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Journal of Neurological Sciences (Turkish)
2010, Volume 27, Number 1, Page(s) 088-092
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Late Surgical Treatment of an Aggressive Vertebral Hemangioma : Case Report
Hasan Kamil SUCU1, Fazıl GELAL2, Aytül EROL1, Mine TUNAKAN3
1İzmir Atatürk Eğitim ve Araştırma Hastanesi, Nöroşirürji, İzmir, Türkiye
2İzmir Atatürk Eğitim ve Araştırma Hastanesi, Radyoloji, İzmir, Türkiye
3İzmir Atatürk Eğitim ve Araştırma Hastanesi, Patoloji, İzmir, Türkiye
Summary
Vertebral hemangiomas are common benign tumors. These are often asymptomatic lesions but sometimes show aggressive nature, and cause neurological deficit as result of spinal cord compression. Such compressive lesions require aggressive treatment. We report a 45 year old male patient with aggressive vertebral hemangioma, whose motor paraplegia for five months duration had recovered almost completely after surgery.

How to cite this article:
H. K. SUCU, F. GELAL, A. EROL, M. TUNAKAN: Late Surgical Treatment of an Aggressive Vertebral Hemangioma : Case Report. J Neurol Sci [Turk] 2010;27:088-092

How to cite this URL & PDF:
H. K. SUCU, F. GELAL, A. EROL, M. TUNAKAN: Late Surgical Treatment of an Aggressive Vertebral Hemangioma : Case Report. J Neurol Sci [Turk] 2010 [cited 2010 March 26];27:088-092. Available from: http://jns.dergisi.org/text.php3?id=345 PDF: http://jns.dergisi.org/pdf/pdf_JNS_345.pdf
E-mail of the corresponding author: hsucu@yahoo.com

  • Top
  • Summary
  • Introduction
  • Case Presentation
  • Discussion
  • Conclusion
  • References
  • Introduction
    Vertebral hemangiomas are common benign tumors seen in almost 10%-11% of spines at autopsy(19). They are often asymptomatic lesions(2,3), but some of them show agressive charecteristic and cause paraparesis/paraplegia with compression of the spinal cord(11,13,14). Treatment options of aggressive hemangiomas include of radiotherapy(2,6,11,20), embolisation(16), and intralesional alcohol injection(5,12,15) as well as surgery(8). We report a patient with aggressive vertebral hemangioma, whose motor paraplegia of five months duration had recovered almost completely after surgery.
  • Top
  • Summary
  • Introduction
  • Case Presentation
  • Disscussion
  • Conclusion
  • References
  • Case Presentation
    A 45 year old man admitted to our hospital with paraplegia for 5 months duration. He had a history of numbness and weakness of the right leg, which had gradually progressed to paraplegia within 3 months. His neurological examination revealed Frankel B(7) motor paraplegia, hypoesthesia below Th7-8 level, bilateral atrophy of thigh and cruris, and bilateral positive anal reflexes. Cremaster and abdominal skin reflexes were negative, and he didn't have urine or stool incontinence.

    Magnetic resonance imaging (MRI) of thoracic spine was performed five months ago, when paraplegia had developed. MRI showed a lesion involving the body of Th4 vertebra. An epidural lesion, with low signal on T1 (Figure 1) and high signal on T2- weighted images(Figure 2), was noted at the level of the involved vertebra, caused spinal cord compression and spinal stenosis. Focal myelomalasia with increased signal was also seen on T2-weighted image (Figure 2). After contrast injection epidural and vertebral body lesions enhanced (Figure 3). A computed tomography (CT) guided biopsy of the lesion was inconclusive; however, partial calcification of the epidural mass was shown on CT (Figure 4).


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    Figure 1: T1WI axial MRI scan showing hypointens epidural extension of the vertebral hemangioma


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    Figure 2: T2WI sagittal MRI scan showing local hyperintensity in the spinal cord at the level of compression of the vertebral hemangioma.


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    Figure 3: Gadolinium-enhanced T1-weighted axial MRI scan showing contras enhancement of the bilobed epidural extension of the vertebral hemangioma


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    Figure 4: Axial CT scan shows biopsy needle entering the vertebrae with polka-dot pattern. In the epidural space the calcification next to the corpus can be seen.

    He underwent operation, and thoracotomy was performing via left posterolateral incision with the excision of the left 6th rib. Th 4 corpectomy as well as excision of most of the calcified epidural mass was achieved. The excised rib was put in the corpectomy site in two pieces as a bone graft. Six units of blood were transfused during the operation. Histopathologic evaluation of the operation specimen showed typical characteristics of capillary hemangioma. Postoperative CT showed gross total corpectomy with minimal right epidural calcified residual mass (Figure 5).


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    Figure 5: Postoperative axial CT scan showing the decompression of the spinal canal and some residue on the right sight. Two parts of costal grafts can be seen anteriorly

    Just after the operation, the patient started to move his legs. His paraplegia had reversed almost completely in a month His ten month follow-up examination revealed normal neurological examination except grade 4/5 strength at the dorsal flexion of the right toe. He did not have any complaints other than slight contractions of the calves during walking.

