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Arai N, Abe H, Hiraoka T, Hanayama K. A Case of Spinal Cavernous Hemangioma with Rapidly Worsening Neurological Symptoms after COVID-19 Infection. Prog Rehabil Med 2024; 9:20240027. [PMID: 39211535 PMCID: PMC11350290 DOI: 10.2490/prm.20240027] [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: 07/08/2024] [Accepted: 08/15/2024] [Indexed: 09/04/2024] Open
Abstract
Background : COVID-19 can cause respiratory symptoms, as well as various complications and sequelae. This report describes a patient with worsening neurological symptoms caused by a spinal cavernous hemangioma after infection with COVID-19. Cavernous hemangioma usually occurs in the upper part of the brain (70%-90%) and rarely occurs in the spinal cord (5%-7%). Approximately 65% of cases of intramedullary spinal cavernous hemangioma present with neurological symptoms, and more than half of these cases show a slow worsening of symptoms. This is a rare case of intramedullary spinal cavernous hemangioma with cysto-rectal involvement in which neurological symptoms rapidly worsened following COVID-19 infection. Case : A woman in her 30s was admitted to the hospital because of the sudden onset of muscle weakness in both lower limbs and cysto-rectal disturbances after COVID-19 infection. She was diagnosed with a hemorrhage from a spinal cord tumor and underwent emergency resection. The pathological diagnosis was a spinal cavernous hemangioma. At first, she had a spinal cord injury (third thoracic vertebrae; American Spinal Injury Association Impairment Scale, C; Frankel classification, B; with cysto-rectal impairment), but 2 months later, she started walking with knee-ankle-foot orthoses and parallel bars. After 3 months, she could move independently around the ward using a wheelchair. Upon discharge, the patient could walk with ankle-foot orthoses and Lofstrand crutches. Discussion : COVID-19 is associated with various extrapulmonary manifestations and may increase the risk of hemorrhage in cases of intramedullary spinal cavernous hemangioma.
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Affiliation(s)
- Nobuyuki Arai
- Department of Rehabilitation Medicine, Kawasaki Medical
School, Kurashiki, Japan
| | - Hiromasa Abe
- Department of Rehabilitation Medicine, Kawasaki Medical
School, Kurashiki, Japan
| | - Takashi Hiraoka
- Department of Rehabilitation Medicine, Kawasaki Medical
School, Kurashiki, Japan
| | - Kozo Hanayama
- Department of Rehabilitation Medicine, Kawasaki Medical
School, Kurashiki, Japan
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Tian A, Cui Z, Ren J, Ren Y, Ye M, Li G, He C, Li X, Zeng G, Hu P, Ma Y, Yu J, Li J, Bian L, Yang F, Li Q, Ling F, Hong T, Sun L, Zhang H. Surgical timing and long-term outcomes in patients with severe haemorrhagic spinal cord cavernous malformations. Stroke Vasc Neurol 2024; 9:439-445. [PMID: 37949480 PMCID: PMC11420913 DOI: 10.1136/svn-2023-002745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/07/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Surgical resection of the lesions remains the main treatment method for most symptomatic spinal cord cavernous malformations (SCCMs) to eliminate the occupation and associated subsequent lifelong haemorrhagic risk. However, the timing of surgical intervention remains controversial, especially for patients in the acute stage after severe haemorrhage. METHODS Patients diagnosed with SCCMs who were surgically treated between January 2002 and December 2021 were selected and retrospectively reviewed. The Modified McCormick Scale (MMS) was used to evaluate neurological and disability status. All medical information was reviewed, and all patients were followed up for at least 6 months. RESULTS A total of 279 patients were ultimately included. With regard to long-term outcomes, 110 (39.4%) patients improved, 159 (57.0%) remained unchanged and 10 (3.6%) worsened. For patients with an MMS score of 2-5 on admission, in univariate and multivariate analyses, a ≤6 weeks period between onset and surgery (adjusted OR 3.211, 95% CI 1.504 to 6.856, p=0.003) was a significant predictor of improved MMS. Among 69 patients who first presented with severe haemorrhage, undergoing surgery within 6 weeks of the onset of severe haemorrhage (adjusted OR 4.901, 95% CI 1.126 to 21.325, p=0.034) was significantly associated with improvement of MMS score. CONCLUSION Surgical timing can influence the long-term outcome of SCCMs. For patients with symptomatic SCCMs, especially those with severe haemorrhage, early surgical intervention within 6 weeks can provide more benefit.
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Affiliation(s)
- An Tian
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Ziwei Cui
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Jian Ren
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Yeqing Ren
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Ming Ye
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Guilin Li
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Chuan He
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Xiaoyu Li
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Gao Zeng
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Peng Hu
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Yongjie Ma
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Jiaxing Yu
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Jingwei Li
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Lisong Bian
- Department of Neurosurgery, Beijing Haidian Hospital, Beijing, China
| | - Fan Yang
- Department of Neurosurgery, United Family Healthcare, Beijing, China
| | - Qianwen Li
- Department of Radiology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Feng Ling
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Tao Hong
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Liyong Sun
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
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Kasriel E, Boecher-Schwarz H, Scalais E. Abdominal Pain Mimicking a Neurological Disorder: A Case Report of Spinal Cavernous Malformation in a Pediatric Patient. Cureus 2024; 16:e67525. [PMID: 39310532 PMCID: PMC11416157 DOI: 10.7759/cureus.67525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2024] [Indexed: 09/25/2024] Open
Abstract
We present a case of a 13-year-old boy with abdominal pain initially misdiagnosed as gastrointestinal in origin. Despite initial outpatient management, his symptoms rapidly deteriorated, revealing a central-medullary cavernous malformation causing spinal cord compression. This case underscores the importance of a comprehensive pediatric examination and highlights new treatment approaches for spinal cavernous malformations.
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Affiliation(s)
- Eliézer Kasriel
- Pediatric Neurology, Hôpital Civil Marie Curie, Charleroi, BEL
| | | | - Emmanuel Scalais
- Pediatric Neurology, Centre Hospitalier de Luxembourg, Luxembourg City, LUX
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Battistelli M, Grilli F, Rapisarda A, Di Domenico M, Montano N, Gessi M, Olivi A, Albanese A, Polli FM. Unsatisfactory Neurological Outcome in an Intramedullary Thoracic Intermediate-Grade Melanocytoma-Systematic Review and Illustrative Case. Cancers (Basel) 2024; 16:1867. [PMID: 38791946 PMCID: PMC11119811 DOI: 10.3390/cancers16101867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 05/10/2024] [Accepted: 05/12/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND Intramedullary melanocytomas are exceedingly rare, with only twenty-four cases reported up to now. They present as local invasive tumors despite their benign biological behavior. Attempting a complete safe resection often results in severe post-operative neurological deficits, as in our case presented here. METHODS A systematic review was conducted across the PubMed and Scopus databases including studies published till February 2024. RESULTS A total of 19 studies were included, encompassing 24 cases. A similar distribution between sexes was noted (M:F 13:11), with ages ranging from 19 to 79 years. The thoracic segment was most affected, and intermediate-grade melanocytoma (19 cases) was the most common histotype. Radiographically, intramedullary melanocytomas usually appear as hyperintense hemorrhagic lesions peripheral to the central canal with focal nodular enhancement. Intraoperatively, they are black-reddish to tan and are tenaciously adherent lesions. In the sampled studies, IONM employment was uncommon, and post-operative new-onset neurological deficits were described in 16 cases. Adjuvant RT was used in four cases and its value is debatable. Recurrence is common (10 cases), and adjuvant therapies (RT or repeated surgery) seem to play a palliative role. CASE PRESENTATION A 68-year-old woman presented with a three-year history of worsening spastic paraparesis and loss of independence in daily activities (McCormick grade 4). An MRI revealed an intramedullary tumor from Th5 to Th7, characterized by T1-weighted hyperintensity and signs of recent intralesional hemorrhage. Multimodal neuromonitoring, comprising the D-Wave, guided the resection of a black-tan-colored tumor with hyper-vascularization and strong adherence to the white matter. During final dissection of the lesion to obtain gross total resection (GTR), a steep decline in MEPs and D-Wave signals was recorded. Post-operatively, the patient had severe hypoesthesia with Th9 level and segmental motor deficits, with some improvement during neurorehabilitation. Histopathology revealed an intermediate-grade melanocytoma (CNS WHO 2021 classification). A four-month follow-up documented the absence of relapse. CONCLUSIONS This literature review highlights that intramedullary T1 hyperintense hemorrhagic thoracic lesions in an adult patient should raise the suspicion of intramedullary melanocytoma. They present as locally aggressive tumors, due to local invasiveness, which often lead to post-operative neurological deficits, and frequent relapses, which overwhelm therapeutic strategies leading to palliative care after several years.
