Clinical presentation and surgical outcome of intramedullary spinal cord cavernous malformations

Object Intramedullary spinal cord cavernous malformations (CMs), once thought to be extremely rare, have been diagnosed more frequently since the advent of MR imaging. In the literature, however, only a few studies include more than 10 cases. The aim of this study was to discuss the clinical presentation of intramedullary spinal cord CMs and the outcome of microsurgery for these histologically benign but clinically progressive lesions. Methods The authors retrospectively reviewed the records of 20 patients who underwent microsurgery for intramedullary spinal cord CMs. All patients had undergone pre- and postoperative MR imaging, and they were all treated using microsurgical resection. The diagnosis of spinal cord CMs was based on pathological criteria. The pre- and postoperative neurological states of the patients were classified according to the McCormick scale and Frankel scale. The microsurgical outcomes are presented and discussed. Results In most cases, CMs can be diagnosed on the basis of MR imaging findings, since these lesions have certain characteristic imaging patterns. Patients with intramedullary spinal cord CMs may present with either a rapid, acute onset of symptoms or slow, progressive neurological decline. The CMs in 19 of 20 patients in this series were totally resected, and most patients neurologically improved postoperatively. As previously reported, the authors confirm that the treatment of choice for symptomatic intramedullary CMs is total removal of the lesion to avoid recurrence and the possibility of further hemorrhage. Conclusions This study has defined the clinical features of symptomatic intramedullary spinal cord CMs. Surgery is the mainstay treatment. Surgical outcome is associated with low mortality with a high probability of functional recovery, especially when symptoms are not severe and are of relatively recent onset.

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Clinical presentation and optimal management for intramedullary cavernous malformations

Neurosurgical FOCUS ◽

10.3171/foc.2006.21.1.11 ◽

2006 ◽

Vol 21 (1) ◽

pp. 1-6 ◽

Cited By ~ 66

Author(s):

George I. Jallo ◽

Diana Freed ◽

Michelle Zareck ◽

Fred Epstein ◽

Karl F. Kothbauer

Keyword(s):

Mr Imaging ◽

Chart Review ◽

Clinical Presentation ◽

Retrospective Chart Review ◽

Acute Onset ◽

Total Removal ◽

Cavernous Malformations ◽

Characteristic Imaging ◽

Preoperative Magnetic Resonance ◽

Microsurgical Resection

Object Intramedullary cavernous malformations (CMs) account for approximately 5% of all intraspinal lesions. The purpose of this study was to define the spectrum of presentation for spinal intramedullary CMs and the results of microsurgery for these benign but clinically progressive lesions. Methods Retrospective chart review was performed in 26 patients with histologically diagnosed CMs. All patients had undergone preoperative magnetic resonance (MR) imaging studies. All patients were treated with a laminectomy and microsurgical resection of the malformation. Conclusions The MR imaging findings are diagnostic for intramedullary CMs; these lesions abut a pial surface and have a characteristic imaging pattern. Spinal intramedullary CMs present with either an acute onset of neurological compromise or a slowly progressive neurological decline. Acute neurological decline occurs secondary to hemorrhage inside the spinal cord. Chronic progressive myelopathy occurs due to microhemorrhages and resulting gliotic reaction to blood products. Surgery and total removal of the lesion tends to halt progression of symptoms.

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Microsurgical resection of intramedullary spinal cord cavernous malformation. Operative video and technical nuances

Neurosurgical FOCUS ◽

10.3171/2014.v3.focus14155 ◽

2014 ◽

Vol 37 (v2supplement) ◽

pp. Video1

Author(s):

James K. Liu

Keyword(s):

