Spinal angiolipomas: A puzzling case and review of a rare entity

Abstract

Patients with spinal epidural abscesses (SEAs) may have a variable presentation. Such an infection has a typical appearance on magnetic resonance imaging (MRI) and enhances with gadolinium. We present a case that was a diagnostic challenge where pre- and intra-operative findings resulted in conflicting impressions. The mimicker was a spinal angiolipoma (SAL). The authors then provide a thorough review of this rare spinal neoplasm. A 55-year-old man presented with back pain, paresis, paresthesia, and urinary retention. MRI was indicative of a longitudinal epidural thoracic mass with a signal homogeneous to nearby fat, curvilinear vessels, and lack of enhancement. Although at emergent surgery, the lesion was found to contain abundant purulent material. Microbiology was positive for methicillin-resistant Staphylococcus aureus and consistent with SEA without evidence of neoplasia. While the imaging features were suggestive of an angiolipoma, the findings at surgery made SEA more likely, which were validated histopathologically. The diagnosis of SEA is often clear-cut, and the literature has reported only a few instances in which it masqueraded as another process such as lymphoma or myelitis. The case highlights SEA masquerading as an angiolipoma, and further demonstrates to clinicians that obtaining tissue diagnosis plays a crucial role diagnostically and therapeutically. SALs, on the other hand, are slow-growing tumors that can be infiltrating or noninfiltrating. They typically present with chronic symptoms and T1-MRI shows an inhomogeneous picture. Complete surgical excision is standard of care and patients tend to do well afterward.

Epidural angiolipoma: A rare cause of spinal cord compression

“…This tissue is trabeculated by vascular elements which enhance variably after contrast injection. Contrast enhancement is clearly observed on T1 sequences with gadolinium injection and fat saturation (fat-saturation sequences) [ 17 ]. The presence of large zones in T1 void signal, is due to the richness in vessels, and can predict preoperatively a high vascularized tumor [ 18 ].…”

“…MRI helps making differential diagnosis with lipomas, spinal vascular tumors such as fistulas, metastases, meningiomas and hemopathies. Angiography, if done, can help with differential diagnosis, assess vascularization of the lesion, and may be used for embolization of the tumor which helps with removal [ 17 ].…”

“…Since SAL are very haemorrhagic lesions, preoperative embolization is recommended [ [17] , [21] ]. Recurrence is exceptional.…”

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

“…SALs were first described by Berenbruch in 1890, and since that time about 200 cases have been reported. 1 , 2 They constitute about 0.04% to 1.2% of spinal axis tumors and about 2% to 3% of extradural spinal tumors. 2 – 4 The typical clinical symptoms in patients with SALs are similar to those of spinal cord or nerve root compression.…”

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

“…The above features make these lesions clinically and pathologically unique (3,5). SEALs are classified into two subtypes: non-infiltrating and infiltrating (5)(6)(7). While the non-infiltrating types are more common and normally well encapsulated, the infiltrating types are sporadic, and usually unencapsulated with imprecise edges.…”