X 2019; 5:100066. [PMID: 31891154 PMCID: PMC6931213 DOI: 10.1016/j.wnsx.2019.100066] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 11/06/2019] [Indexed: 12/01/2022] Open
Abstract
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.
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Affiliation(s)
- Yu-Ichiro Ohnishi
- Department of Neurosurgery, Osaka University Medical School, Suita, Osaka, Japan
| | - Nobuhiko Nakajima
- Department of Neurosurgery, Osaka University Medical School, Suita, Osaka, Japan
| | - Tomofumi Takenaka
- Department of Neurosurgery, Osaka University Medical School, Suita, Osaka, Japan
| | - Sho Fujiwara
- Department of Neurosurgery, Osaka University Medical School, Suita, Osaka, Japan
| | - Shinpei Miura
- Department of Neurosurgery, Osaka University Medical School, Suita, Osaka, Japan
| | - Eisaku Terada
- Department of Neurosurgery, Osaka University Medical School, Suita, Osaka, Japan
| | - Shuhei Yamada
- Department of Neurosurgery, Osaka University Medical School, Suita, Osaka, Japan
| | - Haruhiko Kishima
- Department of Neurosurgery, Osaka University Medical School, Suita, Osaka, Japan
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12
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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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13
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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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14
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Kiyofuji S, Graffeo CS, Yokoyama M, Sora S. Intramedullary and intratumoral hemorrhage in spinal hemangioblastoma: Case report and review of literature. Surg Neurol Int 2018; 9:250. [PMID: 30603234 PMCID: PMC6293603 DOI: 10.4103/sni.sni_344_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 10/31/2018] [Indexed: 12/26/2022] Open
Abstract
Background: Intramedullary hemorrhages involving spinal hemangioblastomas are rare. They are frequently associated with devastating neurologic outcomes, despite with emergent surgical intervention. Here, we presented an example of an intramedullary hemorrhage occurring in a spinal hemangioblastoma, where the patient markedly improved with surgery. Additionally, the appropriate literature was reviewed (including intraoperative video). Case Description: A 49-year-old female with a 4-year history of tingling in the left lower extremity presented with vomiting, stepwise worsening of bilateral scapular pain, new upper motor neuron signs, and severe sensory loss bilaterally below C4 on the left and T4 on the right. The magnetic resonance imaging demonstrated a well-circumscribed, uniformly enhancing intramedullary tumor at the C2 level with hyperintensity on the T2 study consistent with acute hemorrhage and cord edema. An urgent C2 laminectomy was performed for gross total tumor resection. Intraoperatively, intramedullary hemorrhage was identified anterior to the tumor mass and was confirmed histopathologically. Postoperatively, the patient had no new sensorimotor deficits and fully recovered within two postoperative months. Conclusions: Patients presenting with acute intramedullary hemorrhage within hemangioblastomas of the spinal cord may demonstrate significant postoperative neurological recovery.
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Affiliation(s)
- Satoshi Kiyofuji
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA.,Department of Neurosurgery, Tokyo Metropolitan Police Hospital, Tokyo, Japan
| | | | - Munehiro Yokoyama
- Department of Pathology, Tokyo Metropolitan Police Hospital, Tokyo, Japan
| | - Shigeo Sora
- Department of Neurosurgery, Tokyo Metropolitan Police Hospital, Tokyo, Japan
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15
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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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16
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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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17
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Natural history of intramedullary spinal cord ependymoma in patients preferring nonoperative treatment. J Neurooncol 2017; 135:93-98. [DOI: 10.1007/s11060-017-2552-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 06/27/2017] [Indexed: 10/19/2022]
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18