Spinal Cord ◽

Cavernous Malformation ◽

Significant Risk ◽

Complete Resection ◽

Definitive Treatment ◽

Intramedullary Spinal Cord ◽

Cavernous Malformations ◽

Spinal Stabilization ◽

Progressive Myelopathy ◽

Microsurgical Resection

Intramedullary spinal cord cavernous malformations account for approximately 5% of all intraspinal lesions. These lesions can present with either acute neurological compromise secondary to hemorrhage inside the spinal cord, or with chronic progressive myelopathy due to repeated microhemorrhages. Surgical resection of spinal cord cavernous malformations remains the definitive treatment strategy for symptomatic lesions. Because of the intimate relationship with surrounding eloquent neural tissue, these lesions can be technically challenging to remove with a significant risk for morbidity. In this operative video, the author demonstrates an illustrative step-by-step technique for microsurgical resection of a large intramedullary spinal cord cavernous malformation at C4–5 causing progressive myelopathy. Complete resection was achieved without neurologic compromise. The operative technique and surgical nuances, including the surgical approach, intradural cavernoma removal, and spinal stabilization are illustrated.The video can be found here: http://youtu.be/3FUjGSyrKO0.

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Prognostic factors for the outcome of surgical and conservative treatment of symptomatic spinal cord cavernous malformations: a review of a series of 20 patients

Neurosurgical FOCUS ◽

10.3171/2010.6.focus10123 ◽

2010 ◽

Vol 29 (3) ◽

pp. E13 ◽

Cited By ~ 21

Author(s):

Hans-Jakob Steiger ◽

Bernd Turowski ◽

Daniel Hänggi

Keyword(s):

Spinal Cord ◽

Prognostic Factors ◽

Mr Imaging ◽

Neurological Deficits ◽

Mr Images ◽

Duration Of Symptoms ◽

Intramedullary Spinal Cord ◽

Cavernous Malformations ◽

Satisfactory Outcome ◽

History Of

Object In this study, the authors present a review of a series of 20 intramedullary spinal cord cavernous malformations (SCCMs) with particular focus on MR imaging and prognostic factors. Methods Between 1994 and 2009, 20 patients with SCCM were treated under the care of the senior author. The diagnosis was made in all patients after the onset of clinical symptoms. The age of the 9 men and 11 women ranged between 26 and 71 years (median 38.5 years). The duration of symptoms prior to referral ranged from 1 week to 9 years (median 6.5 months). At the time of referral, 4 patients had no significant neurological deficits, 10 patients suffered significant functional restrictions, and 6 patients presented with severe paraparesis and loss of functional strength. None of the patients had complete paraplegia. Seventeen patients underwent microsurgical removal, while 3 patients opted for conservative therapy. For the present analysis, the medical records and MR images and/or reports were reviewed. Classification of length of history, pretreatment status, MR imaging pattern, and treatment modality was done and correlated with outcome. Results The cavernoma was located at the cervical level in 8 patients and between T-1 and L-1 in 12 patients. The cavernoma appeared as mainly T2 hyperintense on MR images in 7 patients, mainly T2 hypointense in 2 patients, and mixed in the remaining 10 patients. The craniocaudal extension of the core varied between 5 and 45 mm. In 2 patients with cervical cavernomas, a distinct T2 signal of the spinal cord cranial and distal to the cavernoma was seen, and in a patient with a large thoracic cavernoma, T2 extinction cranial and caudal to the cavernoma was seen as a sign of hemosiderosis. Neurological deficits improved postoperatively in 12 of the surgically treated patients, remained stable in 2, and deteriorated in 3. The 3 patients who were conservatively treated remained stable over a follow-up of 3–9 years. Postoperative improvement was seen in 5 of 7 surgical patients with a history of symptoms of 2 months or less, 5 of 6 patients with a history of 2–24 months, and in 2 of 4 patients with a history of more than 2 years. Two of the 3 patients with postoperative deterioration had a history of more than 2 years and the third a short history of 1 month. Conclusions Although a satisfactory outcome can be achieved through surgical treatment of SCCMs, some patients worsen after surgery or during the postoperative course. Long-term stability is possible in oligosymptomatic conservatively treated patients. The prevalence and pathophysiological importance of segmental spinal cord edema and hemosiderosis is incompletely understood at the present time.

