Cobb's syndrome and its treatment with embolization. Case report

Report of a case of Cobb syndrome: multimodality imaging

Cobb syndrome is a rare vascular disorder characterized by vascular skin lesions distributed in a dermatomal pattern, with corresponding muscular, osseous, paraspinal, and/or spinal vascular lesions occurring at the same body somite (metamere). We present a case of a 25-year-old man who presented with a history of right upper limb paresthesia followed by bilateral progressive upper and lower limb weakness and heaviness. Physical examination showed large cutaneous port wine stains on the right side of the chest, the nape, and along the whole right upper limb in a dermatomal distribution, with no corresponding limb hypertrophy or asymmetry. MRI and CT scan of the cervical spine showed aggressive vertebral hemangiomas involving the right side of C1 down to C4 vertebrae associated with extraosseous epidural lesion causing cervical cord compression, in addition to right paraspinal muscular low flow vascular malformations. Digital subtraction angiography of the neck vessels showed corresponding vascular blush and delayed contrast pooling in the affected regions. Cobb syndrome was diagnosed based on the dermatomal distribution of the cutaneous vascular lesions and the corresponding vertebral, epidural, and paraspinal vascular lesions occurring at the same metamere. The patient underwent a decompressive laminectomy at C2–C6 levels with removal of the epidural lesion, after which his symptoms had improved.

Paediatric Spinal Arteriovenous Malformations: Angioarchitecture and Endovascular Treatment

This is a retrospective review of the clinical records and imaging of 14 children with spinal arteriovenous malformations referred to the neurointerventional service at our institution. The lesions are categorized by anatomic location into subpial (5 cases), epidural (3 cases), and paraspinal (6 cases).

There were no dural arteriovenous fistulas in this group. The subpial lesions include both the intramedullary arteriovenous malformations (2 cases) and the perimedullary arteriovenous fistulas (3 cases). Two of the patients with perimedullary fistulas were first cousins and both had Rendu-Osler-Weber syndrome. The six paraspinal lesions were vertebral-vertebral fistulas with five of these located at the first cervical metamere.

Eleven cases (79%) were arteriovenous fistulas and three cases (21%) were arteriovenous malformations with a nidus. There were nine (82%) high flow arteriovenous fistulae and two (18%) low flow arteriovenous fistulae. The ages range from seven months to 15 years, with a mean age of seven years.

There were nine males and five females. Clinical presentations included: bruit alone (6 patients), progressive scoliosis (1 patient), pain (2 patients), neurologic deficit (4 patients) and one case of Cobb's syndrome. Management included: no treatment (1 patient), endovascular embolisation (10 patients) and surgery (3 patients). Of the patients who underwent endovascular treatment all were treated from the arterial side. Two patients were treated by N-butyl cyanoacrylate (NBCA) alone, two with NBCA and coils, one with balloons alone, three with balloons and coils and two with coils alone.

In the endovascular treatment group, nine fistulae were completely obliterated (all high flow fistulae) and one patient had partial treatment (a spinal cord arteriovenous malformation). There were no complications from endovascular treatment.

Cobb syndrome: A rare cause of paraplegia

Cobb syndrome is an exceedingly rare clinical condition defined by the presence of a vascular skin nevus and an angioma in the spinal canal at the same metamere. We report the case of a 14-year-old boy who presented with sudden onset paraplegia. Physical examination showed port-wine stains over buttock and thigh. Magnetic resonance (MR) angiogram of the dorso-lumbar spine revealed a large arteriovenous malformation (AVM) at D₁₁-D₁₂ to L₂-L₃ levels. These concurrent findings led to the diagnosis of Cobb’s syndrome. The patient received orally administered prednisolone therapy and underwent endovascular embolization of spinal angioma. Cobb’s syndrome is a rare disease entity and literature search revealed only a few case reports and series mentioning this condition to date. The importance lies in the recognition that cutaneous vascular lesions may clue to an associated spinal cord angioma or AVM that may lead to weakness or paralysis.

Exclusively epidural spinal metameric arteriovenous shunts: case report and literature review

BACKGROUND CONTEXT

Spinal arteriovenous metameric syndrome (SAMS) is a subgroup of spinal arteriovenous malformations (AVMs). Most SAMS cases have intra- and extradural AVMs and suffer from hematomyelia, subarachnoid hemorrhage, or venous congestive myelopathy.

PURPOSE

To present a rare case of SAMS in which spinal AVMs were exclusively epidural. We reviewed previous literature and evaluated the feasibility of a treatment strategy using endovascular interventions, followed by surgical obliteration.

STUDY DESIGN

A case report and literature review of SAMS.

METHODS

We report a case of a 15-year-old boy suffering from SAMS in which epidural venous ectasia because of extradural AVMs caused spinal cord compression.