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Affiliation(s)
- Marco Battistelli
- Department of Neurosurgery, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Rome, Italy; (M.B.); (F.G.); (M.D.D.); (N.M.); (A.O.); (A.A.); (F.M.P.)
| | - Fulvio Grilli
- Department of Neurosurgery, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Rome, Italy; (M.B.); (F.G.); (M.D.D.); (N.M.); (A.O.); (A.A.); (F.M.P.)
| | - Alessandro Rapisarda
- Department of Neurosurgery, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Rome, Italy; (M.B.); (F.G.); (M.D.D.); (N.M.); (A.O.); (A.A.); (F.M.P.)
| | - Michele Di Domenico
- Department of Neurosurgery, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Rome, Italy; (M.B.); (F.G.); (M.D.D.); (N.M.); (A.O.); (A.A.); (F.M.P.)
| | - Nicola Montano
- Department of Neurosurgery, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Rome, Italy; (M.B.); (F.G.); (M.D.D.); (N.M.); (A.O.); (A.A.); (F.M.P.)
| | - Marco Gessi
- Neuropathology Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Università Cattolica S. Cuore, 00168 Rome, Italy;
| | - Alessandro Olivi
- Department of Neurosurgery, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Rome, Italy; (M.B.); (F.G.); (M.D.D.); (N.M.); (A.O.); (A.A.); (F.M.P.)
| | - Alessio Albanese
- Department of Neurosurgery, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Rome, Italy; (M.B.); (F.G.); (M.D.D.); (N.M.); (A.O.); (A.A.); (F.M.P.)
| | - Filippo Maria Polli
- Department of Neurosurgery, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Rome, Italy; (M.B.); (F.G.); (M.D.D.); (N.M.); (A.O.); (A.A.); (F.M.P.)
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Thomas AP, Velayudhan SC, John TR, Sudhakaran P. A Case of Reversible Paraplegia due to Multiple Intraspinal and Intracranial Cavernomas. Neurol India 2024; 72:443-444. [PMID: 38691501 DOI: 10.4103/ni.neurol-india-d-23-00554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 10/23/2023] [Indexed: 05/03/2024]
Affiliation(s)
- Ann P Thomas
- Department of Neurology, Government TD Medical College, Alappuzha, Kerala, India
| | - Shaji C Velayudhan
- Department of Neurology, Government TD Medical College, Alappuzha, Kerala, India
| | - Tisa R John
- Department of Radiodiagnosis, Government TD Medical College, Alappuzha, Kerala, India
| | - Prasanth Sudhakaran
- Department of Neurology, Government TD Medical College, Alappuzha, Kerala, India
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Calderon C, Baron J, Ramdass A, Ramcharan R, Ramnarine D. A rare case of cavernous malformation of the cauda equina a case report. Int J Surg Case Rep 2024; 114:109200. [PMID: 38154230 PMCID: PMC10800712 DOI: 10.1016/j.ijscr.2023.109200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/19/2023] [Accepted: 12/20/2023] [Indexed: 12/30/2023] Open
Abstract
INTRODUCTION Cavernous malformation of the cauda equina is a rare neurosurgical condition. We sought to highlight one of these cases and its resultant diagnosis and management. Additionally, to recommend the need for raised clinical suspicion of these rare masses when an extramedullary lesion is noted on imaging. PRESENTATION OF CASE A 42-year-old female presented to our institution with a 9-month history of lower back pain. Her examination findings revealed a loss of right ankle jerk reflex. Magnetic resonance imaging (MRI) of her lumbosacral spine demonstrated an intradural, extramedullary tumor involving the cauda equina, at the L4/L5 level. The main differential diagnosis at this time was an ependymoma. An L4/5 laminectomy and resection of the cauda equina mass was scheduled. Intra-operatively, a mulberry - like mass was noted involving a single nerve root. A gross total resection was performed, with resolution of most of her symptoms. Histopathological diagnosis of a cavernous malformation was ascertained. DISCUSSION The accurate diagnosis of a cavernous malformation of the cauda equina was only suspected intra-operatively, following gross inspection. Cauda equina masses usually include myxopapillary ependymomas and schwannomas, making this vascular extramedullary lesion low on the possible differentials list. Very few cases have been published in modern literature. CONCLUSION Cavernous malformations of the cauda equina are an extremely uncommon, benign vascular malformation. These malformations have key characteristics on MRI that can aid its differentiation from other intradural lesions. However, because it is so rare, it does not usually make the list of differentials when considering likely extramedullary lesions.
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Affiliation(s)
- Chrystal Calderon
- Eric Williams Medical Sciences Complex, Mount Hope, Trinidad and Tobago.
| | - Jodi Baron
- Eric Williams Medical Sciences Complex, Mount Hope, Trinidad and Tobago
| | - Ariane Ramdass
- Eric Williams Medical Sciences Complex, Mount Hope, Trinidad and Tobago
| | - Robert Ramcharan
- Port of Spain General Hospital, Port of Spain, Trinidad and Tobago
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Xu W, Ren J, Ye M. Concomitant Thoracic Spinal Dural Arteriovenous Fistula and Spinal Cavernous Malformation. World Neurosurg 2024; 181:90-92. [PMID: 36627020 DOI: 10.1016/j.wneu.2023.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 01/03/2023] [Accepted: 01/04/2023] [Indexed: 01/08/2023]
Abstract
Both spinal dural arteriovenous fistula (SDAVF) and spinal cavernous malformation (SCM) are uncommon vascular malformations. To our knowledge, such a case of SDAVF concomitant with SCM has not been reported. We encountered a case of a 55-year-old man who had weakness and numbness in both lower extremities. Magnetic resonance imaging showed a round-shape lesion identified as a cavernous malformation in the middle segment of the thoracic spine, with spinal edema and obvious flow voids. Diagnostic angiography revealed an SDAVF fed by the right T7 radicular artery with venous drainage. The intramedullary venous hypertension due to fistula was suspected of inducing the formation of SCM. This case may provide new insight into the pathogenesis of SCM.
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Affiliation(s)
- Wenlong Xu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; China International Neuroscience Institute, Beijing, China
| | - Jian Ren
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; China International Neuroscience Institute, Beijing, China
| | - Ming Ye
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; China International Neuroscience Institute, Beijing, China.
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Pantel T, Mende KC, Mohme T, Mohme M, Viezens L, Matschke J, Westphal M, Eicker SO. Cavernous Malformations and Hemangioblastomas of the Spinal Cord Show Distinct Differences in Clinical Course - A Retrospective Single-Center Analysis of 112 Patients. Global Spine J 2023:21925682231214363. [PMID: 37948580 DOI: 10.1177/21925682231214363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2023] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE Cavernous malformations (CMs) and hemangioblastomas (HBs) of the spinal cord exhibit distinct differences in histopathology but similarities in the neurological course. The aim of our study was to analyze the clinical differences between the vascular pathologies and a benign tumor of the spinal cord in a perioperative situation. METHODS We performed a retrospective analysis of patients who had undergone surgery for lesions in the spinal cord between 1984 and 2015. Patients were screened for CMs and HBs as the primary inclusion criteria. General patient information, surgical data, and disease-specific data were collected from the records. Cooper-Epstein scores for clinical symptoms were evaluated preoperatively, at discharge, and at the 6-month follow-up. RESULTS A total of 112 patients were included, of which 46 had been diagnosed with CMs and 66 with HBs. Patients with CMs often demonstrated more preoperative neurological deterioration compared to those with HBs (P < .05); accordingly, in took longer to diagnose HBs. Complete resection was possible for 96.8% of all patients with CMs and 90% of those with HBs. At the 6-month follow-up, patients with HBs more often presented with persisting neurologic impairment of the upper extremities compared to the CM patients (P < .001). CONCLUSION CMs and HBs of the spinal cord have similarities but also exhibit significant differences in neurological presentation and perioperative course. Surgical therapy is the treatment of choice for symptomatic lesions, and complete surgical resection is possible in the majority of cases for both entities. Neurologic outcomes are usually favorable, although patients with HBs retain neurologic deficits more often.