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Microsurgical resection of intramedullary spinal cord ependymoma

Neurosurgical FOCUS ◽

10.3171/2014.v3.focus14276 ◽

2014 ◽

Vol 37 (v2supplement) ◽

pp. Video9

Author(s):

Paul C. McCormick

Keyword(s):

Spinal Cord ◽

Growth Rate ◽

Spinal Cord Tumor ◽

Intramedullary Spinal Cord ◽

Clear Margin ◽

Intramedullary Spinal Cord Tumor ◽

Link Type ◽

Microsurgical Resection ◽

Spinal Cord Ependymoma ◽

Posterior Midline

Ependymomas are the most commonly occurring intramedullary spinal cord tumor in adults. With few exceptions these tumors are histologically benign, although they exhibit some biologic variability with respect to growth rate. While unencapsulated, spinal ependymomas are non-infiltrative and present a clear margin of demarcation from the surrounding spinal cord that serves as an effective dissection plane. This video demonstrates the technique of microsurgical resection of an intramedullary ependymoma through a posterior midline myelotomy.The video can be found here: http://youtu.be/lcHhymSvSqU.

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Surgical treatment of primary intramedullary spinal cord tumors in adult patients

Arquivos de Neuro-Psiquiatria ◽

10.1590/s0004-282x2008000100014 ◽

2008 ◽

Vol 66 (1) ◽

pp. 59-63 ◽

Cited By ~ 4

Author(s):

Mario Augusto Taricco ◽

Vinicius Monteiro de Paula Guirado ◽

Ricardo Bragança de Vasconcellos Fontes ◽

José Pindaro Pereira Plese

Keyword(s):

Spinal Cord ◽

Previous Treatment ◽

Cervical Cord ◽

Spinal Cord Tumors ◽

Intramedullary Tumors ◽

Treatment Protocols ◽

Intramedullary Spinal Cord ◽

Neurological Outcomes ◽

Neurological Morbidity ◽

Microsurgical Resection

BACKGROUND: Primary spinal cord intramedullary tumors are rare and present with insidious symptoms. Previous treatment protocols emphasized biopsy and radiation/chemotherapy but more aggressive protocols have emerged. OBJECTIVE: To report our experience. METHOD: Forty-eight patients were diagnosed with primary intramedullary tumors. The cervical cord was involved in 27% and thoracic in 42% of patients. Complete microsurgical removal was attempted whenever possible without added neurological morbidity. RESULTS: Complete resection was obtained in 33 (71%) patients. Neurological function remained stable or improved in 32 patients (66.7%). Ependymoma was the most frequent tumor (66.7%). CONCLUSION: Neurological outcome is superior in patients with subtle findings; aggressive microsurgical resection should be pursued with acceptable neurological outcomes.

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Microsurgical Resection of an Intramedullary Spinal Cord Hemangioblastoma Through an Anterior Cervical Approach: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opaa314 ◽

2020 ◽

Author(s):

Kyle Lindsey McCormick ◽

Nikita Alexiades ◽

Paul C McCormick

Keyword(s):

Spinal Cord ◽

Tumor Resection ◽

Residual Tumor ◽

Complete Recovery ◽

Surgical Removal ◽

Intramedullary Spinal Cord ◽

Dural Closure ◽

Cervical Approach ◽

Anterior Cervical Approach ◽

Microsurgical Resection

Abstract This video demonstrates the microsurgical removal of an intramedullary spinal cord hemangioblastoma through an anterior cervical approach. While most spinal hemangioblastomas arise from the dorsal or dorsolateral pial surface and can be safely resected through a posterior approach,1,2 ventral tumors can present a significant challenge to safe surgical removal.3-5 This patient presented with a progressively symptomatic ventral pial based hemangioblastoma at the C5-6 level with large polar cysts extending from C3 to T1. The tumor was approached through a standard anterior cervical exposure with a C5 and C6 corpectomy. Following midline durotomy, the tumor was identified and complete microsurgical resection was achieved. The principles and techniques of tumor resection are illustrated and described in the video. Following tumor resection and dural closure, a fibular allograft was inserted into the corpectomy defect and a C4-C7 fixation plate was placed. The patient was maintained in a supine position for 36 h. He was discharged home on postoperative day 3 in a cervical collar. The patient did well with near-complete recovery of neurological function. Postoperative magnetic resonance imaging at 6 wk showed a substantial resolution of the polar cysts and no evidence of residual tumor. The patient featured in this video consented to the procedure.

