Letter to the Editor
Spinal epidural cavernous angiomas
Angiomas cavernosos epidurales espinales
G. Rodríguez-Botoa,
, M. Rivero-Garvíab, R. Gutiérrez-Gonzálezc, A. Pérez-Zamarrónd, J. Vaqueroc
Corresponding author
a Servicio de Neurocirugía, Hospital Clínico San Carlos, Departamento de Cirugía, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
b Servicio de Neurocirugía, Hospital Universitario Virgen del Rocío, Sevilla, Spain
c Servicio de Neurocirugía, Hospital Universitario Puerta de Hierro, Madrid, Spain
d Servicio de Neurocirugía, Hospital Universitario La Paz, Madrid, Spain
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Fracturas osteoporóticas en 3 cuerpos vertebrales a distancia. Superior derecha: la lesión es hiperintensa en la secuencia T2 de RM (corte sagital). Inferior izquierda: se confirma la captación de contraste en la RM (corte sagital). Inferior derecha: corte axial de RM, secuencia T1 con contraste, que demuestra la compresión medular causada por el angioma cavernoso.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "G. Rodríguez-Boto, M. Rivero-Garvía, R. Gutiérrez-González, A. Pérez-Zamarrón, J. Vaquero" "autores" => array:5 [ 0 => array:2 [ "nombre" => "G." "apellidos" => "Rodríguez-Boto" ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Rivero-Garvía" ] 2 => array:2 [ "nombre" => "R." "apellidos" => "Gutiérrez-González" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Pérez-Zamarrón" ] 4 => array:2 [ "nombre" => "J." 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"tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "442" "paginaFinal" => "443" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hiperintensidad pulvinar en T1: ¿un signo patognomónico de enfermedad de Fabry?" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1136 "Ancho" => 999 "Tamanyo" => 89839 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Brain CT. Hyperdensities can be seen in both pulvinar nuclei.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J.A. Matías-Guiu, M. Yus, M. Jorquera, J. 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Rodríguez-Boto, M. Rivero-Garvía, R. Gutiérrez-González, A. Pérez-Zamarrón, J. Vaquero" "autores" => array:5 [ 0 => array:4 [ "nombre" => "G." "apellidos" => "Rodríguez-Boto" "email" => array:1 [ 0 => "grboto@yahoo.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M." "apellidos" => "Rivero-Garvía" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "R." "apellidos" => "Gutiérrez-González" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "A." "apellidos" => "Pérez-Zamarrón" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 4 => array:3 [ "nombre" => "J." "apellidos" => "Vaquero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Servicio de Neurocirugía, Hospital Clínico San Carlos, Departamento de Cirugía, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Neurocirugía, Hospital Universitario Virgen del Rocío, Sevilla, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Neurocirugía, Hospital Universitario Puerta de Hierro, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Neurocirugía, Hospital Universitario La Paz, Madrid, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Angiomas cavernosos epidurales espinales" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 454 "Ancho" => 1744 "Tamanyo" => 122631 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Left: Sagittal section, MRI T1-weighted sequence showing well-circumscribed and hypointense epidural lesion. No spinal compression is observed. Centre: Hypointense lesion on T2-weighted MRI image. Right: Sagittal image of MRI with gadolinium where no contrast uptake is observed.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Cavernous angiomas or haemangiomas, also known as cavernomas, are non-cancerous vascular lesions. Anatomical pathology studies show that they are made up of sinusoidal capillaries of different diameters with an endothelial lining, in addition to elastic fibres in which perivascular fibrosis is observed. These elements are enclosed within a connective tissue capsule.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a> Cavernous angiomas are dynamic lesions that normally increase in size over time. Growth is mainly due to 2 processes: thrombosis of the capillaries themselves, or bleeding at the lesion.