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Affiliation(s)
- Tobias Pantel
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Theresa Mohme
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Malte Mohme
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lennart Viezens
- Division of Spine Surgery, Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob Matschke
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sven Oliver Eicker
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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de Almeida RAA, Tatsui CE. Commentary on "Surgical Outcomes of Symptomatic Intramedullary Spinal Cord Cavernous Malformations: Analysis of Consecutive Cases in a Single Center". Neurospine 2023; 20:822-823. [PMID: 37798976 PMCID: PMC10562246 DOI: 10.14245/ns.2346902.451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023] Open
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Cai Z, Hong X, Dai W, Zhang Z, Liang Q, Ding X, Sun W. Surgical Outcomes of Symptomatic Intramedullary Spinal Cord Cavernous Malformations: Analysis of Consecutive Cases in a Single Center. Neurospine 2023; 20:810-821. [PMID: 37798975 PMCID: PMC10562213 DOI: 10.14245/ns.2346430.215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 05/11/2023] [Accepted: 05/23/2023] [Indexed: 10/07/2023] Open
Abstract
OBJECTIVE Intramedullary spinal cavernous malformations (ISCMs) are rare vascular lesions of the spinal cord with unclear natural history and controversy over treatment. This study aimed to report a series of symptomatic ISCMs underwent microsurgical management to illustrate the natural history, clinical presentation, and surgical outcomes and to evaluate factors associated with hemorrhage events and neurological prognosis. METHODS This single-center retrospective study included 29 consecutive patients with whose demographic, symptomology, imaging, neurological, and surgical data were collected. The risk for hemorrhage events and factors affecting surgical outcomes were retrospectively analyzed. RESULTS There were 12 female (41.4%) and 17 male patients (58.6%), with an average age of 45.2 years (range, 17-69 years). The mean size of the lesion was 9.7 mm (range, 3-20 mm). Most patients had a bowel or/and bladder dysfunction symptom (n = 11, 37.9%), followed by sensory deficits (n = 5, 17.2%), gait disturbance (n = 5, 17.2%), pain (n = 4, 13.8%), and weakness (n = 4, 13.8%), most (n = 15, 51.7%) with a chronic onset. All patients received total resection without rehemorrhages after surgical resection in follow-up. Sixty-five point five percent patients (n = 19) improved, 13.8% (n = 4) remained stable, 20.7% (n = 6) got worsen. The overall annual hemorrhage risk was 2.1% per patient-year. A total of 27 hemorrhages occurred in the 18 patients, of which rehemorrhage rate increased to 50.0% (n = 9) with a previous history of hemorrhage. Patients with smaller lesion sizes were more likely to have hemorrhage or rehemorrhage events (p = 0.008). Recurrent hemorrhage of the lesions was a risk factor for neurological outcomes (p = 0.016). CONCLUSION The risk of rehemorrhage was significantly increased in symptomatic ISCM patients with a previous history of hemorrhage. Rehemorrhage was a risk factor for neurological outcomes. Patients can benefit from microsurgical treatment to avoid rehemorrhage and further neurological deterioration.
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Affiliation(s)
- Zheng Cai
- Department of Neurosurgery, Shanghai Institute of Neurosurgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
- Department of Pharmacology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Xinjie Hong
- Department of Neurosurgery, Shanghai Institute of Neurosurgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Wei Dai
- Department of Neurosurgery, Shanghai Institute of Neurosurgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Zhengwei Zhang
- Department of Pathology, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Qiang Liang
- Department of Neurosurgery, Shanghai Institute of Neurosurgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Xuehua Ding
- Department of Neurosurgery, Shanghai Institute of Neurosurgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Wei Sun
- Department of Neurosurgery, Shanghai Institute of Neurosurgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
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Izi Z, El Haddad S, Allali N, Chat L. Spinal Cord Cavernous Malformation: A Case Report. Glob Pediatr Health 2023; 10:2333794X231184317. [PMID: 37434870 PMCID: PMC10331179 DOI: 10.1177/2333794x231184317] [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: 11/23/2022] [Revised: 06/07/2023] [Accepted: 06/08/2023] [Indexed: 07/13/2023] Open
Abstract
Spinal cord cavernous malformation is a rare and uncommon vascular malformation, it may remain asymptomatic for a long period or manifest as a sudden or gradual change in spinal cord functioning. The diagnosis relies essentially on magnetic resonance imaging (MRI). Surgery constitutes the majority of management with all the complications that can occur during and after surgery. We report a case of intramedullary cavernoma of a 12-year-old patient admitted for acute paraparesia with bowel and bladder dysfunction. MRI revealed 2 intramedullary cavernomas at T6-T7 and T11-T12. Through this case report, we discuss the clinical and radiological characteristics of this unusual intramedullary malformation.
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Kurokawa R, Endo T, Takami T. Acceptance of Early Surgery for Treatment of Spinal Cord Cavernous Malformation in Contemporary Japan. Neurospine 2023; 20:587-594. [PMID: 37401077 PMCID: PMC10323330 DOI: 10.14245/ns.2346134.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/10/2023] [Accepted: 03/21/2023] [Indexed: 07/05/2023] Open
Abstract
OBJECTIVE Spinal cord cavernous malformation (CM) is an intramedullary vascular lesion that may present with progressive symptoms. Surgery is recommended for symptomatic patients, but optimal timing of surgery is debatable. Some advocate waiting until plateau of neurological recovery and others support emergency surgery. There is no statistic on how commonly these strategies are utilized. We aimed to find contemporary practice pattern among neurosurgical spine centers in Japan. METHODS A database of intramedullary spinal cord tumors assembled by Neurospinal Society of Japan was surveyed and 160 patients with spinal cord CM were identified. Neurological function, disease duration, and number of days between presentation to hospitals and surgery were analyzed. RESULTS Duration of disease before presentation to hospitals ranged from 0 to 336 months (median, 4 months). Number of days between patients' presentation and surgery ranged from 0 to 6,011 days (median, 32 days). Time from symptom onset to surgery ranged from 0 to 336.9 months (median, 6.6 months). Patients with severe preoperative neurological dysfunction had shorter duration of disease, fewer days between presentation and surgery, and shorter time between symptom onset and surgery. Patients with paraplegia or quadriplegia were more likely to improve when operated on within 3 months from onset. CONCLUSION Timing of surgery for spinal cord CM in Japanese neurosurgical spine centers generally was early, with 50% of patients undergoing surgery within 32 days after presentation. Further study is needed to clarify optimal timing of surgery.
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Affiliation(s)
- Ryu Kurokawa
- Department of Neurosurgery, Dokkyo Medical University, Tochigi, Japan
| | - Toshiki Endo
- Division of Neurosurgery, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Toshihiro Takami
- Department of Neurosurgery, Osaka Medical and Pharmaceutical University, Osaka, Japan
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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 W, Wang C, Wang B, Zhang Y, Jia W. Intramedullary spinal cavernous malformations with high ossification: a case report and review of the literature. Chin Neurosurg J 2023; 9:11. [PMID: 37076925 PMCID: PMC10113117 DOI: 10.1186/s41016-023-00323-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 04/02/2023] [Indexed: 04/21/2023] Open
Abstract
BACKGROUND Cavernous malformations of the spinal cord are a rare type of vascular malformation, comprising approximately 5 to 16% of all vascular lesions in the spinal cord. Depending on their origin position, these malformations can be distributed in different locations within the spinal canal. Although intramedullary cavernous malformations have been reported in the literature, they are exceedingly rare. Furthermore, highly calcified or ossified intramedullary cavernous spinal malformations are even rarer. CASE PRESENTATION Here, we present a case report of a 28-year-old woman diagnosed with a thoracic intramedullary cavernous malformation. The patient had been experiencing progressive numbness in her distal limbs for a period of 2 months. During routine lung computed tomography screening for COVID-19, a hyperdense mass was noted in the patient's spinal canal. Magnetic resonance imaging revealed a mulberry-shaped intramedullary mass at the T1-2 level. The patient underwent surgical treatment, during which the entire lesion was successfully removed, resulting in a gradual improvement of her symptoms. Histological examination confirmed the presence of cavernous malformations with calcification. CONCLUSIONS Intramedullary cavernous malformations with calcification are rare and special type that should be treated surgically in the early stage without significant neurological impairment before rebleeding or enlargement of the lesion can occur.