RESULTS

The patient was successfully treated with multiple sessions of transarterial embolization followed by open surgery. After the treatment, his neurologic deficits resolved. Postoperative angiography confirmed complete obliteration of extradural AVMs.

CONCLUSIONS

Although exclusively epidural spinal AVM is an uncommon type of SAMS, combined endovascular and surgical interventions can be an effective treatment for AVMs to achieve better radiologic outcomes and complete resolution of patient symptoms.

Spinal arteriovenous metameric syndrome in a neonate presenting with congestive heart failure: case report

BACKGROUND

Spinal arteriovenous metameric syndrome (SAMS) is a combination of more than two separate vascular malformations in the same embryonic metameres. This syndrome, also known as Cobb syndrome, is rare, especially in the neonate.

CASE DESCRIPTION

A neonatal girl with a birthmark in the occipital and posterior nuchal regions presented with severe heart failure on the day of birth. The large arteriovenous fistulas in the left hypoglossal canal and in the posterior nuchal region were embolized with detachable coils on the postnatal days 5 and 18, which improved heart failure markedly. The associated intramuscular arteriovenous malformation in the posterior neck was left untreated because large arteriovenous fistulas had been occluded. She grew up without any neurological deficits and developed with normal milestones until the latest follow-up of 8 years old.

CONCLUSION

To our knowledge, this is the first case with SAMS in a neonate presenting with congestive heart failure. Presence of a birthmark in a neonate presenting with congestive heart failure may suggest the possible underlying high-flow vascular malformations in the same metamere.

Vascular diseases of the spinal cord

Vascular disease affecting the spinal can cause substantial neurologic morbidity. Several vascular spinal cord ailments present as neurologic emergencies, and should thus be recognizable to the practicing neurologist. We review the epidemiology, presentation, management strategies, and prognosis of various pathologies, including infarction, dural arteriovenous fistula, arteriovenous malformation, cavernous malformation, compressive epidural hematoma, vasculitis, and genetic abnormalities.

Obliteration of a metameric spinal arteriovenous malformation (Cobb syndrome) using combined endovascular embolization and surgical excision

Cobb syndrome represents the concurrent findings of a metameric spinal vascular malformation and a cutaneous vascular malformation within several dermatomes of each other. This rare entity engenders many difficult decisions with respect to appropriate therapeutic management. Historically, surgical excision carried a high morbidity, and conservative management without intervention was preferred. More recently, several cases of endovascular embolization have been reported with good success. The authors describe the case of a 17-year-old boy who presented with a right gluteal angioma and was found to have a spinal arteriovenous malformation. Multiple embolizations failed to prevent neurological deterioration, and the patient eventually became wheelchair dependent. Surgical excision of the malformation led to partial recovery of neurological function, and at the latest follow-up, 52 months postoperatively, the patient was able to ambulate independently. This case demonstrates the successful treatment of a patient with Cobb syndrome with surgical excision after multiple refractory embolizations. A multidisciplinary approach, which balances the patient's current neurological function against the risks and potential gains from any interventional and surgical procedure, is recommended.

Spinal arteriovenous malformation associated with spinal metameric syndrome: a treatable cause of long-term paraplegia?

Cutaneomeningospinal angiomatosis, or Cobb syndrome, is a rare metameric developmental disorder presenting as an extradural-intradural vascular malformation that involves bone, muscle, skin, spinal cord, and nerve roots. A 14-year-old girl with a red nevus involving the T6-9 dermatomes on the left side of her back presented with a 5-year history of bowel and bladder incontinence, paraplegia, and lower-extremity sensory loss. Magnetic resonance imaging demonstrated a hemangioma in the T-8 and T-9 vertebral bodies and a spinal cord AVM nidus extending from T-6 to T-9. The AVM was successfully embolized and the patient regained lower-extremity strength, ambulation, and normal sphincter functions after 5 years of having been wheelchair bound. The authors report the restoration of ambulation after endovascular embolization of a large spinal AVM in a patient with long-standing paraplegia due to Cobb syndrome.

Spinal arteriovenous malformation presenting as spastic monoplegic cerebral palsy in a child

A case of spinal arterio-venous malformation (AVM) initially diagnosed as unilateral cerebral palsy (CP) is reported. The presentation was of a long-standing spastic monoparesis of the left leg, with initial response to Botulinum toxin injections to the calf and tibialis posterior muscles. This was followed by progressive deterioration occurring over a 3-month period before further investigation and definitive diagnosis at 7 years. Imaging demonstrated a large extra-medullary spinal AVM compressing the mid-thoracic cord. This was successfully managed by embolisation with a non-adhesive polymer: ethylene-vinyl alcohol copolymer injected into the dominant feeding vessel. This case highlights the need to consider alternative diagnoses when a child with a diagnosis of CP presents with atypical clinical features such as monoparesis and has worsening or altered clinical signs. Moreover, a normal magnetic resonance imaging brain scan and the absence of ipsilateral upper limb neurological signs or functional impairment should raise suspicion even in the context of static lower limb signs. A literature review was performed on the management of spinal AVM in children and this will be is discussed.

