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.

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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.

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    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.

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