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Acute Paraplegia Secondary to Hemorrhage of a Thoracic Spinal Cavernous Malformation: Case Illustration with Radiologic-Pathologic Correlation and Review of Literature 2014

Category General Spine Mougnyan Cox
Danielle Fortuna
Ian Hayden
Lisa Tartaligno
Purpose This is a 38 year-old male with morbid obesity who presented with back pain and sudden onset of profound bilateral lower extremity weakness. Physical exam was remarkable for loss of muscle strength in both lower extremities, with retention of limited ankle dorsiflexion on physical exam. CTA of the abdomen to rule out aortic dissection and possible involvement of the artery of Adamkiewicz was negative. MRI of the cervical, thoracic and lumbar spine was performed. Patient underwent resection of the T11 lesion, with some improvement in his lower extremity strength. Materials & Methods Cavernous malformations (CM) are vascular malformations consisting of dilated blood-filled sinusoids lined by endothelial cells with no intervening neural tissue. CM is generally considered to be a stable lesion, though spontaneous hemorrhage is not a rare event. In the brain, these lesions commonly present with seizures. Acute neurologic deficits may also occur, particularly in the setting of recent hemorrhage. In the spine, symptomatic lesions are most commonly located in the thoracic spine followed by the cervical spine and conus medullaris. When symptomatic, spinal CMs may present with motor or sensory deficits. Results Characteristic MR features include a multiloculated or unilocular cystic structure with central T2 hyperintensity surrounded by peripheral rim of hypointensity. The T2 hypointense rim is presumably from hemosiderin staining of adjacent brain parenchyma as a result of repeated episodes of prior hemorrhage. Conclusion For most symptomatic spinal CM lesions, microsurgical resection is the treatment of choice when feasible. Microsurgical resection controls further bleeding and can prevent further neurological deterioration. Surgical resection is usually performed six weeks after hemorrhage to allow for resolution of cord edema, and for the development of a gliotic plane between the CM and surface of the cord via which resection may be performed. References 1. Brown-Sequard syndrome secondary to spontaneous bleed from postradiation cavernous angiomas. Mathews et al. AJNR 29:1989-1990 Nov 2008 2. De novo development of a lesion with the appearance of a cavernous malformation adjacent to an existing developmental venous anomaly. Campeau et al AJNR 26:156-159, Jan 2005 3. Management and prognosis of symptomatic patients with intramedullary spinal cord cavernoma. Liang et al. J Neurosurg Spine 15: 447-456, 2011 4. Practical Surgical Neuropathology: A Diagnostic Approach. Decker, Perry et al. 2010:527-550.