Spinal Epidural hemangioma: a case report



Authors:
Sandip Pal






Department and Institution:
Department of neurosurgery
Bangur Institute of neuroscience and Psychiatry, I.P.G.M.E & R,
S.S.K.M Hospital, Kolkata




Address of correspondence:
Dr.Sandip Pal, 159, N.S.C Bose Road, Kolkata 700040







Running Title: Spinal Epidural Hemangioma: a case report







Summary:
A 45 year old male presented with history of progressive spastic paraparesis with sensory deficit for two and half months. MRI revealed a pure epidural compression with no bony invasion. Histopathology showed it to be a hemangioma.The patient improved significantly after operation.

Key words: Epidural mass, Hemangioma, surgery


Introduction:
Vertebral hemangiomas are found in 10-12% of all autopsies, making it the most common benign spinal neoplasm.1 The peak incidence is in the fifth to sixth decade and thee is a female preponderance in symptomatic lesions.2 10-15% of all vertebral hemangiomas may have concomitant involvement of the posterior elements and most epidural hemangiomas are the extension of the expanding osseous pathology. Pure extra osseous hemangiomas are rare, comprising only 1-2% of all vertebral hemangiomas.1, 3

Hemangiomas, especially epidural hemangiomas of the spinal canal are rare in contrast to intramedullary and extramedullary intradural hemangiomas According to Yasargil, the frequency of the epidural hemangioma is 4 % of all spinal tumors, while in Mullan's and Evans's report it is 12 % .Epidural hemangiomas represent about 4 % of all epidural tumors by Wyburn-Mason and 12 % of all intraspinal hemangiomas by Hurth. The majority of epidural hemangiomas are secondary extensions of vertebral
Hemangiomas to the epidural space. 4

Spinal epidural cavernous hemangiomas present clinically as chronic or acute syndrome of spinal cord compression as well as local back pain or radiculopathy. The authors present a rare case of epidural hemangioma with unusual disease progression.

Case report:
A forty five year old male presented with a history of rapidly progressive paraparesis with sensory deficits for last two and half months. He was catheterized for retention since last one month time. He came to our hospital with a power of 0/5 of both the lower limbs which were spastic and a 70-80% sensory deficit from nipples downwards including perianal sensation. All the tendon reflexes of the lower limbs were exaggerated with extensor response in planters. Superficial abdominal and cremasteric reflexes were absent bilaterally without any spinal deformity or tenderness. MRI revealed D3 vertebral body marrow edema, D2 to D4 posterior epidural enhancing lesion compressing the cord. An infective etiology was suspected by the reporting radiologist. D2, D3, D4 laminectomy was done and a purplish vascular mass was excised. Post operative period was uneventful and he was discharged after seven days with advice to clamp the Foley’s catheter periodically and physiotherapy. At discharge he gained 2-3/5 power at his lower limbs. The microscopical examination showed a lesion composed of dilated endothelium lined vascular channels filled with blood, suggestive of hemangioma.


Discussion:
Solitary epidural cavernous malformations are exceedingly rare compared with vertebral hemangiomas and represent 1~2% of all spinal cavernomas.1, 3
Clinical onset usually occurs during the 3rd to 6th decades of life and does not show any sex prevalence1. The segment most frequently affected is the thoracic one, followed by the lumbar and
Cervical.5
The usual presentation of spinal cord hemangioma is progressive compressive myelopathy. Radiologically it is usually isointense in T1WI and hyperintense in T2WI of MR.6, 7
In our case, the first provisional diagnosis was tuberculosis. Other differential diagnoses were neurofibroma, meningioma, metastasis, and lymphoma.

Reference:
1. Yochum TR, Lile RL, Schultz GD et al: Acquired spinal stenosis secondary to an expanding thoracic vertebral hemangioma. Spine 18: 299-305,1993
2. Fox MW, Onofrio BM: The natural history and management of symptomatic and asymptomatic vertebral hemangiomas. J.Neurosurgery 78:36-45,1993
3. Goiwyn DH, Cardenas CA, Murtagh FR et al: MRI of a cervical extradural cavernous hemangioma. Neuroradiol 34:68-69,1992
4. M.Fukushima, Y.Nabeshima, K.Shimazaki, K.Hirohata: Dumbbell-shaped spinal extradural hemangioma. Ach.Orthop Trauma Surg(1987) 106:394-396
5. Hillman J, Bynke O: Solitary extradural cavernous hemangioma in the spinal canal. Surg. Neurol 36: 19-24,1991
6. Osborn AG. Diagnostic Neuroradiology St. Louis: Mosby, 1994, pp 876-918
7. A.Goyal, A.K.Singh, V.Gupta, M.Tatke: Spinal epidural cavernous hemangioma: a case report and review of literature. Spinal Cord. April 2002. Vol 40, No-4:200-202