Clinical outcomes and prognostic factors for cavernous hemangiomas of the spinal cord: a retrospective cohort study

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OBJECTIVE

Intramedullary cavernous hemangioma (CH) is a rare vascular lesion that is mainly characterized by the sudden onset of hemorrhage in young, asymptomatic patients, who then experience serious neurological deterioration. Despite the severity of this condition, the therapeutic approach and timing of intervention for CH remain matters of debate. The aim of this study was to evaluate the clinical characteristics of CH patients before and after surgery and to identify prognostic indicators that affect neurological function in these patients.

METHODS

This single-center retrospective study included 66 patients who were treated for intramedullary CH. Among them, 57 underwent surgery and 9 patients received conservative treatment. The authors collected demographic, symptomology, imaging, neurological, and surgical data. Univariate and multivariate logistic regression analyses were performed to identify the prognostic indicators for neurological function.

RESULTS

When comparing patients with stable and unstable gait prior to surgery, patients with unstable gait had a higher frequency of hemorrhagic episodes (52.4% vs 19.4%, p = 0.010), as assessed by the modified McCormick Scale. The lesion was significantly smaller in patients who underwent conservative treatment compared with surgery (2.5 ± 1.5 mm vs 5.9 ± 4.1 mm, respectively; p = 0.024). Overall, the patients experienced significant neurological recovery after surgery, but a worse preoperative neurological status was identified as an indicator affecting surgical outcomes by multivariate analysis (OR 10.77, 95% CI 2.88–40.36, p < 0.001). In addition, a larger lesion size was significantly associated with poor functional recovery in patients who had an unstable gait prior to surgery (8.6 ± 4.5 mm vs 3.5 ± 1.6 mm, p = 0.011).

CONCLUSIONS

Once a hemorrhage occurs, surgical intervention should be considered to avoid recurrence of the bleeding and further neurological injury. In contrast, if the patients with larger lesion presented with worse preoperative functional status, surgical intervention could have a risk for aggravating the functional deficiencies by damaging the thinning cord parenchyma. Conservative treatment may be selected if the lesion is small, but regular neurological examination by MRI is needed for assessment of a change in lesion size and for detection of functional deterioration.

ABBREVIATIONS AIS = ASIA Impairment Scale; ASIA = American Spinal Injury Association; CH = cavernous hemangioma; EBL = estimated blood loss; JOA = Japanese Orthopaedic Association; mMS = modified McCormick Scale.

Article Information

Correspondence Narihito Nagoshi: Keio University School of Medicine, Tokyo, Japan. nagoshi@2002.jukuin.keio.ac.jp.

INCLUDE WHEN CITING Published online April 12, 2019; DOI: 10.3171/2019.1.SPINE18854.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Representative MR images and photomicrographs for intramedullary CH. Sagittal (A) and axial (B) MR images prior to surgery. Sagittal (C) and axial (D) images obtained 3 years after resection. H & E–stained photomicrographs at lower (original magnification ×40) (E) and higher (original magnification ×100) (F) magnifications, showing that dilated, thick-walled vessels with flattened endothelial cells were prominent. Arrowheads indicate the location of the CH. Figure is available in color online only.

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    Representative images of the intramedullary CH resection. A: After splitting the dura mater and subarachnoid membrane, the spinal cord was exposed with a visible cavernoma under the pia mater. B: Myelotomy was performed from the dorsal medial sulcus. C and D: The cavernous hemangioma was resected using a microsurgical spatula and forceps. Arrowheads indicate the resected cavernoma. E: The lesion was completely resected. F: The pia mater was sutured with 9-0 nylon string. Figure is available in color online only.

  • View in gallery

    Chi-square test results for categorical variables prior to surgery and at final follow-up. The stable and unstable gait groups consisted of mMS grades 1 and 2 and mMS grades 3 to 5, respectively.

References

  • 1

    Agha RABorrelli MRVella-Baldacchino MThavayogan ROrgill DP: The STROCSS statement: Strengthening the Reporting of Cohort Studies in Surgery. Int J Surg 46:1982022017

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2

    Aoyama THida KHoukin K: Intramedullary cavernous angiomas of the spinal cord: clinical characteristics of 13 lesions. Neurol Med Chir (Tokyo) 51:5615662011

  • 3

    Ardeshiri AÖzkan NChen BStein KPMiller DHütter BO: A retrospective and consecutive analysis of the epidemiology and management of spinal cavernomas over the last 20 years in a single center. Neurosurg Rev 39:2692762016