Angiogenic and inflammatory factor expressions in cutaneomeningospinal angiomatosis (Cobb's syndrome): case report

We report on a case of cervical cutaneomeningospinal angiomatosis (Cobb's syndrome), a rare somatic disorder, characterized by vascular abnormalities of the spinal cord, with a triad of associated vascular skin, muscle, bone, and dura involvement at the same somite. This case follows an 18-year-old male patient presenting with left extremity weakness and back cervical pain. Magnetic resonance imaging (MRI) revealed a spinal cord arteriovenous malformation (AVM) at the C3-C5 level. Cobb's syndrome was diagnosed by coexistence of cutaneous naevi in a dermatomal pattern and neurological signs of a spinal cord lesion together with cervical MRI and angiography. The patient underwent a combination of staged endovascular embolization and microsurgical resection. Multiple biopsies of the mass including the skin, muscle, dura, and spinal cord at the same somite revealed that the lesions had a similar pathology. Post-operative immunohistochemical characterizations on specimen included CD31, smooth muscle actin (SMA), vascular endothelial growth factor (VEGF), and matrix metalloproteinase (MMP-9). The unique associations of somatic and spinal cord lesion as well as angiogenic and inflammatory factor expressions in all specimens are reported.

Metameric thoracic lesion: report of a rare case and a guide to management

Metameric lesions of the spine are rare. The authors present a case of patient with a complex metameric vascular lesion of the thoracic spine and describe a management strategy for this entity.

Cobb syndrome: a case report and systematic review of the literature

We report on a case of Cobb syndrome, a rare metameric disorder, characterized by a vascular abnormality of the spinal cord, with an associated vascular skin lesion of the same metamere, in an 8-year-old girl presenting with leg weakness. Magnetic resonance imaging revealed a spinal arteriovenous malformation at the level of T(10)-L(5). This finding, together with a large, pigmented nevus at this level, is diagnostic for Cobb syndrome. A systematic review of the literature on Cobb syndrome, with a focus on treatment and outcomes, is presented. Current treatment options include combinations of embolization, neurosurgical intervention, corticosteroid therapy, and radiotherapy.

Cobb syndrome in an infant: treatment with endovascular embolization and corticosteroid therapy: case report

OBJECTIVE AND IMPORTANCE

Cobb syndrome is a rare clinical entity characterized by the combination of a vascular skin nevus and an angioma in the spinal canal at the same metamere. We present a case report of an infant with Cobb syndrome.

CLINICAL PRESENTATION

A 5-month-old girl presented with cutaneous hemangioma of the thoracolumbar region (T5-T12) and paraparesis. The infant was examined by magnetic resonance imaging and aortography and was diagnosed with Cobb syndrome.

INTERVENTION

The patient received orally administered prednisolone therapy and underwent endovascular embolization of paravertebral and spinal angiomas with the use of n-butyl-2-cyanoacrylate. Her symptoms improved by combined treatment with liquid embolization and corticosteroid therapy.

CONCLUSION

Although Cobb syndrome has been reported in older children, it is extremely rare in infants. To our knowledge, this is the first report of an infant with Cobb syndrome treated with endovascular embolization and corticosteroid therapy. The combined treatment with corticosteroid therapy and endovascular embolization of cutaneomeningospinal angioma in Cobb syndrome seems effective in alleviating symptoms and minimizing morbidity.

Neurocutaneous vascular hamartomas mimicking Cobb syndrome. Case report

The authors report the rare case of a patient with neurocutaneous vascular hamartomas mimicking Cobb syndrome. An 8-year-old boy was admitted to the authors' hospital with progressive urinary disturbance and upper back pain. Multiple skin nevi had been noted at the child's birth. Radiological examination revealed multiple cavernous angiomas in the spinal cord in the same metamere in which the skin nevi had been observed and also in the left cerebral hemisphere. His symptoms gradually improved without surgical intervention. Four years later he was readmitted because of a cerebral hemorrhage involving the left cerebral peduncle. Nonsurgical treatment was chosen because his symptoms promptly improved. To the best of the authors' knowledge, this is the first case of multiple cavernous angiomas in the brain and spinal cord associated with skin nevi. The authors discuss this clinical entity and the significance of the disease.

