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Muacevic A, Adler JR, Wichmann W, Magagna-Poveda A, Fandino J. Lumbar Epidural Cavernous Hemangioma: A Case Report and Review of the Literature. Cureus 2023; 15:e33677. [PMID: 36788892 PMCID: PMC9918856 DOI: 10.7759/cureus.33677] [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: 01/11/2023] [Indexed: 01/14/2023] Open
Abstract
Pure epidural cavernous hemangioma (ECH) of the spine are rare and account for only 4% of all epidural spinal lesions. We report a case of epidural cavernoma at L3/4 presenting with L4 radiculopathy. Radiological, intraoperative findings and histopathology are presented. We present the case of a 56-year-old man who was admitted with a right L4 radiculopathy including an M4 paresis of the right leg, hypoesthesia L4, and radicular pain. Magnetic resonance imaging (MRI) confirmed an extradural lesion L3/4 partially expanding into the right intervertebral foramen. The lesion had a heterogeneous signal, isointense on T1-weighted and hyperintense on proton density (PD) and T2-weighted images. At surgery, an epidural, ovoid, gray-red, soft mass, lightly adherent to the dura and extending to the right L4 foramen was observed. Findings in the histological examination indicated a cavernous hemangioma without signs of hemorrhage. Symptoms and paresis improved rapidly after surgery. The follow-up MRI showed complete resection of the lesion with no signs of radicular compression. Spinal ECH should be considered as a cause of chronic lumbar radiculopathy with atypical radiological findings. Early diagnosis and total removal of the spinal ECH might prevent hemorrhage and neurological deficits. Fewer than 50 cases of lumbar epidural spinal hemangioma have been reported until today, and our case report is adding valuable knowledge to the existing literature.
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Fiani B, Reardon T, Jenkins R, Covarrubias C, Sekhon M, Soula M, Kortz M. Intramedullary spinal cord cavernous malformations in the pediatric population. Surg Neurol Int 2020; 11:275. [PMID: 33033637 PMCID: PMC7538982 DOI: 10.25259/sni_494_2020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 08/22/2020] [Indexed: 12/25/2022] Open
Abstract
Background: Intramedullary spinal cavernous malformations (ISCM) account for just 1% of all intramedullary pediatric spinal cord lesions. Pathologically, they are well-circumscribed vascular malformations that typically appear dark blue or reddish-brown, often coming to the spinal cord surface. With regard to the histopathology findings, ISCMs are comprised sinusoidal vascular spaces lined by a single layer of endothelial cells within a loose connective tissue stroma. As these lesions are often misdiagnosed in the pediatric population, appropriate treatment may be unduly delayed. Methods: The authors performed an extensive review of the published literature (PubMed) focusing on ISCM in the pediatric age group. Results: The search yielded 17 articles exclusively pertaining to ISCM affecting the pediatric population. Conclusion: Here, we reviewed the clinical, radiographic, surgical, and outcome data for the treatment of ISCM in the pediatric age groups. Notably, over 50% of pediatric patients with ISCM experienced an improvement in their neurological status after a mean postoperative follow-up duration of 4 years. Future meta-analyses are needed to highlight the potential presence of ISCM and, thereby, decrease the rate of misdiagnosis of these lesions in the pediatric population presenting with recurrent intramedullary spinal cord hemorrhages.