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Affiliation(s)
- Weihao Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119, South Fourth Ring West Road, Fengtai District, Beijing, China
| | - Chong Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119, South Fourth Ring West Road, Fengtai District, Beijing, China
| | - Bo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119, South Fourth Ring West Road, Fengtai District, Beijing, China
| | - Yaowu Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119, South Fourth Ring West Road, Fengtai District, Beijing, China
| | - Wenqing Jia
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119, South Fourth Ring West Road, Fengtai District, Beijing, China.
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15
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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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16
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Liao D, Wang R, Shan B, Chen H. Surgical outcomes of spinal cavernous malformations: A retrospective study of 98 patients. Front Surg 2023; 9:1075276. [PMID: 36713668 PMCID: PMC9877401 DOI: 10.3389/fsurg.2022.1075276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 12/28/2022] [Indexed: 01/15/2023] Open
Abstract
Objective Spinal cord cavernous malformation (SCCM) is a rare vascular lesion, and the treatment strategy remains controversial at present. The goal of this retrospective study was to analyze the surgical outcomes of the SCCM and to find more appropriate treatment strategies for a better prognosis. Method A retrospective review of 98 patients with SCCM from 2009 to 2018 was conducted at the neurosurgical center of our hospital. Neurological function was assessed using the American Spinal Injury Association (ASIA) impairment scale. Clinical features were analyzed using the multivariable logistic regression. Results Ninety-eight patients with SCCM were included, of whom 36% were female and 64% male. The mean age was 41.6 years; and family history was reported in 8% of patients. Definite hemorrhage was found in 6%. Before surgery, the neurological status was Grade A in 2%, Grade B in 2%, Grade C in 12%, Grade D in 54%, and Grade E in 30% of the patients. 83% (81/98) patients had long-term follow-up, of whom, 42% had improved, 51% were stable and 7% had deteriorated. Patients with dorsal or superficial lesions showed better improvement than those with ventral or lateral deep lesions. Those with symptoms lasting less than three months had higher rates of improvement than those with symptoms lasting more than three months. However, there was no significant difference in prognosis between hemilaminectomy and laminectomy. Conclusion These results suggest that surgical strategies should be preferred for severe symptomatic SCCMs if total resection can be achieved, thereby avoiding the risk of severe complications with subsequent lesion hemorrhage. Earlier (usually within 3 months of symptom duration) surgical resection generally may lead to a better prognosis. For ventral or lateral deep SCCMs, the surgical strategy should be considered more carefully.
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17
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Abougamil AB, Ashkan K, Rayan T. Peripartum haemorrhage from an intramedullary conus medullaris cavernous malformation: a rare but serious complication. Ann R Coll Surg Engl 2023; 105:82-86. [PMID: 35639098 PMCID: PMC9773293 DOI: 10.1308/rcsann.2022.0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2022] [Indexed: 12/24/2022] Open
Abstract
Cavernous malformations (CMs) represent about 5% of all spinal intramedullary lesions in adults. There is growing evidence to suggest that pregnancy may increase the risk of haemorrhage from CMs. We report the case of a 28-year-old woman who presented with bilateral lower limb paraparesis following an intramedullary haemorrhage from conus medullaris CM during the peripartum period. To the best of our knowledge, this is the first such case. We also review a handful of other reported cases of peripartum symptomatic spinal intramedullary CMs from the literature highlighting the pathogenesis of such cases and the best timing for intervention.
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Affiliation(s)
- AB Abougamil
- King's College Hospital NHS Foundation Trust, UK
| | - K Ashkan
- King's College Hospital NHS Foundation Trust, UK
| | - T Rayan
- Alexandria University, Alexandria, Egypt
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18
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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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19
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How I do it: resection of spinal cord cavernous malformation. Acta Neurochir (Wien) 2022; 164:2257-2261. [PMID: 35764695 DOI: 10.1007/s00701-022-05269-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 05/28/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Spinal cord cavernous malformations (CMs) account for 5 to 12% of all spinal vascular malformations. Surgical removal is indicated in symptomatic patients, especially if the CM comes close to the dorsal or lateral surface of the spinal cord. Spinal cord CMs pose critical challenges for the potential of severe disabling complications. METHOD We described the step-by-step surgical principles of spinal cord CM microsurgical resection. The main surgical steps are also illustrated in an accompanying operative video. CONCLUSION Pre-surgical planning of the basic steps and good contingency management skills are paramount for an effective and safe spinal cord CM excision.
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20
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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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Intramedullary spinal cord cavernous malformations-association between intraoperative neurophysiological monitoring changes and neurological outcome. Acta Neurochir (Wien) 2022; 164:2595-2604. [PMID: 36066749 PMCID: PMC9519689 DOI: 10.1007/s00701-022-05354-z] [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: 01/24/2022] [Accepted: 08/22/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Microsurgical resection of spinal cord cavernous malformations can be assisted by intraoperative neurophysiological monitoring (IONM). While the clinical outcome after surgical resection has been discussed in several case series, the association of intraoperative IONM changes and detailed neurological outcome, however, has not been analyzed so far. METHODS Seventeen patients with spinal cavernomas underwent surgery between 02/2004 and 06/2020. Detailed neurological and clinical outcome as well as IONM data including motor-evoked potential (MEP) and somatosensory-evoked potential (SSEP) monitoring were retrospectively analyzed. Intraoperative IONM changes were compared to outcome at 3-month and 1-year follow-up in order to identify surrogate parameters for an impending neurological deficit. RESULTS Compared to the preoperative state, McCormick score at 1-year follow-up remained unchanged in 12 and improved in five patients, none worsened, while detailed neurological examination revealed a new or worsened sensorimotor deficit in 4 patients. The permanent 80% amplitude reduction of MEP and 50% amplitude reduction of SSEP showed the best diagnostic accuracy with a sensitivity of 100% and 67% respectively and a specificity of 73% and 93% respectively. The relative risk for a new neurological deficit at 1-year follow-up, when reversible IONM-deterioration was registered compared to irreversible IONM deterioration, was 0.56 (0.23-1.37) for MEP deterioration and 0.4 (0.18-0.89) for SSEP deterioration. CONCLUSIONS Reversible IONM changes were associated with a better neurological outcome at follow-up compared to irreversible IONM deterioration during SCCM surgery. Our study favors the permanent 80% amplitude reduction criterion for MEP and 50% amplitude reduction criterion for SSEP for further prospective evaluation of IONM significance and the effectiveness of corrective maneuvers during SCCM surgeries.
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22
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Abstract
The blood-spinal cord barrier (BSCB) has been long thought of as a functional equivalent to the blood-brain barrier (BBB), restricting blood flow into the spinal cord. The spinal cord is supported by various disc tissues that provide agility and has different local immune responses compared to the brain. Though physiologically, structural components of the BSCB and BBB share many similarities, the clinical landscape significantly differs. Thus, it is crucial to understand the composition of BSCB and also to establish the cause–effect relationship with aberrations and spinal cord dysfunctions. Here, we provide a descriptive analysis of the anatomy, current techniques to assess the impairment of BSCB, associated risk factors and impact of spinal disorders such as spinal cord injury (SCI), amyotrophic lateral sclerosis (ALS), peripheral nerve injury (PNI), ischemia reperfusion injury (IRI), degenerative cervical myelopathy (DCM), multiple sclerosis (MS), spinal cavernous malformations (SCM) and cancer on BSCB dysfunction. Along with diagnostic and mechanistic analyses, we also provide an up-to-date account of available therapeutic options for BSCB repair. We emphasize the need to address BSCB as an individual entity and direct future research towards it.
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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] [Key Words] [MESH Headings] [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.