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4

    Azad TDVeeravagu ALi AZhang MMadhugiri VSteinberg GK: Long-term effectiveness of gross-total resection for symptomatic spinal cord cavernous malformations. Neurosurgery 83:120112082018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Badhiwala JHFarrokhyar FAlhazzani WYarascavitch BAref MAlgird A: Surgical outcomes and natural history of intramedullary spinal cord cavernous malformations: a single-center series and meta-analysis of individual patient data. Clinical article. J Neurosurg Spine 21:6626762014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Choi GHKim KNLee SJi GYOh JKKim TY: The clinical features and surgical outcomes of patients with intramedullary spinal cord cavernous malformations. Acta Neurochir (Wien) 153:167716852011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Gross BADu RPopp AJDay AL: Intramedullary spinal cord cavernous malformations. Neurosurg Focus 29(3):E142010

  • 8

    Hirabayashi KMiyakawa JSatomi KMaruyama TWakano K: Operative results and postoperative progression of ossification among patients with ossification of cervical posterior longitudinal ligament. Spine (Phila Pa 1976) 6:3543641981

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Imagama SIto ZAndo KKobayashi KHida TIto K: Optimal timing of surgery for intramedullary cavernous hemangioma of the spinal cord in relation to preoperative motor paresis, disease duration, and tumor volume and location. Global Spine J 7:2462532017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Kivelev JNiemelä MHernesniemi J: Treatment strategies in cavernomas of the brain and spine. J Clin Neurosci 19:4914972012

  • 11

    Labauge PBouly SParker FGallas SEmery ELoiseau H: Outcome in 53 patients with spinal cord cavernomas. Surg Neurol 70:1761812008

  • 12

    Liang JTBao YHZhang HQHuo LRWang ZYLing F: Management and prognosis of symptomatic patients with intramedullary spinal cord cavernoma. Clinical article. J Neurosurg Spine 15:4474562011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Manzano GGreen BAVanni SLevi AD: Contemporary management of adult intramedullary spinal tumors—pathology and neurological outcomes related to surgical resection. Spinal Cord 46:5405462008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Maslehaty HBarth HPetridis AKDoukas AMehdorn HM: Symptomatic spinal cavernous malformations: indication for microsurgical treatment and outcome. Eur Spine J 20:176517702011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Maynard FM JrBracken MBCreasey GDitunno JF JrDonovan WHDucker TB: International standards for neurological and functional classification of spinal cord injury. Spinal Cord 35:2662741997

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    McCormick PCMichelsen WJPost KDCarmel PWStein BM: Cavernous malformations of the spinal cord. Neurosurgery 23:4594631988

  • 17

    McCormick PCStein BM: Intramedullary tumors in adults. Neurosurg Clin N Am 1:6096301990

  • 18

    Mitha APTurner JDAbla AAVishteh AGSpetzler RF: Outcomes following resection of intramedullary spinal cord cavernous malformations: a 25-year experience. J Neurosurg Spine 14:6056112011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Nagoshi NIshii KKameyama KTsuji OOkada EFujita N: Total resection of cervical ventral intramedullary cavernous hemangiomas with an anterior corpectomy. Spine Surg Relat Res 2:3313342018 (https://www.jstage.jst.go.jp/article/ssrr/2/4/2_2017-0088/_article) [Accessed February 22 2019]

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 20

    Ogilvy CSLouis DNOjemann RG: Intramedullary cavernous angiomas of the spinal cord: clinical presentation, pathological features, and surgical management. Neurosurgery 31:2192301992

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Reitz MBurkhardt TVettorazzi ERaimund FFritzsche ESchmidt NO: Intramedullary spinal cavernoma: clinical presentation, microsurgical approach, and long-term outcome in a cohort of 48 patients. Neurosurg Focus 39(2):E192015

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 22

    Santoro APiccirilli MFrati ASalvati MInnocenzi GRicci G: Intramedullary spinal cord cavernous malformations: report of ten new cases. Neurosurg Rev 27:93982004

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Steiger HJTurowski BHänggi D: Prognostic factors for the outcome of surgical and conservative treatment of symptomatic spinal cord cavernous malformations: a review of a series of 20 patients. Neurosurg Focus 29(3):E132010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Zevgaridis DMedele RJHamburger CSteiger HJReulen HJ: Cavernous haemangiomas of the spinal cord. A review of 117 cases. Acta Neurochir (Wien) 141:2372451999

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Zhang LYang WJia WKong DYang JWang G: Comparison of outcome between surgical and conservative management of symptomatic spinal cord cavernous malformations. Neurosurgery 78:5525612016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

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