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Imagama S, Ito Z, Ando K, Kobayashi K, Hida T, Ito K, Tsushima M, Ishikawa Y, Matsumoto A, Morozumi M, Tanaka S, Machino M, Ota K, Nakashima H, Wakao N, Sakai Y, Matsuyama Y, Ishiguro N. Optimal Timing of Surgery for Intramedullary Cavernous Hemangioma of the Spinal Cord in Relation to Preoperative Motor Paresis, Disease Duration, and Tumor Volume and Location. Global Spine J 2017; 7:246-253. [PMID: 28660107 PMCID: PMC5476360 DOI: 10.1177/2192568217707938] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Prospective study. OBJECTIVE Investigate factors associated with preoperative motor paresis, recovery, ambulatory status, and intraoperative neurophysiological monitoring (IONM) among patients with no preoperative paresis (N group), complete preoperative motor recovery (CR group), and no complete recovery (NCR group) in patients with intramedullary spinal cavernous hemangioma to determine the optimal timing of surgery. METHODS The study evaluated 41 surgical cases in our institute. Disease duration, tumor lesion, manual muscle testing (MMT), and gait at onset, just before surgery, and final follow-up (FU), tumor and lesion volume, IONM, extent of tumor resection, and tumor recurrence were evaluated among N, CR, and NCR groups. RESULTS Motor paresis at onset was found in 26 patients (63%), with 42% of those in CR group. Disease duration from onset negatively affected stable gait just before surgery and FU as well as lower preoperative MMT (P < .05). Thoracic tumors were associated with patients with unstable gait before surgery (P < .05). Tumor volume was larger in NCR group (P < .05). IONM significantly decreased in NCR and CR groups than in N group (P < .05). The NCR group had residual mild motor paresis at FU (P < .05). Stable gait at FU was similar in N group and CR group, though lower in NCR group (P < .05). CONCLUSIONS Early surgery is generally recommended for thoracic tumors and large tumors during stable gait without motor paresis before long disease duration. Surgery may be postponed until patients recover from preoperative motor paresis to allow optimal surgical outcome. IONM should be carefully monitored in patients with a history of preoperative paresis even with preoperative complete motor recovery.
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Affiliation(s)
- Shiro Imagama
- Department of Orthopaedic Surgery, Nagoya University, Nagoya, Aichi, Japan,Shiro Imagama, Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65, Tsurumai, Showa-ku, Nagoya, Aichi 466-8550, Japan.
| | - Zenya Ito
- Department of Orthopaedic Surgery, Nagoya University, Nagoya, Aichi, Japan
| | - Kei Ando
- Department of Orthopaedic Surgery, Nagoya University, Nagoya, Aichi, Japan
| | | | - Tetsuro Hida
- Department of Orthopaedic Surgery, Nagoya University, Nagoya, Aichi, Japan
| | - Kenyu Ito
- Department of Orthopaedic Surgery, Nagoya University, Nagoya, Aichi, Japan
| | - Mikito Tsushima
- Department of Orthopaedic Surgery, Nagoya University, Nagoya, Aichi, Japan
| | - Yoshimoto Ishikawa
- Department of Orthopaedic Surgery, Nagoya University, Nagoya, Aichi, Japan
| | - Akiyuki Matsumoto
- Department of Orthopaedic Surgery, Nagoya University, Nagoya, Aichi, Japan
| | - Masayoshi Morozumi
- Department of Orthopaedic Surgery, Nagoya University, Nagoya, Aichi, Japan
| | - Satoshi Tanaka
- Department of Orthopaedic Surgery, Nagoya University, Nagoya, Aichi, Japan
| | - Masaaki Machino
- Department of Orthopaedic Surgery, Nagoya University, Nagoya, Aichi, Japan
| | - Kyotaro Ota
- Department of Orthopaedic Surgery, Nagoya University, Nagoya, Aichi, Japan
| | - Hiroaki Nakashima
- Department of Orthopaedic Surgery, Nagoya University, Nagoya, Aichi, Japan
| | - Norimitsu Wakao
- Department of Orthopaedic Surgery, Aichi Medical University, Aichigun, Aichi-ken, Japan
| | - Yoshihito Sakai
- Department of Orthopaedic Surgery, National Center for Geriatrics and Gerontology, Obu, Aichi, Japan
| | - Yukihiro Matsuyama
- Department of Orthopaedic Surgery, Hamamatsu University, Hamamatsu, Shizuoka, Japan
| | - Naoki Ishiguro
- Department of Orthopaedic Surgery, Nagoya University, Nagoya, Aichi, Japan
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19
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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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20
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Jain VK, Kumar S, Singh RK, Netam SS, Jain SG, Shah PJ. “Spinal intramedullary cavernous venous malformation”: A dormant volcano. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2016. [DOI: 10.1016/j.ejrnm.2015.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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21
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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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22
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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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Koda M, Mannoji C, Itabashi T, Kita T, Murakami M, Yamazaki M, Aramomi M, Ikeda O, Furuya T. Intramedullary hemorrhage caused by spinal cord hemangioblastoma: a case report. BMC Res Notes 2014; 7:823. [PMID: 25409856 PMCID: PMC4289217 DOI: 10.1186/1756-0500-7-823] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 11/11/2014] [Indexed: 11/10/2022] Open