</p><p id="par0010" class="elsevierStylePara elsevierViewall">It is estimated that up to 12% of all vascular alterations of the spinal cord are caused by cavernous angiomas or cavernomas. They are mainly located on vertebral bodies and they occasionally reach epidural regions. They can be found in the intradural extramedullary space or they may be limited to an intramedullary location. Cavernous angiomas account for 4% of the lesions located in the epidural space, with the most common manifestation being extension into that space from the vertebral body.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">An exclusively epidural location is rare. This study presents 2 cases of spinal epidural cavernous angiomas with different radiological presentations. This made presurgical diagnosis more difficult.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Our patients, both women, were aged 31 years (case 1) and 58 years (case 2) and had similar clinical courses: progressive back pain developing for several years, localised by the patient at the midline (apophyseal joint pain upon examination). Pain intensity increased with movement, which prevented patients from performing daily activities. The 58-year-old patient had a personal history of hypothyroidism and several vertebral fractures secondary to osteoporosis. Results from the neurological examination were completely normal in both cases.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Radiology studies showed kyphosis in both patients and old compression fractures of the vertebrae (from T8 to T10) in case 2.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Magnetic resonance imaging (MRI) scans showed different findings in the two patients. In case 1, MRI scan showed a nodule in the posterior epidural space measuring 1.7<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>0.6<span class="elsevierStyleHsp" style=""></span>cm in diameter. It was located on the T5 vertebral body and exerted no obvious compression on the spinal cord. The lesion was hypointense in the T1-weighted image and hyperintense in the T2-weighted image, with no enhancement when intravenous contrast was administered (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The lesion in case 2 was located in the posterior extradural space and measured 4.5<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>2.2<span class="elsevierStyleHsp" style=""></span>cm in diameter, extending from T5 to T7. It was compressing the spinal cord. Unlike in case 1, this lesion was isointense in the T1-weighted image, hyperintense in the T2-weighted image, and showed intense enhancement after intravenous administration of contrast (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Both patients underwent surgical resection of their lesions; the main objective was completing a histological study. In case 2, surgery was also indicated because the lesion was causing spinal cord compression. After marking under fluoroscopic guidance, dorsal laminectomy was employed as the surgical technique. These 2 lesions were very similar macroscopically; both were exclusively located in the epidural space and closely adherent to the dura mater. They were nodular in appearance, dark-coloured, and highly vascularised. While both exhibited significant intraoperative bleeding, blood transfusions were not necessary. In case 2, the lesion had invaded the right intervertebral foramen slightly at T6–T7, without widening it or causing extraforaminal protrusion.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Anatomical pathology results were compatible with cavernous haemangioma or angioma in both cases.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Patients remained neurologically asymptomatic after surgery and their progress has been satisfactory.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Cavernous angiomas or haemangiomas, also known as cavernomas, are non-cancerous vascular lesions that may be found at many locations. However, radiological manifestations of extra-axial or durally attached cavernous angiomas or haemangiomas, and specifically extradural spinal haemangiomas, differ significantly from intraparenchymal or intra-axial cavernomas in that they mimic tumours.