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Affiliation(s)
- Tong Liu
- 1Department of Neurosurgery, Tianjin Institute of Neurology, Tianjin Medical University General Hospital, Tianjin; and
| | - Kai Li
- 1Department of Neurosurgery, Tianjin Institute of Neurology, Tianjin Medical University General Hospital, Tianjin; and
| | - Yongli Wang
- 1Department of Neurosurgery, Tianjin Institute of Neurology, Tianjin Medical University General Hospital, Tianjin; and
| | - Zilong Zhao
- 1Department of Neurosurgery, Tianjin Institute of Neurology, Tianjin Medical University General Hospital, Tianjin; and
| | - Xin Chen
- 1Department of Neurosurgery, Tianjin Institute of Neurology, Tianjin Medical University General Hospital, Tianjin; and
| | - Fanjian Li
- 1Department of Neurosurgery, Tianjin Institute of Neurology, Tianjin Medical University General Hospital, Tianjin; and
| | - Lu Zhao
- 2Department of Radiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Zhijun Peng
- 2Department of Radiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Tao Zhu
- 1Department of Neurosurgery, Tianjin Institute of Neurology, Tianjin Medical University General Hospital, Tianjin; and
| | - Jianning Zhang
- 1Department of Neurosurgery, Tianjin Institute of Neurology, Tianjin Medical University General Hospital, Tianjin; and
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Herten A, Saban D, Santos AN, Chen B, Darkwah Oppong M, Rauschenbach L, Jabbarli R, Wrede K, Bingel U, Müller D, Holle-Lee D, Schmidt B, Li Y, Sure U, Dammann P. The occurrence of neuropathic pain following surgery of brainstem cavernous malformations. Eur J Neurol 2021; 29:865-872. [PMID: 34762327 DOI: 10.1111/ene.15179] [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: 06/11/2021] [Accepted: 09/22/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND PURPOSE This study aimed to assess the occurrence and significance of postoperative neuropathic pain (NP) in patients with surgically treated brainstem cavernous malformations (BSCMs). METHODS Seventy-four BSCM patients surgically treated between 2003 and 2019 were reviewed for the occurrence of postoperative NP and related treatment. The relevance of BSCM location, preoperative characteristics, influence on functional outcome, postoperative health-related quality of life (HRQOL) and life satisfaction was evaluated. RESULTS Six out of 74 patients (8%) suffered from NP. The Leeds Assessment of Neuropathic Symptoms and Signs scores ranged from 12 to 16 (mean 14.28 ± 1.6). Visual analog scale pain was 5.2 ± 2.0. NP had no effect on preoperative characteristics or functional outcome. Bodily pain (HRQOL) and vocational time (life satisfaction) were significantly decreased in NP compared to non-NP patients. Specific BSCM location (regarding brainstem nuclei involved in pain processing) and other preoperative patient- and BSCM-related parameters were not associated with the occurrence of postoperative NP. Three out of six patients were currently under NP-specific treatment. The proportion of patients suffering from postoperative NP (8%) was substantially higher compared to previously published studies. The pain affected the HRQOL of patients, most of whom were insufficiently treated and not satisfied with treatment results. CONCLUSION Our findings may help to raise awareness for postoperative NP in BSCM, which is essential to improve diagnosis and initiation of proper treatment, as well as preoperative informed consent of patients.
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Affiliation(s)
- Annika Herten
- ¹Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Dino Saban
- ¹Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Alejandro N Santos
- ¹Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Bixia Chen
- ¹Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Marvin Darkwah Oppong
- ¹Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Laurèl Rauschenbach
- ¹Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Ramazan Jabbarli
- ¹Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Karsten Wrede
- ¹Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Ulrike Bingel
- Department of Neurology, Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
| | - Daniel Müller
- Department of Neurology, Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
| | - Dagny Holle-Lee
- Department of Neurology, Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
| | - Börge Schmidt
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital of Essen, Essen, Germany
| | - Yan Li
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Ulrich Sure
- ¹Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Philipp Dammann
- ¹Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
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Wang Z, Wu H, Piao Y, Wang C. Cervical Cord Hemorrhage in Cerebral Cavernous Malformations. J Clin Neurol 2021; 17:576-578. [PMID: 34595868 PMCID: PMC8490898 DOI: 10.3988/jcn.2021.17.4.576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 06/18/2021] [Accepted: 06/21/2021] [Indexed: 12/02/2022] Open
Affiliation(s)
- Zhanjun Wang
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Hao Wu
- Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Yueshan Piao
- Department of Pathology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Chaodong Wang
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China.
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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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Ginalis EE, Herschman Y, Patel NV, Jumah F, Xiong Z, Hanft SJ. Lateral Myelotomy for Resection of a Ruptured Intramedullary Cervico-Thoracic Cavernous Malformation. Oper Neurosurg (Hagerstown) 2021; 20:E317-E321. [PMID: 33372222 DOI: 10.1093/ons/opaa417] [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: 05/07/2020] [Accepted: 10/09/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Intramedullary spinal cord cavernous malformations represent 5% to 12% of spinal vascular disease. Most patients present with acute or progressive neurological symptoms, including motor weakness or sensory loss. Surgical resection is the only definitive management and is recommended for symptomatic lesions that are surgically accessible. CLINICAL PRESENTATION A 35-yr-old woman presented with a sudden onset of pain and temperature sensation loss in the left lower extremity. Magnetic resonance imaging of the spine showed a hemorrhage located ventral and slightly lateral to the right of the midline of the spinal cord from C7 through T3. Ultimately, a right lateral myelotomy between the ventral and dorsal roots was performed, and the cavernous malformation was removed. Postoperative imaging confirmed gross total resection of the cavernous malformation. CONCLUSION In this article, we report a highly unusual case of a multisegment, ruptured intramedullary cavernous malformation that was ultimately resected through a lateral myelotomy approach. This case demonstrates that a lateral approach to the spinal cord substance can be utilized for ruptured cavernous malformation, especially if there is hemorrhage at the surface of the spinal cord. This can be used as an entry into the anterolateral compartment of the spinal cord, which would otherwise be regarded as a highly morbid approach due to the sensory deficits induced. We believe this entry point to the spinal cord is feasible in highly select cases such as this.
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Affiliation(s)
- Elizabeth E Ginalis
- Department of Neurological Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Yehuda Herschman
- Department of Neurological Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Nitesh V Patel
- Department of Neurological Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Fareed Jumah
- Department of Neurological Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Zhenggang Xiong
- Department of Pathology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Simon J Hanft
- Department of Neurological Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
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Long-term surgical outcomes and prognostic factors of adult symptomatic spinal cord cavernous malformations. J Clin Neurosci 2021; 90:171-177. [PMID: 34275545 DOI: 10.1016/j.jocn.2021.05.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 04/10/2021] [Accepted: 05/17/2021] [Indexed: 11/21/2022]
Abstract
Cervical and thoracic or lumbar intramedullary spinal cavernous malformations (ISCMs) may behave differently. We conducted this retrospective study by using data from adult ISCMs to compare their natural histories and explore prognostic factors for improved clinical outcomes. Neurological functions were assessed by using the Modified McCormick Scale (MMCS) and Aminoff-Logue Disability Scale. A total of 111 study-eligible adult patients were included in this study. Patients with cervical ISCMs mostly demonstrated a shorter duration of symptoms (P = 0.026), an acute onset pattern with some recovery (P = 0.026), and a larger lesion size (P = 0.033) than their thoracic or lumbar counterparts. Thoracic or lumbar lesions had a higher proportion of motor symptoms (P = 0.001) and sphincter problems (P = 0.005), and they were usually associated with an aggressive clinical course (P = 0.001, OR = 9.491, 95% CI = 2.555-35.262) in multivariate analysis. There was no difference in age, sex distribution, hemorrhage risk between the cervical and thoracic-lumbar groups. A better preoperative neurological status (P = 0.034, OR = 2.768, 95% CI = 1.081-7.177) and improvement immediately after surgery (P < 0.001, OR = 8.756, 95% CI = 4.837-72.731) were identified as indicators for long-term improvement by multivariate analysis. Cervical lesions had a high proportion for long-term improvement, but it was not a predictor for improvement in multivariate analysis. ISCMs in the thoracic or lumbar location should be considered for surgical removal more aggressively than those in the cervical location. Surgical removal of symptomatic ISCMs can avoid further neurological deterioration and usually result in satisfactory long-term outcomes.