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Affiliation(s)
- Brian Fiani
- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, CA
| | - Taylor Reardon
- Kentucky College of Osteopathic Medicine, University of Pikeville, Pikeville, KY
| | - Ryne Jenkins
- College of Osteopathic Medicine, Western University of Health Sciences, Pomona, CA, United States
| | - Claudia Covarrubias
- School of Medicine, Universidad Anáhuac Querétaro, Cto. Universidades, Santiago, de Querétaro, Mexico
| | - Manraj Sekhon
- William Beaumont School of Medicine, Oakland University, Rochester, Michigan
| | - Marisol Soula
- Grossman School of Medicine, New York University, New York
| | - Michael Kortz
- Department of Neurosurgery, University of Colorado, Aurora, Colorado, United States
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Radiation-Induced Spinal Cord Cavernous Malformations Associated with Medulloblastoma: Case Report and Review of the Literature. World Neurosurg 2020; 141:318-322. [PMID: 32592964 DOI: 10.1016/j.wneu.2020.06.125] [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: 05/01/2020] [Revised: 06/13/2020] [Accepted: 06/16/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Radiation-induced spinal cord cavernous malformations (CMs) are rare pathologies compared with radiation-induced cerebral CMs. We present a case of a radiation-induced spinal cord CM developed 31 years after radiation therapy for medulloblastoma. CASE DESCRIPTION A 37-year-old man developed a symptomatic spinal hemorrhagic lesion 31 years after radiation therapy for medulloblastoma. Magnetic resonance imaging revealed an intramedullary cystic lesion with a fluid-fluid level in the C7 area. Surgery was performed leading to an unclear diagnosis. Two years later, the patient had a relapse and underwent a second operation, allowing a definitive diagnosis of radiation-induced spinal cord CM. This is believed to be the second case of de novo intramedullary CM formation following spinal radiation therapy for medulloblastoma. CONCLUSIONS Radiation-induced spinal cord CMs should be recognized as a possible late adverse effect in patients treated with radiation therapy for medulloblastoma.
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Won YI, Kim CH, Chung CK, Yun TJ. Delayed diagnosis of probable radiation induced spinal cord vascular disorders. J Korean Neurosurg Soc 2015; 57:215-8. [PMID: 25810864 PMCID: PMC4373053 DOI: 10.3340/jkns.2015.57.3.215] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Revised: 08/07/2014] [Accepted: 08/13/2014] [Indexed: 11/27/2022] Open
Abstract
Occasionally, unexpected neurological deficits occur after lumbar spinal surgery. We report a case of monoparesis after lumbar decompressive surgery. A 63-year-old man, who had undergone decompression of L4-5 for spinal stenosis 4 days previously in the other hospital, visted the emergency department with progressive weakness in the left leg and hypoesthesia below sensory level T7 on the right side. He had been cured of lung cancer with chemotherapy and radiation therapy 10 years previously, but detailed information of radiotherapy was not available. Whole spine magnetic resonance (MR) imaging showed fatty marrow change from T1 to T8, most likely due to previous irradiation. The T2-weighted MR image showed a high-signal T4-5 spinal cord lesion surrounded by a low signal rim, and the T1-weighted MR image showed focal high signal intensity with focal enhancement. The radiological diagnosis was vascular disorders with suspicious bleeding. Surgical removal was refused by the patient. With rehabilitation, the patient could walk independently without assistance 2 months later. Considering radiation induced change at thoracic vertebrae, vascular disorders may be induced by irradiation. If the spinal cord was previously irradiated, radiation induced vascular disorders needs to be considered.
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Affiliation(s)
- Young Il Won
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea. ; Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea. ; Neuroscience Research Institute, Seoul National University Medical Research Center, Seoul, Korea. ; Clinical Research Institute, Seoul National University Hospital, Seoul, Korea
| | - Chi Heon Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea. ; Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea. ; Neuroscience Research Institute, Seoul National University Medical Research Center, Seoul, Korea. ; Clinical Research Institute, Seoul National University Hospital, Seoul, Korea
| | - Chun Kee Chung
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea. ; Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea. ; Neuroscience Research Institute, Seoul National University Medical Research Center, Seoul, Korea. ; Clinical Research Institute, Seoul National University Hospital, Seoul, Korea. ; Department of Brain and Cognitive Sciences, Seoul National University College of Natural Sciences, Seoul, Korea
| | - Tae Jin Yun
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
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El Hassani Y, Burkhardt K, Delavellle J, Vargas MI, Boex C, Rilliet B. Symptomatic syringomyelia occurring as a late complication of posterior fossa medulloblastoma removal in infancy in a boy also suffering from scaphocephaly. Childs Nerv Syst 2009; 25:1633-7. [PMID: 19662425 DOI: 10.1007/s00381-009-0968-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2009] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The association of a medulloblastoma and a syringomyelia has been already described in rare instances albeit without symptoms related to the syrinx. CASE REPORT The case of a 23-year-old man operated in infancy for a medulloblastoma and then treated solely with adjuvant chemotherapy is reported. He was also operated in infancy for a scaphocephaly. With a very long time delay, he has developed a Chiari I and a symptomatic cervico-dorsal syringomyelia. The symptoms attributed to the syrinx consisted of a unilateral prurigo over the left arm which was so severe to lead to self-mutilation. DISCUSSION Clinical and magnetic resonance imaging follow-up after cervico-dorsal decompression shows a significant improvement of the symptoms together with a reduction of the size of the syrinx. This case is discussed in the light of the presumed pathophysiology of the syrinx and its exceptional clinical presentation.