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Intramedullary Cavernous Malformation of the Spinal Cord in Two Dogs

Veterinary Pathology ◽

10.1354/vp.44-4-528 ◽

2007 ◽

Vol 44 (4) ◽

pp. 528-532 ◽

Cited By ~ 6

Author(s):

E. MacKillop ◽

N. J. Olby ◽

K. E. Linder ◽

T. T. Brown

Keyword(s):

Spinal Cord ◽

Cavernous Malformation ◽

Postmortem Examination ◽

Spinal Cord Lesion ◽

Intraparenchymal Hemorrhage ◽

Intramedullary Spinal Cord ◽

Cavernous Malformations ◽

Vascular Channels ◽

Thin Walled ◽

Cord Lesion

Intramedullary cavernous malformations (CVMs) of the spinal cord were diagnosed in 2 adult dogs that presented for paraparesis. An intramedullary spinal cord lesion was identified on a myelogram in the first dog, and expansion of the vertebral canal was evident on radiographs in the second. Extensive intraparenchymal hemorrhage was found on gross postmortem examination in both dogs, and a distinct lobulated intramedullary mass was evident in the second dog. Microscopically, both lesions were composed of dilated, thin-walled vascular channels with little-to-no intervening neural parenchyma. Both dogs had evidence of channel thrombosis along with perilesional hemorrhage and hemosiderin accumulation. The second dog had additional degenerative changes, including thickened fibrous channel walls with hyalinization, foci of mineralization, and occasional tongues of entrapped gliotic neuropil. CVMs appear to be an uncommon cause of both acute and chronic spinal cord disease in the dog.

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Intramedullary ependymoma of the spinal cord

Journal of Neurosurgery ◽

10.3171/jns.1990.72.4.0523 ◽

1990 ◽

Vol 72 (4) ◽

pp. 523-532 ◽

Cited By ~ 449

Author(s):

Paul C. McCormick ◽

Roland Torres ◽

Kalmon D. Post ◽

Bennett M. Stein

Keyword(s):

Spinal Cord ◽

Mr Imaging ◽

Tumor Recurrence ◽

Neurological Deficits ◽

Functional Improvement ◽

Consecutive Series ◽

Intramedullary Spinal Cord ◽

Content Type ◽

Fine Print

✓ A consecutive series of 23 patients underwent operative removal of an intramedullary spinal cord ependymoma between January, 1976, and September, 1988. Thirteen women and 10 men between the age of 19 and 70 years experienced symptoms for a mean of 34 months preceding initial diagnosis. Eight patients had undergone treatment prior to tumor recurrence and referral. Mild neurological deficits were present in 22 patients on initial examination. The location of the tumors was predominantly cervical or cervicothoracic. Radiological evaluation revealed a wide spinal cord in all cases. Magnetic resonance (MR) imaging was the single most important radiological procedure. At operation, a complete removal was achieved in all patients. No patient received postoperative radiation therapy. Histological examination revealed a benign ependymoma in all cases. The follow-up period ranged from 6 to 159 months (mean 62 months) with seven patients followed for a minimum of 10 years after surgery. Fourteen patients underwent postoperative MR imaging at intervals ranging from 8 months to 10 years postoperatively. No patient has been lost to follow-up review and there were no deaths. No patient showed definite clinical or radiological evidence of tumor recurrence during the follow-up period. Recent neurological evaluation revealed functional improvement from initial preoperative clinical status in eight patients, no significant change in 12 patients, and deterioration in three patients. The data support the belief that long-term disease-free control of intramedullary spinal ependymomas with acceptable morbidity may be achieved utilizing microsurgical removal alone.

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