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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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Nwachuku E, Duehr J, Kulich S, Marker D, Moossy J. Cervical intramedullary spinal cavernoma in setting of unresolved myelopathy: A case report. Surg Neurol Int 2020; 11:176. [PMID: 32754351 PMCID: PMC7395550 DOI: 10.25259/sni_87_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 06/12/2020] [Indexed: 11/29/2022] Open
Abstract
Background: Spinal cavernous malformations are rare, accounting for approximately 5–12% of all spinal cord vascular lesions. Fortunately, improvements in imaging technologies have made it easier to establish the diagnosis of intramedullary spinal cavernomas (ISCs). Case Description: Here, we report the case of a 63-year-old male with an >11-year history of left-sided radiculopathy, ataxia, and quadriparesis. Initially, radiographic findings were interpreted as consistent with spondylotic myelopathy with cord signal changes from the C3-C7 levels. The patient underwent a C3-C7 laminectomy/foraminotomy with instrumentation. It was only after several symptomatic recurrences and repeated magnetic resonance images (MRI) that the diagnosis of a ventrally-located intramedullary lesion, concerning for a cavernoma, at the level C6 was established. Conclusion: Early and repeated enhanced MR studies may be required to correctly establish the diagnosis and determine the optimal surgical management of ISCs.
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Affiliation(s)
- Enyinna Nwachuku
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pennsylvania, United States
| | - James Duehr
- Department of Neurosurgery, University of Pittsburgh School of Medicine, Pennsylvania, United States
| | - Scott Kulich
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Daniel Marker
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - John Moossy
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pennsylvania, United States
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Mabray MC, Starcevich J, Hallstrom J, Robinson M, Bartlett M, Nelson J, Zafar A, Kim H, Morrison L, Hart BL. High Prevalence of Spinal Cord Cavernous Malformations in the Familial Cerebral Cavernous Malformations Type 1 Cohort. AJNR Am J Neuroradiol 2020; 41:1126-1130. [PMID: 32467184 DOI: 10.3174/ajnr.a6584] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 03/19/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND PURPOSE Cavernous malformations occur most often in the brain but can occur in the spinal cord. Small studies of patients with familial cerebral cavernous malformations suggested a prevalence of spinal cord cavernous malformations of 20%-42%. We aimed to review our familial cohort and prospectively estimate the prevalence of spinal cord cavernous malformations. MATERIALS AND METHODS We initially reviewed our familial cerebral cavernous malformations cohort for spinal cord cavernous malformations and reviewed clinical spine MR imaging examinations for sequence sensitivity. We then prospectively performed research MR imaging of the spinal cord in 29 patients from the familial cohort to estimate the prevalence. RESULTS Gradient-based sequences identified the most spinal cord cavernous malformations on clinical MR images, forming the basis for developing our screening MR imaging. Screening spinal cord MR imaging demonstrated a prevalence of 72.4%, and a positive correlation with patient age and number of cerebral cavernous malformations. CONCLUSIONS Spinal cord cavernous malformations occur commonly in the familial cerebral cavernous malformation population. Gradient-based sequences are the most sensitive and should be used when spinal cord cavernous malformations are suspected. This study establishes the prevalence in the familial population at around 70% and supports the idea that this condition is a progressive systemic disease that affects the entire central nervous system.
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Affiliation(s)
- M C Mabray
- From the Departments of Radiology (M.C.M., J.S., J.H., B.L.H.)
| | - J Starcevich
- From the Departments of Radiology (M.C.M., J.S., J.H., B.L.H.)
| | - J Hallstrom
- From the Departments of Radiology (M.C.M., J.S., J.H., B.L.H.)
| | - M Robinson
- Neurology (M.R., M.B., A.Z., L.M.), University of New Mexico Health Sciences Center, University of New Mexico, Albuquerque, New Mexico
| | - M Bartlett
- Neurology (M.R., M.B., A.Z., L.M.), University of New Mexico Health Sciences Center, University of New Mexico, Albuquerque, New Mexico
| | - J Nelson
- Departments of Anesthesia and Perioperative Care, Center for Cerebrovascular Research (J.N., H.K.)
| | - A Zafar
- Neurology (M.R., M.B., A.Z., L.M.), University of New Mexico Health Sciences Center, University of New Mexico, Albuquerque, New Mexico
| | - H Kim
- Departments of Anesthesia and Perioperative Care, Center for Cerebrovascular Research (J.N., H.K.).,Epidemiology and Biostatistics (H.K.), University of California San Francisco, San Francisco, California
| | - L Morrison
- Neurology (M.R., M.B., A.Z., L.M.), University of New Mexico Health Sciences Center, University of New Mexico, Albuquerque, New Mexico
| | - B L Hart
- From the Departments of Radiology (M.C.M., J.S., J.H., B.L.H.)
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Panda A, Diehn FE, Kim DK, Bydon M, Goyal A, Benson JC, Carr CM, Rinaldo L, Flemming KD, Lanzino G. Spinal Cord Cavernous Malformations: MRI Commonly Shows Adjacent Intramedullary Hemorrhage. J Neuroimaging 2020; 30:690-696. [PMID: 32462668 DOI: 10.1111/jon.12738] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 05/15/2020] [Accepted: 05/15/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND AND PURPOSE There is a relative paucity of radiology literature on spinal cord cavernous malformations (SCMs). We hypothesized that the classic MRI features of cavernous malformations are not highly prevalent. The purpose was to review MR imaging findings of SCMs with a focus on prevalence of hemorrhagic features, including adjacent intramedullary hemorrhage at initial presentation. METHODS In this single-institution study, 78 SCMs in 76 patients diagnosed on imaging/pathology were retrospectively evaluated for size, location, cord expansion, exophytic component, popcorn morphology, signal characteristics, including T1 weighted (T1w) and T2w rims, blood-fluid levels, and adjacent intramedullary hemorrhage. Intramedullary hemorrhage was defined as centrally and/or eccentrically located linear or flame shaped non-edematous signal abnormality extending longitudinally away from SCMs, distinct from lesional rim. RESULTS Sixty-three percent (49/78) of SCMs measured <1 cm in length, 78% (61/78) extended to the cord surface, 65% (51/78) were expansile, and 32% (25/78) were exophytic. Popcorn morphology was seen in 15% (12/78) on T1w and 22% (17/78) on T2w. Internal blood-fluid levels were evident in 4% (3/78). Sixty-nine percent (54/78) showed T2w hypointense rims; the T2w rim was complete/near-complete in 37% (29/78). A rim on T1w was visible in 49% (38/78); this was hyperintense in 58% (22/38). Adjacent intramedullary hemorrhage was seen in 45/78 (58%), was most commonly bidirectional in 67% (30/45) and eccentric in 68% (30/44). Cord edema was seen in 22% (17/78); 53% (9/17) also demonstrated intramedullary hemorrhage with edema. CONCLUSIONS The classically described popcorn morphology, internal blood-fluid levels, and complete/near-complete T2w hypointense rims are often absent on MRIs in SCMs. Adjacent intramedullary hemorrhage is frequently present, often eccentric and bidirectional.
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Affiliation(s)
- Ananya Panda
- Department of Neuroradiology, Mayo Clinic, Rochester, MN
| | - Felix E Diehn
- Department of Neuroradiology, Mayo Clinic, Rochester, MN
| | - Dong Kun Kim
- Department of Neuroradiology, Mayo Clinic, Rochester, MN
| | - Mohamad Bydon
- Department of Neurosurgery, Mayo Clinic, Rochester, MN
| | - Anshit Goyal
- Department of Neurosurgery, Mayo Clinic, Rochester, MN
| | - John C Benson
- Department of Neuroradiology, Mayo Clinic, Rochester, MN
| | - Carrie M Carr
- Department of Neuroradiology, Mayo Clinic, Rochester, MN
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Surgical management of spinal intramedullary tumors: Ten-year experience in a single institution. J Clin Neurosci 2020; 73:201-208. [PMID: 31932186 DOI: 10.1016/j.jocn.2019.12.054] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 12/30/2019] [Indexed: 11/21/2022]
Abstract
Despite their rare occurrence, intramedullary spinal cord tumors can cause considerable morbidity and mortality without treatment. Timing of surgery, extent of resection and selection of favorable treatment option are important considerations for a good surgical outcome. In this clinical study, we report our patient series and convey our treatment strategy. We retrospectively reviewed 91 patients with primary intramedullary spinal cord tumors who underwent microsurgical resection at our institution between 2008 and 2018. Data were collected consisting of age, sex, location and histology of tumor, extent of resection, presenting symptoms and neurological outcomes. Modified McCormick Scale was used to assess neurological status of patients. 47 female and 44 male patients were followed-up for a mean period of 35.7 months. The most frequent pathological diagnosis was ependymoma in 56 patients, followed by astrocytoma in 21 and hemangioblastoma in 5 patients. The rest of the tumors consisted of 3 cavernomas, 3 mature cystic teratomas, 2 PNET, one epidermoid tumor. Gross total resection was achieved in 67 patients, while subtotal resection and biopsy was performed in 15 and 9 respectively. The most commonly involved localization was cervical (n = 39), followed by thoracic region (n = 24). Despite immediate postoperative worsening of neurological status, a great number of patients improved at the last follow-up. Gross total resection remains the primary goal of treatment while adjuvant radiation and/or chemotherapy may be alternative options for high grade tumors. Preoperative neurological status was the most important and the strongest predictor of functional outcome.