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Affiliation(s)
- Yassine El Hassani
- Service de Neurochirurgie, Hôpital Cantonal Universitaire, 24 rue Micheli-du-Crest, 1211 Geneva 14, Switzerland
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Ducray F, Guillevin R, Psimaras D, Sanson M, Mokhtari K, Delanian S, Navarro S, Maisonobe T, Cornu P, Hoang-Xuan K, Delattre JY, Pradat PF. Postradiation lumbosacral radiculopathy with spinal root cavernomas mimicking carcinomatous meningitis. Neuro Oncol 2008; 10:1035-9. [PMID: 18755918 DOI: 10.1215/15228517-2008-069] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Lumbosacral radiculopathy is a rare complication of radiotherapy and may be challenging to differentiate from diagnosis of a tumor recurrence. We reviewed the records of three patients with a past history of cancer and radiotherapy who were referred for suspicion of carcinomatous meningitis on lumbar MRI, but whose final diagnosis was radiation-induced lumbosacral radiculopathy. The three patients developed a progressive lumbosacral radiculopathy at 20, 13, and 47 years after lumbar radiotherapy delivered for renal cancer, Hodgkin's disease, and a seminoma, respectively. MRI showed a diffuse, nodular enhancement of the cauda equina nerve roots on T1 sequences, suggestive of leptomeningeal metastasis. A slowly progressive clinical course over several years and negative cerebrospinal fluid cytologic analysis ruled out the diagnosis of carcinomatous meningitis. Because of the radiologic findings, a biopsy was performed in two patients. In the first, a biopsy limited to the arachnoid excluded a malignant infiltration. In the second, a biopsy of the enhancing lesions demonstrated spinal root cavernomas. These observations, together with three recent case reports in the literature, delineate a syndrome of "radiationinduced lumbosacral radiculopathy with multiple spinal root cavernomas" that mimics carcinomatous meningitis on MRI. Its diagnosis is important in order to avoid inappropriate treatment and useless or dangerous spinal root biopsies.
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Affiliation(s)
- François Ducray
- Service de Neurologie Mazarin, APHP, Groupe hospitalier Pitié-Salpêtrière, Paris, France
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Lena G, Ternier J, Paz-Paredes A, Scavarda D. Cavernomes du système nerveux central chez l'enfant. Neurochirurgie 2007; 53:223-37. [PMID: 17507057 DOI: 10.1016/j.neuchi.2007.02.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2007] [Accepted: 02/22/2007] [Indexed: 11/20/2022]
Abstract
UNLABELLED Cavernomas represent 1.7 to 18% of all vascular malformations in children and 25% are observed in children under 18 years of age. Cases observed in neonates and infants have been published, but the mean age varies from 9.1 to 10.2 years. There is no predominance between boys and girls. CLINICAL PRESENTATION In children, hemorrhage is a common manifestation with an incidence varying from 27.3 to 78% versus 8 to 37% in adult patients. Isolated headaches occur in 2.8% of patients and elevated ICP is observed in 20.1%. Epilepsy is reported in 16 to 60% of children, depending on the series. Neurological deficits are observed in 22.7% of patients and are more severe for deep-seated and brainstem cavernoma. About 14.2% of the cases are discovered fortuitously in asymptomatic patients. Spinal cord deficits are observed in 5% of the cases. LOCATION Using data in the literature plus our personal series of 57 cases, 79.4% of lesions are in the supratentorial compartment and 20.6% in the posterior fossa, the majority located in the brainstem, most of them in the pons. Spinal cord cavernomas represent 5% and multiples cavernomas (12.6%) of the reviewed cases. MANAGEMENT Appropriate management of cavernomas has long been a subject of much debate. Today, a consensus has been reached to favor medical management of asymptomatic and non hemorrhagic lesions and surgical management of symptomatic and/or hemorrhagic cavernomas whatever the localization. Progress in neuroimaging, surgical mapping, intraoperative monitoring and microsurgical techniques has greatly contributed to improved approach to those lesions. RESULTS Results obtained in 217 cases were reviewed. Near 70% of the children are neurologically intact, 19.3% are improved or stable, 2.7% worsened and 1.13% died. Results for epilepsy are very encouraging, surgery is efficient in almost all the children except for temporal lobe cavernomas where invasive presurgical evaluation is recommended. Deep-seated and brainstem cavernomas can safely be removed in most of the cases. Only two children died from recurrent hemorrhage due to residual lesions.