Nonadhesive liquid embolic agent for cerebral arteriovenous malformations: preliminary histopathological studies in swine rete mirabile

OBJECTIVE

To assess acute and chronic histopathological changes observed in a swine arteriovenous malformation model after endovascular delivery of Embolyx E (Micro Therapeutics Inc., San Clemente, CA) and its organic solvent dimethyl sulfoxide (DMSO). To develop standard endovascular delivery techniques of Embolyx through microcatheters into swine rete mirabile (RMB).

METHODS

Forty RMBs in 22 swine were used to analyze acute and chronic angiographic and histological changes after superselective delivery of Embolyx E and/or its organic solvent (DMSO). Four RMBs (two for DMSO and two for Embolyx E study) were used as control specimens. Angiographic and histological evaluations were obtained 18 days, 1 month, 3 months, and 6 months after the procedure. Particular attention was paid to the presence of focal or diffuse angionecrosis, arterial revascularization, and perivascular inflammatory response.

RESULTS

Staged and/or continuous delivery of Embolyx E were performed through the DMSO-compatible microcatheters without untoward catheter "gluing." All subacute/chronic specimens embolized with Embolyx E showed no evidence of angiographic recanalization. Twelve RMBs were used in acute studies, and all specimens showed no evidence of angionecrosis or aggressive inflammatory reaction. Subacute and chronic (total, n = 14) histological examinations of the RMBs showed mild inflammatory response manifested by monocellular infiltration and scattered foreign body giant cell reaction. In the 9 of 14 subacute and chronic specimens, focal disruption of elastica was observed along with embolic materials. Fourteen RMBs in eight swine were used to determine the safety range for DMSO injection. Two RMBs were used as control specimens. Rapid intra-arterial delivery (0.5 ml/5-15 s, n = 6) of DMSO caused angiographic vasospasm and histological endothelial necrosis. Slow injection (0.5 ml/30-120 s, n = 8) of DMSO showed minimum or no angiographic vasospasm, minimal adventitial inflammatory response, and no clinical complications.

CONCLUSION

Embolyx E, an occlusive and nonadhesive embolic agent, is capable of producing permanent occlusion of swine RMB with the development of mild intra- and perivascular inflammatory changes and no clinical complications. The slow endovascular delivery of DMSO produces no untoward angiographic, pathological, or clinical changes. A fast injection of DMSO causes endothelial necrosis and severe inflammatory response in the arterial wall. This embolic material seems to have appropriate biochemical, anatomic, and histopathological characteristics to be used in the treatment of cerebral arteriovenous malformations or vascular cranial base tumors.

Classification and therapeutic modalities of spinal vascular malformations in 80 patients

OBJECTIVE

To set up a more detailed classification system for spinal vascular malformations and to discuss the relationship between the classification and therapeutic alternatives.

METHODS

Case series from the tertiary care center were studied. Spinal vascular malformations in 80 patients were reviewed and classified into intramedullary arteriovenous malformations (AVMs) (juvenile and glomus AVMs), intradural arteriovenous fistulas (AVFs) (Type I-III), dural AVFs, paravertebral AVMs, and Cobb's syndrome. Therapeutic alternatives to each type of spinal vascular malformations, including surgery, endovascular embolization, and a combination of both, as well as the short-term outcomes, were analyzed.

RESULTS

Of the 80 patients, 38 (47.5%) had intramedullary AVMs (23 juvenile and 15 glomus AVMs), 27 (33.8%) had intradural AVFs (6 Type I, 14 Type II, and 7 Type III), 8 (10%) had dural AVFs, and 7 (8.8%) had other malformations. Most of the juvenile AVMs and the Types II and III AVFs were treated by endovascular embolization. Other lesions were treated by surgery or preoperative embolization plus surgery. Among the 76 patients whom we treated, early clinical improvement was achieved in 66 (86.8%). Six (7.9%) remained stable, and four (5.3%) became worse.

CONCLUSION

Our classification system offers only limited guidance for the treatment of spinal vascular malformations. Successful treatment in each individual spinal vascular malformation requires correct understanding of the lesion's anatomic location and its angioarchitecture, as well as the limitations of both surgery and endovascular embolization.

The department of neurosurgery, Kyoto University School of Medicine

Kyoto University, founded in 1897, is the second oldest national university in Japan. Kyoto University Hospital opened in 1899, and neurosurgical activities began soon thereafter, mainly within the Department of Surgery. The Department of Neurosurgery was established in 1964 and has since steadily extended its clinical territory. The department has provided neurosurgeons and residents for 80 neurosurgical services at 12 related universities/colleges and 68 satellite hospitals. Approximately 400 operations per year are performed, and more than 30 research projects are ongoing in collaboration with other departments and scientific institutions. The main function of our department is the education and production of leading neurosurgeons who have profound knowledge in basic sciences.