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Gendle C, Salunke P, Karthigeyan M, Gupta K. Spinal Cavernoma in an Infant: A Rare Pathological Entity with an Atypical Presentation. Pediatr Neurosurg 2020; 55:210-214. [PMID: 32894835 DOI: 10.1159/000509164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 06/04/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Cavernous malformation (CM) of the pediatric spine is uncommon, and its presentation especially in infancy is extremely rare. We report an unusual case of thoracolumbar intramedullary CM with hemorrhage in a 5-month-old male child. CASE PRESENTATION The child presented with the predominant symptom of urinary retention, and the underlying neurological cause was initially overlooked. However, magnetic resonance imaging obtained after the onset of progressive limb weakness revealed a D11-L1 intramedullary lesion with features of intralesional bleed. Intraoperatively, the lesion showed evidence of hemorrhage and was completely excised. The final histopathology confirmed a cavernoma. CONCLUSION Although rare, spinal CM can present with bleed in very young children. It is imperative to identify the subtle clinico-radiological findings and suspect such lesions, as an early treatment portends a good outcome.
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Affiliation(s)
- Chandrashekhar Gendle
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Pravin Salunke
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Madhivanan Karthigeyan
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India,
| | - Kirti Gupta
- Department of Histopathology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Vercelli GG, Cofano F, Santonio FV, Vincitorio F, Zenga F, Garbossa D. Natural History, Clinical, and Surgical Management of Cavernous Malformations. Methods Mol Biol 2020; 2152:35-46. [PMID: 32524542 DOI: 10.1007/978-1-0716-0640-7_3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
We describe Natural history, clinical and surgical management of cavernous malformation of the brain and spinal cord. Decision-making for treatment of cavernous malformations cannot ignore their natural history and risk of bleeding, which is different depending on the location. Surgical morbidity also depends on the position of the lesion. We performed a review of hemorrhage risk and clinical assessment of superficial and deep supratentorial, brainstem and intramedullary cavernous malformations.
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Affiliation(s)
- Giovanni G Vercelli
- Neurosurgery Unit, Department of Neuroscience, University of Torino, Torino, Italy.
| | - Fabio Cofano
- Neurosurgery Unit, Department of Neuroscience, University of Torino, Torino, Italy
| | | | - Francesca Vincitorio
- Neurosurgery Unit, Department of Neuroscience, University of Torino, Torino, Italy
| | - Francesco Zenga
- Neurosurgery Unit, Department of Neuroscience, University of Torino, Torino, Italy
| | - Diego Garbossa
- Neurosurgery Unit, Department of Neuroscience, University of Torino, Torino, Italy
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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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Sudden Paraplegia in a Patient With Chronic Myelopathy: Two Faces of Spinal Cavernous Hemangioma. Am J Phys Med Rehabil 2019; 99:e56-e57. [DOI: 10.1097/phm.0000000000001320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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38
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Kang MG, Kim KH, Park JY, Koo SW, Chin DK, Kim KS, Cho YE. Intramedullary Cavernous Hemangioma with Calcification of Spinal Cord. World Neurosurg 2019; 130:298-303. [DOI: 10.1016/j.wneu.2019.07.061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Revised: 07/05/2019] [Accepted: 07/06/2019] [Indexed: 11/28/2022]
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Ren J, Hong T, Zeng G, He C, Li X, Ma Y, Yu J, Ling F, Zhang H. Characteristics and Long-Term Outcome of 20 Children With Intramedullary Spinal Cord Cavernous Malformations. Neurosurgery 2019; 86:817-824. [DOI: 10.1093/neuros/nyz381] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 06/27/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
No prior reports have focused on the natural history and long-term outcomes of intramedullary spinal cord cavernous malformations (ISCCMs) in children.
OBJECTIVE
To investigate the clinical characteristics and long-term outcomes of pediatric ISCCMs and identify the risk of hemorrhage.
METHODS
We retrospectively reviewed a series of 20 pediatric patients (<18 yr old) from a consecutive series of 254 patients with ISCCMs evaluated at a single institution.
RESULTS
Of the 20 pediatric patients, 9 (45.0%) presented with a severe neurological and disability status. The annual hemorrhagic rate in pediatric patients was 8.2%/patient/year. After initial overt hemorrhage events, the annual overt rehemorrhage rate increased to 30.7%/patient/year. In 234 adult patients, the respective rates were 2.8% and 7.4%. Thoracic or lumbar level lesions (P = .002, OR = 3.425, 95% CI = 1.588-7.387) and rehemorrhagic events (P = .005, OR = 3.209, 95% CI = 1.415-7.279) were more likely to follow an aggressive course. There were no significant differences in the sex distribution, location and size of lesions, types of symptoms, likelihood of a severe neurological and disability status, or immediate and long-term postoperative outcomes between pediatric and adult patients with ISCCMs
CONCLUSION
The annual overt hemorrhage rate and rehemorrhage rate of ISCCMs were higher in affected children than in affected adults. Surgical resection of pediatric ISCCMs remains the preferred therapeutic option and provides favorable outcomes.
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Affiliation(s)
- Jian Ren
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Tao Hong
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Gao Zeng
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Chuan He
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Xiaoyu Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Yongjie Ma
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Jiaxing Yu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Feng Ling
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
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Moldovan K, Konakondla S, Barber SM, Nakhla J, Fridley JS, Telfeian AE, Gokaslan ZL, Oyelese AA. Intraoperative Computed Tomography Navigation-Assisted Resection of Symptomatic Intramedullary Spinal Cord Cavernoma: A Technical Note and Case Report. World Neurosurg 2019; 129:311-317. [DOI: 10.1016/j.wneu.2019.06.101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 06/11/2019] [Accepted: 06/12/2019] [Indexed: 10/26/2022]
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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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Maj E, Wójtowicz K, Aleksandra, Podlecka-Piȩtowska, Prokopienko M, Marchel A, Rowiński O, Bekiesińska-Figatowska M. Intramedullary spinal tumor-like lesions. Acta Radiol 2019; 60:994-1010. [PMID: 30537844 DOI: 10.1177/0284185118809540] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
The development of magnetic resonance imaging (MRI) has led to an increasingly frequent detection of changes in the spinal cord. The most common intramedullary lesions are: demyelinating; vascular; inflammatory; infectious; and congenital, largely called tumor-like lesions. Spinal cord tumors are relatively rare, as compared with brain tumors. The hardest task is to conclude whether the spinal cord lesion is a tumor or a tumor-like lesion. This review is intended to help evaluate the spinal cord and gives an overview of the tumor-like lesions occurring in the spinal cord along with their characteristic.