Abstract
Background Hemorrhage caused by spinal cord hemangioblastoma is rare, usually presenting as a subarachnoid hemorrhage. Intramedullary hemorrhage is an extremely rare manifestation of spinal cord hemangioblastoma. Case presentation Forty-year-old Japanese male patient presented with acute paraplegia. Magnetic resonance (MR) imaging of the spinal cord revealed intramedullary hemorrhage. An intramedullary mass lesion was detected at the 8th thoracic vertebral level (T8) in a gadolinium enhanced-MR image. Spinal angiography revealed an intramedullary tumor stain at the level of T8. Therefore we diagnosed the problem as intramedullary hemorrhage caused by the hemangioblastoma. One month after the onset, extirpation of the intramedullary hemangioblastoma was performed. The tumor was completely removed. Pathological findings revealed a typical hemangioblastoma. At his final follow-up visit, the patient showed no apparent neurological recovery. Conclusion Hemangioblastoma can be a cause of intramedullary hemorrhage should be considered in such cases.
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Affiliation(s)
- Masao Koda
- Department of Orthopedic Surgery, Chiba Aoba Municipal Hospital, 1-8-1, Inohana, Chuo-K, Chiba 260-8670, Japan.
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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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Kim KM, Chung CK, Huh W, Lee WJ, Park SB, Kim CH, Kim KJ, Jahng TA. Clinical outcomes of conservative management of spinal cord cavernous angiomas. Acta Neurochir (Wien) 2013; 155:1209-14. [PMID: 23709003 DOI: 10.1007/s00701-013-1760-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Accepted: 05/07/2013] [Indexed: 11/24/2022]
Abstract
BACKGROUND There have been numerous studies on the outcomes of surgery for spinal cord cavernous angiomas. However, the natural history of conservatively treated disease is not well known. The aim of this retrospective study was to investigate the outcomes of conservatively managed patients with spinal cord cavernous angioma to determine the appropriate treatment strategies. METHODS Twenty-four patients who visited a single institution over an 11-year period and who were treated conservatively were enrolled in this study. Their medical records and radiological images were reviewed retrospectively. The neurologic status of the patients was assessed using the Japanese Orthopedic Association scoring system and the clinical presentation of the patients was classified into the following 4 categories: type A, asymptomatic; B, pain only; C, sensory deficits; and D, sensory and motor deficits. The results of types C and D patients were compared with the results of previously reported surgical series from our institution. RESULTS The mean age of the enrolled patients was 52.0 years (21-73). The mean duration of the clinical follow-up was 60.5 months (11-119) and the follow-up using magnetic resonance imaging was 52.4 months (3-122). Cavernous angiomas presented in the cervical spinal cord in 12 patients, thoracic spinal cord in 10 patients and in multiple levels of the spinal cord in 2 patients. There were 5, 5, 7, and 7 patients, respectively, classified with types A, B, C, and D for clinical presentations. The rate of recurrent hemorrhage was 1.7 %/patient-year and all recurrent hemorrhages only developed in type C or D patients. In types C and D patients, improvement in the JOA score during the follow-up period was 0.77 ± 1.8 in the conservative group and 1.07 ± 1.8 in the surgical group (p = 0.500). However, improvement in the JOA sensory score after surgical treatment was statistically significant (P = 0.007). CONCLUSIONS Conservative treatment may be a reasonable treatment strategy for patients with types A and B. If patients present with type C or D, surgical treatment is recommended considering the better improvements in sensory deficits and the high rate of recurrent hemorrhage in such patients.
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Affiliation(s)
- Kang Min Kim
- Department of Neurosurgery, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Republic of Korea
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Klekamp J. Treatment of intramedullary tumors: analysis of surgical morbidity and long-term results. J Neurosurg Spine 2013; 19:12-26. [DOI: 10.3171/2013.3.spine121063] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Object
Surgery of intramedullary tumors is established as the treatment of choice for these challenging lesions. This study presents a detailed analysis of risk factors for surgical morbidity and data on long-term results for intramedullary tumors.