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In the epidural vertebral space, cavernous haemangiomas appear as homogeneous lesions (with no haemorrhages and therefore lacking the haemosiderin deposits that give rise to ‘popcorn-like’ images or the perilesional halo of intraparenchymal cavernomas). They are well-circumscribed, either hypointense or isointense in T1-weighted images and hyperintense in T2-weighted images, and display contrast enhancement. This has been observed in the largest patient series in the literature, including the 5 cases reported by Talacchi et al.,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> the 5-patient series by Shin et al.,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and the 6 cases documented by Feng et al.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> This was also true for case 2. Nevertheless, the epidural cavernoma in patient 1 did not show gadolinium uptake, which made it difficult to establish a working presurgical diagnosis. This is in fact the second case of epidural spinal cavernous angioma displaying no contrast uptake to be reported in the international literature. The first case was described in 2007 by Lee et al.,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> who reported that only one of their 14 patients presented epidural spinal haemangioma with no gadolinium uptake.</p><p id="par0055" class="elsevierStylePara elsevierViewall">After ruling out technical problems with the contrast injection, as in case 1, we cannot explain the difference in behaviour between these examples of epidural spinal cavernomas. We could not find any histopathological differences between the 2 cases that could provide a rationale for these disparate radiological findings.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Regarding clinical presentation and the treatment approach for this entity, we should highlight the following considerations. Clinical presentation of back pain or apophyseal joint pain pinpointed by the patient is not exclusive to this type of lesion; it can also be a sign of any epidural lesion stimulating nociceptors due to increased spinal pressure as a result of mass effect. This is also the case for skull haemangiomas. Surgical treatment of these lesions is indicated for two reasons: true cord compression, as in case 2, or to complete a histological study to determine the diagnosis of the lesion, as in case 1.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Differential diagnosis of this entity should consider other epidural tumours, such as lymphomas, metastatic tumours, meningiomas, or neurinomas-neurofibromas. Another entity that should be considered is epidural angiolipoma, a lipoma with a significant vascular component. An MRI scan with fat suppression sequences should therefore be performed in order to rule out this tumour type.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3,9</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Lastly and according to the findings from our study, we highlight that cavernous angioma must always be considered in the differential diagnosis of epidural spinal lesions, whether or not they display contrast uptake in the imaging studies.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Rodríguez-Boto G, Rivero-Garvía M, Gutiérrez-González R, Pérez-Zamarrón A, Vaquero J. Angiomas cavernosos epidurales espinales. Neurología. 2014;29:443–445.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 454 "Ancho" => 1744 "Tamanyo" => 122631 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Left: Sagittal section, MRI T1-weighted sequence showing well-circumscribed and hypointense epidural lesion. No spinal compression is observed. Centre: Hypointense lesion on T2-weighted MRI image. Right: Sagittal image of MRI with gadolinium where no contrast uptake is observed.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 814 "Ancho" => 817 "Tamanyo" => 73836 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Upper left: sagittal section, T1-weighted MRI image showing isointense epidural lesion affecting various levels. Osteoporotic fractures of 3 vertebral bodies. Centre: hypointense lesion on T2-weighted MRI image (sagittal section). Lower left: MRI image confirms contrast uptake (sagittal section). Lower right: Axial section, T1-weighted MRI image with contrast uptake showing spinal compression caused by the cavernous angioma.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Extradural spinal cavernous haemangioma: case report and review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "G.A. Appiah" 1 => "N.W. Knuckey" 2 => "P.D. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 3 | 1 | 4 |
