✓ The authors present a documented sporadic de novo cavernous malformation of the central nervous system (CNS) in a patient undergoing follow-up magnetic resonance imaging after resection of an acoustic neuroma. The authors believe that this is the first report of a de novo cavernous malformation in a patient without a familial history of this disease or a history of treatment with cranial radiation. The occurrence of de novo lesions invalidates the common assumption that cavernous malformations are congenital lesions. The use of this assumption to calculate bleeding risks retrospectively in patients with cavernous malformations is likely to underestimate the risk of symptomatic hemorrhage significantly. Consequently, the de novo formation of cavernous malformations may be more common than appreciated and may explain the higher bleeding rates reported in prospective compared with retrospective studies of these lesions.
De novo formation of a central nervous system cavernous malformation: implications for predicting risk of hemorrhage
Case report and review of the literature
Paul W. Detwiler, Randall W. Porter, Joseph M. Zabramski and Robert F. Spetzler
Paul W. Detwiler, Randall W. Porter, Neil R. Crawford, Paul J. Apostolides and Curtis A. Dickman
The goals of surgery for metastatic disease of the lumbosacral spine are to relieve compression of the thecal sac and nerve roots, to resect malignant tissue, and to create a stable reconstruction of the spine. Reconstruction of the lumbosacral junction, specifically the L-5 vertebral body, is particularly challenging because the biomechanical properties of this level differ from other areas of the spine.
A 40-year-old woman with intraductal breast carcinoma that metastasized to the L-5 vertebral body presented with progressive low-back pain, right-sided L-5 radiculopathy, and weakness. Magnetic resonance imaging revealed a pathological fracture of the L-5 vertebral body with compression of the cauda equina. The L-5 posterior arch, both facet joints and pedicles, and the posterior third of the vertebral body were removed via a posterior approach. A pedicle screw fixation system was applied from L-4 to S-1. The patient was repositioned, and a transabdominal approach was used to resect the anterior two thirds of the L-5 body, which was reconstructed using an allograft bone strut. An interference bone screw was placed through the inferior aspect of the allograft and screwed into the body of S-1 to provide stability for the reconstructive graft.
The patient's clinical recovery was excellent. She was ambulating without difficulty when seen at 19-month follow-up examination.
Complete spondylectomy by using this novel fusion technique was efficacious in the treatment of metastatic disease to the vertebral column.
Paul W. Detwiler, Randall W. Porter, Timothy R. Harrington, Volker K. H. Sonntag and Robert F. Spetzler
✓ Vertebral artery tortuosity and loop formation are rare causes of cervical radiculopathy. The authors present the case of a 70-year-old man with 9 years of progressive right-sided cervical and scapular pain but no history of trauma. Computerized tomography myelography and magnetic resonance imaging revealed an ovoid mass in the right C3–4 intervertebral foramen. The patient underwent a right C-3 and C-4 hemilaminectomy and a complete C3–4 facetectomy. A pulsatile vascular structure was found compressing the right C-4 nerve root. The bone overlying the vascular structure was removed, producing decompression of the nerve root. Immediate postoperative angiography showed that this lesion was a focal vertebral artery loop. The patient's symptoms resolved after surgery, supporting the use of vascular decompression of a cervical nerve root compressed by a vertebral artery loop for the relief of radicular symptoms.
L. Fernando Gonzalez, Gregory P. Lekovic, Jennifer Eschbacher, Stephen Coons, Randall W. Porter and Robert F. Spetzler
✓Cavernous hemangiomas that occur within the cavernous sinus (CS) are different from cerebral cavernous malformations (CMs) clinically, on imaging studies, and in their response to treatment. Moreover, CMs are true vascular malformations, whereas hemangiomas are benign vascular tumors. Because of these differences, the authors suggest that these two entities be analyzed and grouped separately. Unfortunately, despite these differences, much confusion exists in the literature as to the nature, behavior, and classification of these two distinct lesions. This confusion is exacerbated by subtle histological differences and the inconsistent use of nomenclature. The authors use the term “cavernous malformation” to refer to intraaxial lesions only; they prefer to use the term “cavernous sinus hemangioma” to refer to extraaxial, intradural hemangiomas of the CS.
Paul W. Detwiler, Frederick F. Marciano, Randall W. Porter and Volker K. H. Sonntag
Although the efficacy of posterior decompression for symptomatic lumbar stenosis that is recalcitrant to conservative therapy is well proven, uniform agreement on the need for simultaneous arthrodesis is lacking. The variability in the rate of lumbar fusion with and without instrumentation has been attributed to a number of factors: advances in surgical technique; rapid development of instrumentation; radiographic advances in the diagnosis of disease entities of the lumbar spine; evolution in our understanding of bone healing; improved pre- and postoperative care; aggressive rehabilitation; patient compensation; hospital and surgeon reimbursement; better education of residents, fellows, and practicing neurosurgeons; and, most important, the lack of clear indications based on defined diagnostic categories. Based on review of the literature and their experience at the Barrow Neurological Institute, the authors have attempted to define indications for lumbar fusion with or without instrumentation based on defined diagnostic categories. Clear indications for fusion include trauma, tumor, or infection with two- or three-column injury, iatrogenic instability, and isthmic spondylolisthesis. Relative indications for fusion include degenerative spondylolisthesis, radiographically proven dynamic instability with pain or neurological findings, adult scoliosis, and mechanical back pain. Fusion is rarely indicated with discectomy, abnormal radiographs without appropriate findings (such as degenerative disc disease), facet joint syndrome, failed back surgery, or stable spinal stenosis.
Case report and review of the literature
L. Fernando Gonzalez, Ruth E. Bristol, Randall W. Porter and Robert F. Spetzler
✓ The authors report the case of a patient with a de novo arteriovenous malformation (AVM), indicating that the origin of these lesions may not always be congenital.
A 3-year-old girl who was struck by a car suffered a mild head injury and experienced posttraumatic epilepsy. The initial magnetic resonance (MR) image obtained in this child revealed only a small contusion in the left frontal lobe. Intractable epilepsy subsequently developed. A second MR image obtained almost 4 years after the injury demonstrated an AVM in the right posterior temporal lobe that was verified using angiography. The lesion was classified as a Spetzler—Martin Grade III AVM. The patient underwent embolization of the feeding vessels followed by gamma knife surgery. Fourteen months after treatment she was asymptomatic. Follow-up MR images demonstrate no evidence of an AVM and no changes in the white matter.
This case presents a de novo AVM that developed within approximately 4 years. The findings indicate that AVMs may not always be congenital and reinforce the concept that the natural history of AVMs is dynamic. Lesions may appear de novo, grow, and thrombose spontaneously.