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Affiliation(s)
- G Lena
- Unité fonctionnelle de neurochirurgie pédiatrique, hôpital des enfants de La Timone, 286 rue Saint-Pierre, 13385 Marseille cedex 05, France.
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Keene DL, Johnston DL, Grimard L, Michaud J, Vassilyadi M, Ventureyra E. Vascular complications of cranial radiation. Childs Nerv Syst 2006; 22:547-55. [PMID: 16607532 DOI: 10.1007/s00381-006-0097-4] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2004] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Cerebral vascular disease has been reported as a long-term complication of cranial radiotherapy. The purpose of this study was to examine the frequency and risk factors associated with development of cerebral vascular disease in children after cranial radiation. MATERIALS AND METHODS A retrospective chart review of all cancer patients treated between 1985 and 2003 who were under the age of 18 years at the time of initial radiotherapy was performed. Variables examined include diagnosis and site of malignancy, age at the time of radiotherapy, sex, total radiation dosage, number of fractions, duration, and whether the patient had proven cerebral vascular event. RESULTS Two hundred and forty-four patients met the study criteria. One hundred and 13 cases involved tumors of the central nervous system. The remaining patients had systemic neoplastic disease. Post radiation cerebral vascular disease occurred in 11 (5%) patients, and all but one patient had a tumor involving the central nervous system (mainly in the posterior fossa and supratentorial midline). CONCLUSION There is an increased risk of cerebral vascular disease after radiation therapy in childhood, especially in children who received high dose radiation at the posterior fossa and supratentorial axial region.
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Affiliation(s)
- Daniel L Keene
- Department of Pediatrics, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON K1H 8L1, Canada.
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Duhem R, Vinchon M, Leblond P, Soto-Ares G, Dhellemmes P. Cavernous malformations after cerebral irradiation during childhood: report of nine cases. Childs Nerv Syst 2005; 21:922-5. [PMID: 15662523 DOI: 10.1007/s00381-004-1120-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2004] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Cavernous hemangioma is increasingly recognized as a late complication of cerebral irradiation (CI); however, the significance of the problem, especially the risk of hemorrhage, is not documented in the literature. In order to discover this, we reviewed our experience of radiation-induced cavernous hemangiomas (RICH) in patients who had received CI during childhood. METHODS We reviewed retrospectively our pediatric database of 965 brain tumors, 419 of which were irradiated between 1964 and 2003. We collected nine cases of RICH diagnosed in patients who had received CI during childhood. RESULTS The CI dosage ranged between 25 and 55 Gy. The interval between CI and the diagnosis of RICH ranged from 4 to 22 years. The RICH was the cause of brain hemorrhage in five cases, three of which required surgical evacuation. DISCUSSION Radiation-induced cavernous hemangiomas are an underestimated problem, and systematic screening of irradiated patients with gradient-echo MRI will probably yield more asymptomatic cases. We think that not all RICH require surgery, but only those responsible for intracerebral hemorrhage or that show radiological progression. CONCLUSION With respect for the long interval between CI and diagnosis of RICH, we advise control with MRI, including gradient-echo sequence, as late as 15 years after CI, and closer monitoring of asymptomatic RICH.
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Affiliation(s)
- Raphaël Duhem
- Department of Pediatric Neurosurgery, University Hospital Lille, Lille, France.
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