A Pure Epidural Spinal Cavernous Hemangioma — With an Innocuous Face But A Perilous Behaviour!!

Abstract

Cavernous hemangiomas occur frequently in the intracranial structures but they are rare in the spine, with an incidence of 0.22 cases/million/year, which account for 5 -12% of the spinal vascular lesions, 51% of which are extradural. Most of the epidural hemangiomas are secondary extensions from the vertebral lesions. The spinal cavernous hemangiomas which do not involve the vertebrae are referred to as "pure" types. The pure epidural hemangiomas are rare, which account for only 4% of all the epidural lesions.A case of a Pure spinal epidural cavernous hemangioma in a 50 year old male, with the clinical picture of a slowly progressive compressive myelopathy, has been presented here.The imaging studies showed a well-defined, enhancing epidural lesion at the T7 -T8 level, with dorsal cordedema and myelomalacic changes. A radiological diagnosis of a meningioma was considered. Histopathologically, the lesion was diagnosed as a hemangioma. The patient improved dramatically after the excision of the lesion. CASe RepoRTA 50 year old male presented with a history of progressive weakness in both the lower limbs since 1 year. He also complained of inability in walking, lifting or appreciating sensations in the lower limbs, as well as loss of the bowel and bladder control. The general examination revealed no significant abnormalities. A detailed Central Nervous System (CNS) examination showed no neurological deficit in the upper limbs. The lower limbs were flaccid, with a reduced bulk and a power of grade 1/5. A loss of sensation was observed upto the groin crease. An examination of the spine revealed no tenderness or deformity. The systemic examination showed no abnormality. The routine haematological investigations showed mild anaemia. Magnetic Resonance Imaging (MRI) of the dorsal spine showed a well-defined, oval, enhancing lesion which measured 4.4 x 1.3 x 2.0 cm, in the posterior epidural compartment, at the T7 -T8 level, with dorsal cord oedema and early myelomalacia. The lesion was homogenously iso-intense in the T1 images and it was hyperintense in the T2 images, with effacement of the subarachnoid space posteriorly. The spinal cord showed mild extension into the neural foramina. The radiological diagnosis which was offered was meningioma [Table/ Fig-1].The patient underwent laminectomy from the T7-T8 level. Peroperatively, an epidural reddish brown mass which measured 6x2 cm at the T7-T8 level, with no dural attachment, or spinal extension or bony involvement, was observed. The excised mass was subjected to a histopathological examination.the histopathological examination findings were as follows: The gross examination of the specimen showed a single, brownish black, soft tissue mass which measured 3.5 x 1.5 x 0.5 cm. The cut section showed a brown black colour with a spongy appearance. The microscopic examination showed a benign tumour which was composed of vascular spaces of variable sizes, with fibrocollagenous walls which were lined by a single layer of flattened endothelial cells. The lumina containe...

Thoracic Extraosseous Epidural Cavernous Hemangioma

“…These lesions can occur in every region of the body; however, the most common area of occurrence in the cranial region of the central nervous system is the supratentorial area 8) . CHs have rarely been seen in the spinal canal 1 , 6 , 10) , while only 4% of all cavernous hemangiomas (0.22/1.000.000) are purely epidural CHs 1 , 10) . Spinal CHs appear at an average age of 40 (30-60) and are more common in women (70%).…”

“…Spinal CHs appear at an average age of 40 (30-60) and are more common in women (70%). According to frequency, the localization in the spinal vertebrae can be listed in order of occurrence as in the thoracic (54-60%), cervical (30%), and lumbar (10%) vertebral regions 1 , 7 , 9) ; they are seen most commonly in the posterior part of the spinal canal 1 , 9) . There are two currently accepted hypotheses in the literature with regard to the frequent occurrence in the thoracic vertebrae; the first is that the thoracic epidural space is wider 3 , 6) , while the second is that the resistance in the posterior part of the thoracic spinal canal is lower 3 , 6) .…”

“…CHs create 5-12% of all spinal vascular malformations 10) . Existence in the epidural space without bone involvement is rare 1 , 10) , and only 4% of all CHs (0.22/1.000.000) are purely epidural 1 , 10) . Clinical symptoms are usually seen as slowly progressive paraparesis, myelopathy and localized pain 1 , 5) .…”

“…Existence in the epidural space without bone involvement is rare 1 , 10) , and only 4% of all CHs (0.22/1.000.000) are purely epidural 1 , 10) . Clinical symptoms are usually seen as slowly progressive paraparesis, myelopathy and localized pain 1 , 5) . Although magnetic resonance imaging (MRI) is the best diagnostic method for this lesion, it is not a definitive one 8) .…”

A rare case of thoracic extradural thrombosed primary cavernous haemangioma in a relatively asymptomatic patient

“…However, highly vascular lesions preventing complete resection can be treated with radiotherapy. [ 5 ]…”