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Affiliation(s)
- Edyta Maj
- Second Department of Clinical Radiology, Medical University of Warsaw, Warsaw, Poland
| | | | | | | | - Marek Prokopienko
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
| | - Andrzej Marchel
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
| | - Olgierd Rowiński
- Second Department of Clinical Radiology, Medical University of Warsaw, Warsaw, Poland
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Ren J, Hong T, He C, Li X, Ma Y, Yu J, Ling F, Zhang H. Surgical approaches and long-term outcomes of intramedullary spinal cord cavernous malformations: a single-center consecutive series of 219 patients. J Neurosurg Spine 2019; 31:123-132. [PMID: 30952112 DOI: 10.3171/2018.12.spine181263] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 12/28/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Optimal surgical strategies for intramedullary spinal cord cavernous malformations (ISCCMs) are not optimized and remain problematic. In this study the authors identify rational surgical strategies for ISCCMs and predictors of outcomes after resection. METHODS A single-center study was performed with 219 consecutive surgically treated patients who presented from 2002 to 2017 and were analyzed retrospectively. The American Spinal Injury Association (ASIA) Impairment Scale was used to evaluate neurological functions. Patient characteristics, surgical approaches, and immediate and long-term postoperative outcomes were identified. RESULTS The average ISCCM size was 10.5 mm. The spinal level affected was cervical in 24.8% of patients, thoracic in 73.4%, and lumbar in 1.8%. The locations of the lesions in the horizontal plane were 30.4% ventral, 41.6% dorsal, and 28.0% central. Of the 214 patients included in the cohort for operative evaluation, 62.6% had superficially located lesions, while 37.4% were embedded. Gross-total resection was achieved in 98.1% of patients. The immediate postoperative neurological condition worsened in 10.3% of the patients. Multivariate logistic regression identified mild preoperative function (p = 0.014, odds ratio [OR] 4.5, 95% confidence interval [CI] 1.4-14.8) and thoracolumbar-level lesions (p = 0.01, OR 15.7, 95% CI 1.9-130.2) as independent predictors of worsening. The mean follow-up duration in 187 patients was 45.9 months. Of these patients, 63.1% were stable, 33.2% improved, and 3.7% worsened. Favorable outcomes were observed in 86.1% of patients during long-term follow-up and were significantly associated with preoperative mild neurological and disability status (p = 0.000) and cervically located lesions (p = 0.009). The depths of the lesions were associated with worse long-term outcomes (p = 0.001), and performing myelotomy directly through a yellowish abnormal surface in moderate-depth lesions was an independent predictor of worsening (p = 0.023, OR 35.3, 95% CI 1.6-756.3). CONCLUSIONS Resection performed with an individualized surgical approach remains the primary therapeutic option in ISCCMs. Performing surgery in patients with mild symptoms at the thoracolumbar level and embedded located lesions requires more discretion.
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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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Li X, Zhang HQ, Ling F, He C, Ren J. Differences in the Electrophysiological Monitoring Results of Spinal Cord Arteriovenous and Intramedullary Spinal Cord Cavernous Malformations. World Neurosurg 2019; 122:e315-e324. [DOI: 10.1016/j.wneu.2018.10.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 10/01/2018] [Accepted: 10/03/2018] [Indexed: 11/30/2022]
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Wen R, Shi Y, Gao Y, Xu Y, Xiong B, Li D, Gong F, Wang W. The Efficacy of Gamma Knife Radiosurgery for Cavernous Malformations: A Meta-Analysis and Review. World Neurosurg 2018; 123:371-377. [PMID: 30583131 DOI: 10.1016/j.wneu.2018.12.046] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 12/07/2018] [Accepted: 12/10/2018] [Indexed: 02/05/2023]
Abstract
OBJECTIVE This meta-analysis is to evaluate the clinical efficacy of gamma knife radiosurgery (GKRS) for treating cavernous malformations. METHODS PubMed, Ovid Embase, and Ovid Medline electronic databases were searched. The primary outcome is hemorrhage rate and this meta-analysis is performed. RESULTS Nine studies are included in this meta-analysis. The overall risk ratio (RR) of hemorrhage rate of pre-GKRS and post-GKRS is 6.08 (95% confidence interval [CI], 5.04-7.35). The overall RR is 3.03 (95% CI, 2.65-4.11) between the hemorrhage rate of pre-GKRS and the first 2 years postradiosurgery, and the overall RR is 12.13 (95% CI, 1.73-85.07) comparing pre-GKRS with 2 years after GKRS. There is no significant difference of the hemorrhage rate between the first 2 years postradiosurgery and 2 years after GKRS (RR = 2.81; 95% CI, 0.20-13.42). The neurologic deficiency is the most common radiosurgery-related complication. CONCLUSIONS Patients with cerebral cavernous malformations, especially ones that were deep seated and surgically inaccessible, seem to benefit from GKRS owing to a reduction of annual hemorrhage rate in the first 2 years and 2 years after, despite several cases that suffer from negative side effects of radiation.
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Affiliation(s)
- Rong Wen
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Yifeng Shi
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Yuan Gao
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Yangyang Xu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Botao Xiong
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Denghui Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Feilong Gong
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Wei Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China.
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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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Anterior to Dorsal Root Entry Zone Myelotomy (ADREZotomy): A New Surgical Approach for the Treatment of Ventrolateral Deep Intramedullary Spinal Cord Cavernous Malformations. Spine (Phila Pa 1976) 2018; 43:E1024-E1032. [PMID: 29462072 DOI: 10.1097/brs.0000000000002607] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective review of prospectively collected data. OBJECTIVE To confirm the feasibility of using anterior to dorsal root entry zone myelotomy (ADREZotomy), a new surgical approach, for the treatment of ventrolateral deep intramedullary spinal cord cavernous malformation (ISCCMs). SUMMARY OF BACKGROUND DATA Surgical removal of ventrolateral deep ISCCMs is highly risky and remains problematic. METHODS The authors performed a retrospective study exploring the surgical removal of ventrolateral intrinsic ISCCMs using ADREZotomy in 10 patients. The Frankel grading system was used to evaluate the patients' neurological function at the preoperative, postoperative and follow-up stages. American Spinal Injury Association Scale scores at the preoperative and postoperative were also obtained. The patient characteristics and surgical outcomes were analyzed. The indication, operative steps, complications, and anatomical basis of the myelotomies were described and discussed. RESULTS In total, nine (90%) patients presented with mild symptoms before surgery. Gross total resections were performed in all 10 patients. Immediately after surgery, the neurological function of eight (80.0%) patients remained the same. One patient improved and one (10%) patient worsened. There were no other immediate or delayed complications related to the surgical procedure. No decrease of total American Spinal Injury Association sensory scores was observed. The follow-up neurological function evaluation showed that two (20%) patients improved from a Frankel grade of D to E and eight (80.0%) patients were stable. No recurrences or other additional neurological deterioration was observed. CONCLUSION Surgical removal of ventrolateral deep ISCCMs can be feasible using proper surgical techniques. ADREZotomy is a minimally invasive technique for the removal of cervical and thoracic ventrolateral deep ISCCMs, without disrupting the important spinal cord tracts or the need to broadly expose bone. LEVEL OF EVIDENCE 4.
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Ghobrial GM, Liounakos J, Starke RM, Levi AD. Surgical Treatment of Vascular Intramedullary Spinal Cord Lesions. Cureus 2018; 10:e3154. [PMID: 30345209 PMCID: PMC6191006 DOI: 10.7759/cureus.3154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Vascular lesions represent a rare subset of intramedullary spinal cord pathology and consist of cavernous malformations (CM), hemangioblastomas, and arteriovenous malformations (AVM). These lesions are each unique and the literature pertaining to their surgical management is largely limited to retrospective case series and case reports. Objectives To evaluate the surgical management of each of these lesions with special attention to postoperative functional status. Methods A single-institution case series of intramedullary vascular lesions treated with surgery was retrospectively evaluated. The primary variables of interest included preoperative and postoperative McCormick grades. Other variables of interest included frequency and indication for conventional spinal angiography, rates of preoperative embolization, postprocedural complications, operative time, intraoperative blood loss, and length of hospital stay. Results Thirty-six patients were identified over the 17-year study period, including 20 with hemangioblastomas, 13 with CMs, and three with AVMs. The median preoperative McCormick grades were 2, 2, and 3 for hemangioblastomas, CMs, and AVMs, respectively. The median postoperative McCormick grades were 2, 2, and 2 for hemangioblastomas, CMs, and AVMs, respectively at the most recent follow-up. Preoperative angiography was performed in all AVM cases and 29% of hemangioblastomas. Preoperative embolization was performed in 40% of hemangioblastoma cases undergoing preoperative angiography. Operative times were similar between the three lesion groups. In three cases of hemangioblastoma resection and one case of CM resection, McCormick grade improved by one point following surgery. At a mean follow-up of 30.9 months for hemangioblastomas, 7.95 months for CMs, and 24 months for AVMs, all patients were at least at their discharge baseline, with no new neurologic complaints. Conclusion Intramedullary vascular lesions are rare and represent a complex surgical patient population. Surgical resection with or without preoperative angiography and embolization appears to be safe and to halt neurologic decline.
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Affiliation(s)
| | | | | | - Allan D Levi
- Neurosurgery, University of Miami Miller School of Medicine, Miami, USA
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