Methods
Among 1317 patients with tumors of the spinal canal treated between 1980 and 2012, 278 patients with intramedullary tumors are presented. A total of 225 of these patients underwent 246 operations for treatment of 250 tumors. The mean patient age was 41 ± 17 years (range 3 weeks to 83 years). Patients underwent follow-up through outpatient visits and questionnaires with a mean follow-up of 41 ± 53 months. Tumors were subdivided into 3 groups: displacing tumors (Type A, n = 162), infiltrating tumors (Type B, n = 80), and nonproliferating tumors (Type C, n = 8). A gross-total resection (GTR) was attempted for every tumor except for Type C lipomas. Participating surgeons were divided into 3 groups according to the number of operations they performed. Short-term results were determined for individual symptoms and the modified McCormick Scale, whereas tumor recurrence rates were calculated with Kaplan-Meier statistics.
Results
Overall, 83.3% of Type A tumors underwent GTR compared with 22.5% of Type B and none in Type C. Gross-total resection rates increased throughout the study period and correlated significantly with surgical experience. A worsened neurological state after surgery was seen in 61% of patients. This deterioration was transient in 41.5% and was a common observation after GTR. Permanent morbidity (19.5%) was lowest after GTR and correlated significantly with surgical experience and the preoperative neurological state. Further analysis showed that patients with tumors of thoracic levels, tumor hemorrhages, and malignant and recurrent tumors were at a higher risk for permanent morbidity. In the long term, tumor recurrence rates for ependymomas and benign astrocytomas correlated significantly with the amount of resection. Long-term morbidity affected 3.7% with a postoperative myelopathy related to cord tethering at the level of surgery and 21.9% in form of neuropathic pain syndromes. The rate of postsurgical cord tethering could be lowered significantly by using pia sutures after tumor resection. Neuropathic pain syndromes were more common after surgery for tumors with associated syringomyelia or those located in the cervical cord.
Conclusions
Intramedullary tumors should be surgically treated as soon as neurological symptoms appear. Gross-total resection is possible for the majority of benign pathologies. Cervical tumors are associated with higher GTR and lower permanent morbidity rates compared with thoracic tumors. Surgery on intramedullary tumors should be performed by neurosurgeons who deal with these lesions on a regular basis as considerable experience is required to achieve high GTR rates and to limit rates of permanent morbidity.
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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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Eicker SO, Szelényi A, Mathys C, Steiger HJ, Hänggi D. Custom-tailored minimally invasive partial C2-corpectomy for ventrally located intramedullary cavernous malformation. Neurosurg Rev 2013; 36:487-91. [DOI: 10.1007/s10143-013-0457-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Revised: 01/08/2013] [Accepted: 01/13/2013] [Indexed: 10/27/2022]
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Maslehaty H, Barth H, Petridis AK, Doukas A, Mehdorn HM. Symptomatic spinal cavernous malformations: indication for microsurgical treatment and outcome. 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 2011; 20:1765-70. [PMID: 21755413 DOI: 10.1007/s00586-011-1898-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2011] [Accepted: 06/28/2011] [Indexed: 11/30/2022]
Abstract
PURPOSE We demonstrate clinical features, therapy and outcome of 14 patients with symptomatic spinal cavernous malformations (CM). METHODS We retrospectively reviewed all patients who underwent microsurgical treatment of symptomatic spinal CM during the last decade in our department through an analysis of our database. RESULTS We analyzed the data of 14 patients (11 females, 3 males) with symptomatic spinal CM in a range of 16-77 years (mean age 47.8 years). Seven patients (50%) experienced significant improvement of their symptoms rapidly after surgery. The remaining seven patients presented new non pre-existing complaints, which improved gradually with a favourable outcome at the last follow-up examination in six cases. CONCLUSION Microsurgical treatment under perioperative electrophysiological monitoring is justified to prevent severe neurofunctional deterioration in symptomatic spinal CM. Although some of the patients deteriorate after surgery, the symptoms are rapidly declining with a favourable outcome in majority of them.
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Affiliation(s)
- Homajoun Maslehaty
- Department of Neurosurgery, Klinik für Neurochirurgie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, 24105 Kiel, Germany.
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