Spinal cord and spinal canal epidural space hemangiomas
- Spinal cord and spinal canal epidural space hemangiomas
- Neurologic manifestations (symptoms, syndromes) of the spinal cord vessels arteriovenous malformations
- Instrumental and laboratory diagnosis of the spinal cord vessels arteriovenous malformations
- Spinal cords and spinal canal's epidural space cavernous hemangiomas
Into the spinal canal's epidural space can be observed several types of hemangiomas. These hemangiomas are classified according to the predominant type of vascular bed. Different types of hemangiomas include:
- cavernous hemangiomas,
- capillary hemangiomas,
- arteriovenous hemangiomas (malformation, AVM),
- venous hemangiomas.
The most common type of the spinal canal's epidural space hemangiomas is the cavernous type. In modern literature, little information about the capillary, venous and arteriovenous hemangiomas. Arteriovenous and venous hemangiomas is often defined as a small cystic mass, while the cavernous and capillary types are usually displayed as a solid mass with increased vasculature (vascularization).
On spinal cord MRI without contrast at the Th12-L1 vertebrae level shows epidural cavernous hemangioma and spinal cord, pushed anterior (white arrow).
Neurologic manifestations (symptoms, syndromes) of the spinal cord vessels arteriovenous malformations
Spinal cords arteriovenous malformations (AVMs, angiomas, hemangiomas) - is the most difficult for diagnose pathological processes, affecting the spinal vessels (arteries and veins). Clinical manifestations of spinal cord arteriovenous malformations (AVMs, angiomas, hemangiomas) in patients are diverse in nature. Neurological symptoms and syndromes may resemble multiple sclerosis, transverse myelitis, spinal stroke, neoplastic compression.
Spinal cord's arteriovenous malformation (AVM).
Arteriovenous malformations (AVMs, angiomas, hemangiomas) are more often localized in lower thoracic and lumbar the spinal cord levels. This spinal cord vascular lesion often diagnosed in middle-aged men. In most cases, arteriovenous malformations (AVMs, angiomas, hemangiomas) begin to manifest as progressive syndrome of incomplete spinal cord lesions. This syndrome can occur in patients occasionally and subacute, resembling multiple sclerosis and the accompanying by symptoms of bilateral involvement of corticospinal, spinothalamic tract and posterior columns in a variety of combinations. Almost all patients suffering from paraparesis and unable to walk for several years.
Arteriovenous malformations (AVMs, angiomas, hemangiomas) look like a blood vessels tangle (arteries and veins), which is found in the brain's and spinal cord different parts.
Approximately, in 30% of patients may suddenly develop an acute transverse myelopathy syndrome because of hemorrhage, which reminiscent of acute myelitis in its neurological manifestations. Other patients may experience some strong exacerbations.
Approximately 50% of patients with arteriovenous malformations (AVMs, angiomas, hemangiomas) complain about the back pain or radicular pain. These pains may cause intermittent claudication, as in lumbar canal stenosis. Sometimes patients describe the acute onset of their illness with sharp, localized back pain.
Development of myelopathy with arteriovenous malformations (AVMs, angiomas, hemangiomas), which are not bleeding, may be caused by non-inflammatory necrotizing process accompanied by spinal cord ischemia. Necrotic myelopathy with arteriovenous malformations syndrome accompanies progressive spinal cord intramedullary lesions.
Spinal cords MRI shows malformation (AVM) at its cone level (white arrows).
Changing the pain intensity and the severity of neurological symptoms during physical activity, in specific body positions and during menstruation (in women) helps neurosurgeons in the diagnosis. Auscultation noises over the area of arteriovenous malformations (AVMs, angiomas, hemangiomas) are rarely listened. They should try to detect in patients at rest and after physical activity.
In most patients cerebrospinal fluid (CSF) can be increased protein with possible pleocytosis.
In patients with arteriovenous malformations (AVMs, angiomas, hemangiomas) are possible bleeding in the spinal cord and cerebrospinal fluid (CSF). During diagnostic myelography and CT contrast angiography vascular lesions found in the majority of cases. The study produced in the patient's supine position. Spinal cords vascular malformations majority anatomical structure can be detected by selective spinal angiography. The procedure of selective spinal angiography requires a doctor neurosurgeon experience.
Lumbar puncture (LP) was performed to measure the CSF pressure, spinal cord subarachnoid space passableness studies, cerebrospinal fluid's composition, color and transparency definition.
Spinal canals epidural space cavernous hemangiomas are rare. Epidural space cavernous hemangiomas can be reliably diagnosed in a patient after obtained surgical materials histological examination. Depending on the of the epidural cavernous hemangioma relative to the spinal cord level, in a patient will complain of pain in the back, increasing weakness and numbness in hands and feet. On spinal cord MRI will be seen formation with uniform intense signal, and increase homogeneous high-intensity signal after intravenous contrast, which is typical for epidural cavernous hemangioma.
