Pakistan Journal of Medical Sciences

Published by : PROFESSIONAL MEDICAL PUBLICATIONS

ISSN 1681-715X

HOME   |   SEARCH   |   CURRENT ISSUE   |   PAST ISSUES

-

CASE REPORT

-

Volume 25

January - March 2009

Number  1


 

Abstract
PDF of this Article

Thoracic spinal epidural mixed capillary-cavernous
haemangioma: Case report and review of literature

HA Chatha1, S Ullah2, F Chan3

SUMMARY:

We describe a case of a patient with a thoracic spinal mixed capillary/ cavernous haemangioma, who was operated for decompression. The literature regarding spinal haemangiomas is reviewed and the symptomatology, neuro-radiology, pathology, management and prognosis of these lesions are discussed. The need to include cavernomas in the differential diagnosis of various spinal conditions is emphasized.

Key Words: Cavernous Haemangiomas.

Pak J Med Sci    January - March 2009    Vol. 25 No. 1   155-158

How to cite this article:

Chatha HA, Ullah S, Chan F. Thoracic spinal epidural mixed capillary-cavernous haemangioma: case report and review of literature. Pak J Med Sci 2009;25(1):155-158.


1. HA Chatha
SHO Tameside Hospital NHS Trust,
Ashton under Lyne,
UK,OL69RW.
2. Sana Ullah
SHO Castle Hill Hospital,
Cottingham,UK.HU165JQ
3. F Chan
1-3: Department of Trauma & Orthopaedics,
Tameside General Hospital
Ashton Under Lyne,
United Kingdom.

Correspondence

Mr. Hamid Aizaz Chatha
E-Mail: hamidchatha@hotmail.com

* Received for Publication: July 15, 2008
* Revision Received: December 17, 2008
* Revision Accepted: December 20, 2008


INTRODUCTION

Cavernous haemangiomas are uncommon vascular malformations that usually effect central nervous system. They occur in both sporadic and familial form. They are usually located intracerebral or in the brain stem but can occur in any part of neuraxis including the spine1,2 and may be associated with hemorrhages, focal deficits and fits.3-7 In the spine, most of the vascular lesions are the secondary extensions of vertebral haemangiomas.8 Epidural haemangiomas represent 4% of spinal epidural tumors and 12% of all intraspinal haemangiomas.4,6,9

CASE REPORT

Presentation and examination: Seventy Two years old lady presented to A&E with severe back pain, progressive weakness with dysesthesia in both lower limbs for last four weeks and now unable to walk. There was history of difficulty in opening bowels, however there was no problem with bladder. There was no history of trauma.

Neurological examination on current presentation revealed decreased sensation of pain, position and touch below T6, power in lower limbs was Grade 4, reflexes were normal and Babinski’s reflexes were negative. X-rays did not show any abnormality. Routine blood investigations including Myeloma screen were normal. In view of her symptoms a suspicion of thoracic spinal cord lesion was raised and thoraco-lumber MRI scan was requested. MRI scan showed a mass compressing onto the cord extending from the posterior element of T4 and T5 (Fig 1 & 2). There was mixed signal characteristics in this vertebral body and adjacent bony structures with low signal on T1 (Fig-1), high on T2 (Fig-2) and evidence of some enhancement following Gadolinium on T1 sequences. Next day she developed urinary retention and her Babinski’s reflexs were positive.

Operation and recovery: She was shifted to local spinal unit, where she had decompression on spinal cord at T4 and T5 level along with extirpation of brown lesion which was displacing the spinal cord anteriorly. The patient had good recovery in both motor strength and sensations, bowel and bladder functions recovered and could easily walk with out support.

Histology: The lesion was highly vascular replacing paraspinal soft tissue and bone. It was composed of conglomerate of blood vessels lined by single layer of plump endothelial cells on fibromyxoid stroma. Some of these were filled with blood. Some vessels were more in keeping with cavernous spaces in appearance. There was no evidence of atypia or neoplastic change. A diagnosis of mixed capillary / cavernous haemangioma was made.

DISCUSSION

Epidural cavernous haemangiomas are extremely rare benign lesion. The majority of these represent extension from vertebral haemangiomas into spinal canal.10 They constitute approximately 4% of all epidural tumors4,6-7 and 12% of all intraspinal haemangiomas.4,6,9 Any part of spine may be effected,9,11-16 but they usually develop at the thoracic or lumber level.4,9,17 Cervical lesions are rare. Laredo et al.,18 classified vertebral haemangiomas into three categories on the basis of clinical presentation.

1. a common inactive lesion, not requiring treatment;

2. Uncommon symptomatic haemangiomas with intermediate aggressiveness with possible neurological compression and requiring treatment;

3. A rare active compressive lesion which needs urgent and aggressive treatment.

The most frequent clinical picture of epidural cavernous haemangioma is progressive compressive myelopathy associated with back and/or radicular pain preceding the onset of neurological deficits. Sphincter disturbances are late manifestation.19 The sudden onset of symptoms might occur due to hemorrhage or thrombosis with in the haemangioma.5-7,12 In our case, the symptoms were gradual but progressive in nature.

