Spinal thoracic extradural angiolipoma manifesting as acute onset of paraparesis: Case report and review of literature

Demographic and clinical data of patients with spinal epidural angiolipomas

Spinal epidural angiolipomas are rare, benign, mesenchymal tumors. It remains unclear whether spinal epidural angiolipomas are genuinely rare or merely underreported. Herein, we assessed the demographic and clinical characteristics of patients with spinal epidural angiolipoma. We collected data from patients with spinal epidural angiolipoma from three sources. First, we retrospectively analyzed data from patients diagnosed with spinal epidural angiolipoma in our hospital between January 1, 2014, and December 31, 2023. Second, we performed a literature review of studies retrieved from PubMed. Third, we retrieved detailed data of patients with spinal angiolipoma from the Surveillance, Epidemiology, and End Results (SEER) database. We conducted a descriptive analysis to investigate the demographic and clinical characteristics of patients with spinal epidural angiolipoma. At our institution, three patients were diagnosed with spinal epidural angiolipoma. Additionally, we identified 116 patients from the literature review and 15 patients from the SEER database. We reviewed the treatment history and imaging features of the three patients from our institution. The descriptive analysis of the data collected from the literature review was consistent with previous reports. For example, 63.0% of lesions were located at the thoracic level. 31.9% of these lesions involved two vertebral bodies, while 75.6% involved 2-4 vertebral bodies. The most common symptoms experienced by patients were back pain, paraparesis, and numbness in the legs. Surgery was the primary treatment option for most patients, and complete tumor resection was achieved in the majority of patients. The male:female ratio was 1:1.4, the median age at diagnosis for the patients from the literature was 49 years old, and the median follow-up was 24 months. Notably, most of the reports came from Asia and there were few reports from Africa. The findings from the SEER database indicated a male:female ratio of 2:1. The peak incidence, which is typically reported in the fifth decade of life, was not observed. We presented three cases of spinal epidural angiolipoma and supplemented our findings with a literature review and population-based analysis according to the SEER database for the United States population. We believe that our research will enhance clinicians' comprehension of this uncommon tumor.

Thoracic Spinal Angiolipomas: A Systematic Review

BACKGROUND

 Spinal angiolipomas (SAs) are rare, benign tumors, representing 0.0004 to 1.2% of angiolipomas, usually located at the extradural and posterior thoracic level, with multimetameric extension.

METHODS

 A systematic literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The authors searched on PubMed and Scopus databases for published articles with the Mesh term "spinal angiolipoma" and pertinent associations. Language restriction to English papers was applied. The authors also reported three emblematic cases of patients who underwent surgical resection of spindle-shaped (type IA) and dumbbell-shaped (type II) SAs between 2014 and 2020.

RESULTS

 Of the 256 retrieved articles, 33 were included in the meta-analysis. These 33 studies, together with our 3 reported cases, included a total of 60 patients, 36 females (60%) and 24 males (40%), with a mean age of 53.12 ± 12.82 years (range: 12-77 years).T5 was the most represented level (22 patients). Usually, the localization of SA was extradural, with 53 patients suffering from spindle-shaped type IA SA (88.3%) and 7 patients from dumbbell-shaped type II SA (11.6%). Almost all patients underwent laminectomy (78.3%) and presented a full recovery of motor deficits (85%). Gross total removal (GTR) was performed in 93.3% of patients. The mean follow-up was of 22.71 ± 21.45 months (range: 2-80 months). There was no documented recurrence at follow-up magnetic resonance imaging in any of the patients.

CONCLUSIONS

 SAs are rare, benign tumors with a great vascular component that presents a favorable outcome. GTR is the gold standard treatment and usually an adjuvant therapy is not required. Even infiltrative lesions, which are more complex, can be treated successfully with a good prognosis. Dumbbell-shaped SAs must be differentiated from schwannomas and meningiomas, and require different surgical techniques, given the profuse bleeding associated with the attempt of debulking. En block resection is the key to treat these common benign tumors with acceptable blood loss.

Hemorrhagic Sudden Onset of Spinal Epidural Angiolipoma

Angiolipomas are relatively rare benign tumors. Spinal angiolipomas that generally induce slow progressive cord compression are most commonly found in the thoracic region. A 49-year-old female with obesity presented with a 1-week history of progressively worsening back pain, paresthesia of lower limbs, and gait disturbance. When thoracic magnetic resonance imaging (MRI) revealed a dorsal epidural mass at the Th5–Th8 level, the patient underwent a laminectomy for gross total excision of the lesion. Both mature fatty tissue and abnormal proliferating vascular elements with thin or expanded walls were observed in the resected tumor. Nonfiltrating spinal angiolipoma was diagnosed and confirmed by pathology. After the operation, sensory loss, numbness, and gait disturbance were improved following the disappearing severe back pain. Following examinations indicated the absence of recurrence within 1 year. The angiolipomas of the spine are rare causes of spinal cord compression that generally induce slow progressive cord compression, but sudden onset or rapid worsening of neurological deterioration is observed in hemorrhagic spinal angiolipoma.

Spinal extradural angiolipoma: a report of two cases and review of literature

Spinal extradural angiolipomas (SEALs) are extremely extraordinary benign extradural lesions. They are infrequently encountered in normal clinical practice although several authors have report single cases or case series. We present two cases of SEAL which we successfully surgical resected with no further neurological deficits. Our cases comprise of a male and a female with ages ranging from 30 to 60 years. Their principal presenting complains were numbness and pain at the lower extremity with associated fecal and urinary incontinence. In all our cases, MRI revealed extradural spinal lesions that exerted compressive effect on the spinal cord. The male patient had an infiltrating type while the female had non-infiltrating type. We attained total resection in both cases without any further neurological complication. The diagnosis of SEALs initially can be challenging radiologically since they may mimic other spinal lesions. The gold standard treatment modality should always be surgery although total resection may not be achievable in some cases.

Epidural angiolipoma: A rare cause of spinal cord compression

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Spinal epidural angiolipoma is a rare cause of progressive spinal cord compression.

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Magnetic resonance imaging is necessary for diagnosis.

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Total resection is the treatment of choice.

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Necessary precautions before and during surgery have to be taken (embolisation, transfusion).

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Prognosis after surgical management is excellent even at the stage of complete paraplegia.

Introduction

Angiolipomas are benign, slow growing lesions, almost always located subcutaneously in the trunc or limbs. They are composed of mature lipocytes admixed with abnormal blood vessels. Spinal epidural angiolipoma are rare accounting for approximately 0.14–1.2% of all spinal axis tumors and 2–3% of epidural spinal tumors.

Presentation of case

We report the case of a 65 years-old-woman, presenting with complete paraplegia installed since 7 months. Magnetic resonance imaging (MRI) showed an epidural dorsal fatty mass. The patient recovered immediately after surgery. The pathological examination concluded to an angiolipoma.

Discussion

Angiolipoma patients most commonly have long-lasting pain and then develop progressive neurological symptoms secondary to spinal cord compression. The mean duration of symptom progression at diagnosis is 1 year. MRI is the most reliable examination for the diagnosis of spinal angiolipoma. Total resection is the treatment of choice. No adjuvant treatment is indicated.

Since SAL are very haemorrhagic lesions, preoperative embolization is recommended.

Conclusion

We think that spinal cord compression caused by angiolipoma have very good functional prognosis, even if tardily diagnosed