| 2024 October | 16 | 12 | 28 |
| 2024 September | 35 | 17 | 52 |
| 2024 August | 31 | 12 | 43 |
| 2024 July | 25 | 5 | 30 |
| 2024 June | 27 | 8 | 35 |
| 2024 May | 13 | 5 | 18 |
| 2024 April | 15 | 21 | 36 |
| 2024 March | 32 | 7 | 39 |
| 2024 February | 30 | 5 | 35 |
| 2024 January | 44 | 8 | 52 |
| 2023 December | 30 | 11 | 41 |
| 2023 November | 29 | 5 | 34 |
| 2023 October | 35 | 22 | 57 |
| 2023 September | 36 | 38 | 74 |
| 2023 August | 19 | 4 | 23 |
| 2023 July | 31 | 9 | 40 |
| 2023 June | 39 | 9 | 48 |
| 2023 May | 41 | 12 | 53 |
| 2023 April | 30 | 1 | 31 |
| 2023 March | 19 | 3 | 22 |
| 2023 February | 22 | 6 | 28 |
| 2023 January | 16 | 7 | 23 |
| 2022 December | 29 | 7 | 36 |
| 2022 November | 40 | 13 | 53 |
| 2022 October | 23 | 8 | 31 |
| 2022 September | 52 | 9 | 61 |
| 2022 August | 33 | 19 | 52 |
| 2022 July | 55 | 12 | 67 |
| 2022 June | 16 | 7 | 23 |
| 2022 May | 23 | 9 | 32 |
| 2022 April | 20 | 9 | 29 |
| 2022 March | 26 | 7 | 33 |
| 2022 February | 36 | 9 | 45 |
| 2022 January | 51 | 8 | 59 |
| 2021 December | 19 | 8 | 27 |
| 2021 November | 33 | 15 | 48 |
| 2021 October | 24 | 11 | 35 |
| 2021 September | 13 | 16 | 29 |
| 2021 August | 28 | 5 | 33 |
| 2021 July | 13 | 12 | 25 |
| 2021 June | 11 | 13 | 24 |
| 2021 May | 22 | 12 | 34 |
| 2021 April | 35 | 17 | 52 |
| 2021 March | 18 | 5 | 23 |
| 2021 February | 17 | 10 | 27 |
| 2021 January | 18 | 10 | 28 |
| 2020 December | 11 | 5 | 16 |
| 2020 November | 15 | 6 | 21 |
| 2020 October | 20 | 3 | 23 |
| 2020 September | 20 | 8 | 28 |
| 2020 August | 12 | 5 | 17 |
| 2020 July | 17 | 10 | 27 |
| 2020 June | 14 | 8 | 22 |
| 2020 May | 12 | 14 | 26 |
| 2020 April | 16 | 1 | 17 |
| 2020 March | 19 | 6 | 25 |
| 2020 February | 22 | 3 | 25 |
| 2020 January | 19 | 14 | 33 |
| 2019 December | 13 | 9 | 22 |
| 2019 November | 15 | 11 | 26 |
| 2019 October | 12 | 5 | 17 |
| 2019 September | 22 | 14 | 36 |
| 2019 August | 14 | 4 | 18 |
| 2019 July | 27 | 21 | 48 |
| 2019 June | 51 | 40 | 91 |
| 2019 May | 122 | 45 | 167 |
| 2019 April | 63 | 29 | 92 |
| 2019 March | 11 | 4 | 15 |
| 2019 February | 8 | 9 | 17 |
| 2019 January | 4 | 9 | 13 |
| 2018 December | 7 | 9 | 16 |
| 2018 November | 6 | 2 | 8 |
| 2018 October | 20 | 11 | 31 |
| 2018 September | 9 | 2 | 11 |
| 2018 August | 5 | 1 | 6 |
| 2018 July | 6 | 3 | 9 |
| 2018 June | 2 | 14 | 16 |
| 2018 May | 6 | 8 | 14 |
| 2018 April | 3 | 7 | 10 |
| 2018 March | 4 | 1 | 5 |
| 2018 February | 10 | 2 | 12 |
| 2018 January | 8 | 1 | 9 |
| 2017 December | 13 | 1 | 14 |
| 2017 November | 9 | 9 | 18 |
| 2017 October | 10 | 2 | 12 |
| 2017 September | 12 | 9 | 21 |
| 2017 August | 17 | 6 | 23 |
| 2017 July | 13 | 5 | 18 |
| 2017 June | 26 | 15 | 41 |
| 2017 May | 14 | 18 | 32 |
| 2017 April | 14 | 12 | 26 |
| 2017 March | 13 | 5 | 18 |
| 2017 February | 16 | 5 | 21 |
| 2017 January | 17 | 1 | 18 |
| 2016 December | 11 | 8 | 19 |
| 2016 November | 10 | 2 | 12 |
| 2016 October | 24 | 13 | 37 |
| 2016 September | 20 | 13 | 33 |
| 2016 August | 35 | 1 | 36 |
| 2016 July | 13 | 2 | 15 |
| 2016 June | 20 | 4 | 24 |
| 2016 May | 20 | 20 | 40 |
| 2016 April | 32 | 15 | 47 |
| 2016 March | 22 | 9 | 31 |
| 2016 February | 27 | 5 | 32 |
| 2016 January | 13 | 6 | 19 |
| 2015 December | 14 | 4 | 18 |
| 2015 November | 17 | 11 | 28 |
| 2015 October | 30 | 14 | 44 |
| 2015 September | 21 | 15 | 36 |
| 2015 August | 34 | 2 | 36 |
| 2015 July | 33 | 7 | 40 |
| 2015 June | 15 | 7 | 22 |
| 2015 May | 33 | 9 | 42 |
| 2015 April | 37 | 13 | 50 |
| 2015 March | 40 | 10 | 50 |
| 2015 February | 24 | 7 | 31 |
| 2015 January | 22 | 5 | 27 |
| 2014 December | 34 | 10 | 44 |
| 2014 November | 24 | 6 | 30 |
| 2014 October | 30 | 13 | 43 |
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