MRI more accurately characterizes and demonstrates the location and extent of compression on the spinal canal. From our review of literature and MRI finding in present case, these lesions are isointense with spinal cord on T1-weighted images and hyper intense on T2-weighted images and showed homogenous strong enhancement in all patients.3,5,7,20-23

The differential diagnosis of epidural cavernous haemangiomas include neurogenic tumors, lymphomas, metastasis and rarely meningiomas.6 The above mentioned characteristics help to distinguish cavernous haemangiomas from the other pathologies of spinal cord. An epidural mass with extension to intervertebral neural foramen can be seen in neurogenic tumors.12 These tumors however have smooth contour instead of lobulated contour and frequent cystic changes could be the clue to the differential diagnosis with cavernous haemangioma.20 According to Mascalchi,14 lymphomas frequent isointense signal intensity on T2-weighted images, and less frequent paravertebral extension and intervertebral neural foraminal widening could be the clues to differential diagnosis with cavernous haemangiomas. Rarely, meningiomas can present with dumbbell or extradural location.5,7,20,22,23 However the isointense signal with spinal cord with frequent broad dural attachment (tails sign) favors the diagnosis of meningiomas.6,22

Surgical resection is the treatment of choice. Severe intraoperative hemorrhage and inrathoracic extension are the main factors limiting tumor removal.4,7,11,12,16,17,23

CONCLUSIONS

Spinal epidural cavernous haemangiomas are benign lesions, with characteristic finding on the MRI and should be considered for differential diagnosis of epidural mass. Surgical treatment has a good out come (as in our case) and should be performed, before patient’s neurological deficit becomes irreversible.

REFERENCES

1. Ogilvy CS, Louis DN, Ojemann RG. Intramedullary cavernous angiomas of the spinal cord: clinical presentation, pathological features and surgical management. Neurosurgery 1992;31:219-30.

2. Sharma R, Rout D, Radhakrishnan VV. Intradural spinal cavernomas. Br J Neurosurg 1992;6:351-6.

3. D’ Andrea G, Ramundo OE, Trillo G, Roperto R, Isidori A, Ferrante L. Dorsal foramental extraosseous hemangioma. Neurosurg Rev 2003;26:292-6.

4. Goyal A, Singh AK, Gupta V, Tatke M. Spinal epidural cavernous haemangioma: a case report and review of literature. Spinal Cord 2002;40:200-2.

5. Riccardo P, Giovanmi A. Michele P. Luigi CP. Vitale R, Piergiogio C. Epidural spinal cavernous hemangioma. Spine 1998;23:1136-40.

6. Shin JH, Lee HK. Rhim SC. Park SH, Choi CG. Suh DC. Spinal cpi­dural cavernous hemangioma: MR findings. J Comput Assist Tomogr 2001;25:257-61.

7. Talacchi A, Spinnato S, Alessandrini F, luzzolino P, Bricolo A. Radiologic and surgical aspects of pure spinal epidural cavernous angiomas: report on 5 cases and review of the literature. Surg Neurol 1999;52:198-203.

8. Enomoto H, Goto H. Spinal epidural cavernous angioma MRI finding. Neuroradiology 1991;33:462.

9. Pastushyn Al, Slin’ko El, Mirzoyeva GM. Vertebral hemangiomas: diagnosis, natural history and clinicopathological correlates in 86 patients. Surg Ncurol 1998;50:535-47.

10. Golwyn DH, Cardenas CA, Murtagh FR, Balis GA, Klei JB. MRI of cervical extradural cavernous haemangioma. Neuroradiology 1992;34:68-9.

11. Bozkus H. Tanriverdi T, Kizilkilic O, Tureci E, Oz B, Hanci M.Capillary haemangiomas of the spinal cord: report of two cases. Minim Invasive Neurosurg 2003;46:41-6.

12. Carlier R, Engerand S, Lamer S, Vallee C, Bussel B, Polivka M. Foraminal epidural extra osseous cavernous hemangioma of the cervical spine. Spine 2000;25:629-31.

13. Hillman J, Bynke O. Solitary extradural cavernous hemangioma in the spinal canal: report of five cases. Surg Neurol 1991;36:19-24.

14. Mascalchi M, Torselli P. Falaschi F. MRI imaging of spinal epidural lymphoma, Neuroradiology 1995;37:303-7.

15. Nozari K, Inomoto T, Takagi Y, Hasimoto N. Spinal intradural extramedullary cavernous angioma. J Neurosurg Spine 2003;99(3):316-9.

16. Tamimi AF, Tamimi SO. Extensive epidural hemangioma with skin and bone involvement. Spine 1995;20:2470-2.

17. Rao GP, Bhaskar G, Hemaratnan A, Srinivas TV. Spinal intradural extramedullary cavernous angiomas: report of four cases and review of the literature. Br J Neurosurg 1997;11(3):228-32.

18. Laredo JD, reizine D, Bard M, Merland JJ. Vertebral hemangiomas: radiologic evaluation. Radiology 1986;161:183-9.

19. Puvaneswary M, Cuganesan R, Barbarawi M, Spittaler P. Vertebral haemangioma causing cord compression: MRI findings. Australasian Radiology 2003;47:190-3.

20. Demachi H. Takashima T, Kadoya M,. MR imaging of spinal neurinomas with pathologic correlation. J Comput Assist Tomogr 1990;14:250-4.

21. Daneyemez M, Sirin S, Duz B. Spinal epidural cavernous angioma: case report. Minim Invasive Ncurosurg 2000;43:159-62.

22. Osborn AG. Diagnostic neuroradiology. St. Louis (Mo): Mosby; 1994;820-918.

23. Shapiro GS, Millett PJ, DiCarlo EF, Mintz DN, Gamache FW, Rawlins BA. Spinal epidural hemangioma related to pregnancy. Skeletal Radiol 2001;30:290-4.


HOME   |   SEARCH   |   CURRENT ISSUE   |   PAST ISSUES

Professional Medical Publications
Room No. 522, 5th Floor, Panorama Centre
Building No. 2, P.O. Box 8766, Saddar, Karachi - Pakistan.
Phones : 5688791, 5689285 Fax : 5689860
pjms@pjms.com.pk