On the spinal cord MRI on its transverse slice at the level of Th12-L1 vertebrae shows epidural cavernous hemangioma, pushed aside anterior spinal cord (white arrow).
Epidural cavernous hemangioma in a pure form is rare. It is only 4% of the epidural tumors and 12% of all intraspinal (intramedullary) hemangiomas. Cavernous hemangioma is a conglomeration of densely packed, dilated, thin-walled vessels with the absence of the elastic layer (elastic membrane). The tumor is not cancerous, but due to its volume causes a secondary problem, compressing the spinal cord or nerve roots.
Manifestations of spinal epidural cavernous hemangioma syndromes include spinal cord compression and radiculopathy. Spinal cord injury will depend on tumor's position and level in the spinal canal. These tumors can be detected in spinal canals on cervical, thoracic and lumbar levels. In the spinal canal they can grow on the spinal cords front and rear surfaces or in lateral sides of the epidural space, compressing the intervertebral foramen with the nerve roots. Cavernous hemangiomas have a tendency to bleeding. With a large amount of bleeding may occur spinal cord compression with acute onset of neurological symptoms. Patient may experience chronic neurological symptoms if cavernous hemangioma grows slowly and is not accompanied by bleeding. Patients may also suffer from bladder dysfunction. However, it is less common than pain syndromes or paresis of the muscles with impaired sensitivity.
On spinal cord MRI at the level of Th12-L1 vertebrae shows epidural cavernous hemangioma after contrast injection, pushed aside anterior spinal cord (white arrow).
The differential diagnosis of epidural cavernous hemangioma includes:
- herniated disk,
- synovial cyst,
- granulomatous infection,
- true epidural hematoma,
- extramedullary hemorrhage.
Combination of medical history of the patient, the results of his neurological examination, and laboratory data, as well as MRI can be used to improve differential diagnosis. Medical history can help distinguish epidural cavernous hemangioma from some other spinal cord lesions. For example, in trauma, on spine structure surgery or coagulopathies can be assumed true epidural hematoma. If the patient complains of pain while lifting weights or physical exertion, more likely diagnosis is herniated intervertebral discs. Patient’s examination helps to diagnose epidural infection (bacterial epidurit), that manifests itself by fever, muscle tension and necks spinous processes painful palpation. Patients with sickle cell disease may be predisposed to development of extramedullary hematopoiesis. This disease must be associated with abnormalities found on spine MRI in the adjacent vertebrae bone marrow.
Visible hemangiomas on spinal cord MRI after contrast agent injection (white arrows).
Spinal cords MRI is the best diagnostic method of examination in the study of epidural cavernous hemangioma. The classic finding on spinal cord MRI is the mass, located in the epidural space. This mass is usually pressed into the contour of the spinal cord and can spread to neighboring nerve exit point in the intervertebral foramen. On T1-weighted images, these masses tend to give similar to the adjacent intervertebral disc signal, or isointense with foci of hyperintense signal. T2-weighted images often show a homogeneous or heterogeneous increase in signal. The images obtained after injection of contrast, usually produce a noticeable signal enhancement of the cavernous hemangioma estimated mass. Some cavernous hemangioma on spinal cord MRI may also have a low signal on T1-weighted images, T2-weighted images and post-contrast images. Low signal on T2-weighted images is the most common.
Some cavernous hemangioma may also have a connection with the dura (dural tail). Dural tail is considered true if there is a subtle thickening of the dura mater near the hemangiomas mass with wide angle. If cavernous hemangioma positioned at the side of the spinal canals epidural space, it may lead to an expansion of the intervertebral foramen (nerve root’s exit point).
Spinal cords MRI shows bleeding complications arising in a patient after hemangioma remove surgery (white arrows).
Intramedullary cavernous hemangiomas are more common than epidural (extramedullary) hemangiomas.
Hemangiomas surgical removal currently recommended only after failure of other treatments methods (embolization, radiation therapy) as the risk of bleeding with such interventions is about 1.4% -4.5% per year. If the patient has had an episode of hemangiomas bleeding, the risk of re-bleeding estimated at 66% per year.
Shows the procedure of spinal cord extradural arteriovenous malformation embolization under X-ray control with the use of contrast material.
Even in the absence of bleeding from the intramedullary and extramedullary cavernous hemangiomas, they cause progressive worsening in patient's clinical symptoms. This is due to the hemangiomas growing volume, which is observed in most cases. Postoperatively, the best clinical results obtained in patients with extramedullary localization of cavernous hemangioma than intramedullary. Intramedullary cavernous hemangioma grow within the spinal cord, which is required to be dissect for access to a tumor (62% improvement after surgery). Extramedullary cavernous hemangioma is located outside of the spinal cord and can be removed, leaving intact spinal cord (90% improvement after surgery).
If you have any questions on the diagnosis or treatment of spinal cord and spinal canal's epidural space hemangiomas, you can ask them to our neurosurgeon or neurologist: (499) 130–08–09
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