  • Top
  • Summary
  • Introduction
  • Case Presentation
  • Disscussion
  • Conclusion
  • References
  • Discussion
    Hemangiomas of the vertebrae are common lesions estimated incidence of 9-12%(8,11). Most vertebral hemangiomas are asymptomatic(2,3), but rarely showed aggressive character and causing neurological deficit because of compression of the spinal cord(11,13,14). Both sexes are equally affected and the mean age group is about 40 years(2). This lesions are seen frequently at the thoracic region especially between T3 and T9(1).

    Vertebral hemangiomas can cause myelopathy related by many factors. Most common are the subperiostal (epidural) growth of tumor into the spinal canal and expansion of the bone (cortical “blistering”) with widening of the pedicles and lamina producing a “bony” spinal stenosis. Other causes compressing the spinal cord reported as vessels feeding or draining the lesion(10), by a pathological fracture(9) or a hematoma. Spinal cord ischemia due to diversion of the blood flow can also cause neurological symptoms(4). In our case, it was the protrusion of the tumor into the spinal canal that caused cord compression and paraplegia.

    Numerous treatment alternatives exist for aggressive vertebral hemangiomas presenting with myelopathy such as surgery(8), embolisation(16), vertebroplasty(17,18), radiotherapy(2,6,11,20), and injection of ethanol into the affected vertebral body, which has become popular lately(5,12,15). Cases with complete reversal of paraplegia have been reported after being treated by various modalities. Yang et al(20) and Faria et al(6) reported complete reversal of paraplegia of several weeks duration following radiation therapy alone. Doppman reported complete reversal of paraplegia in one patient following intralesional injection of ethanol(5). When cord compression is caused by soft tissue tumor, it may be reasonable to choose embolisation, intralesional alcohol injection, or radiotherapy for treatment. Treatment by these modalities causes intralesional thrombosis and destruction of the endothelium that composes the hemangioma. Devascularisation is followed by shrinkage of the lesion, which decompresses the cord and nerve roots(15). However, when cord compression is caused by either bony expansion or a hard – calcified tumor, as in our case, decompression can only be achieved by surgery. It has been reported that the recurrence rate of 20-30% after subtotal resections may be lowered to 7% by the addition of radiotherapy(10). However, we have not chosen radiotherapy after surgery, because of the small volume of the calcified residual tumor and the risk of post-radiotherapy myelopathy or pulmonary radio-necrosis.

  • Top
  • Summary
  • Introduction
  • Case Presentation
  • Discussion
  • Conclusion
  • References
  • Conclusion
    Decompressive surgery may prove effective in patients with paraplegia when cord compression is caused by slow growing tumors like hemangiomas, even if the duration of paraplegia is long. Complete or almost complete reversal of symptoms can be achieved even when the decompression is not 100%.

    Received by: 13 March 2006
    Revised by: 03 September 2006
    Accepted: 20 October 2006

  • Top
  • Summary
  • Introduction
  • Case Presentation
  • Discussion
  • Conclusion
  • References
  • References

    1) Abi-Fadel W, Afif N, Farah S, Haddad A, Rizk K, Raad J: Hemangiome vertebral sympto-matique au course de la grossesse. J Gynecol Obstet Biol Reprod 1997, 26: 90-94

    2) Cortet B, Cohen A, Deprez X, Deramond H, Lejeune J: Interet de la vertebroplastie couplee a une decompression chirurgicale dans le traitement des angiomes vertebraux agressifs, Rev. Rhumatisme 1994, 61(1): 16-22

    3) Derenbaum F, Cote D, Rancurel G: Complications tardives d’un angiome vertebral, Revue de rhumatisme 1990, 57(3): 211-212

    4) Djindjian M, Nguyen JP, Gaston A: Mutiple vertebral angiomas with neurological signs. J Neurosurg 1992, 76: 1025-1028

    5) Doppman JL, Oldfield EH, Heiss JD. Symptomatic vertebral hemangiomas: treatment by means of direct intralesional injection of ethanol. Radiology. 2000 Feb;214(2):341-8.

    6) Faria SL, Schlupp WR, Chiminazzo H Jr : Radiotherapy in the treatment of vertebral hemangiomas. Int J Radiat Oncol Biol Phys 1985; 11: 387-390.

    7) Frankel HL, Hancock DO, Hyslop G, Melzak J, Michaelis LS, Ungar GH, Vernon JD, Walsh JJ. The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia. I. Paraplegia. 1969 Nov;7:179-92.

    8) Fox MW, Onofrio BM: The natural history and management of symptomatic and asymptomatic vertebral hemangiomas J Neurosurg 1993, 78: 36-45

    9) Graham JJ, Yang WC.Vertebral hemangioma with compression fracture and paraparesis treated with preoperative embolization and vertebral resection. Spine. 1984 Jan-Feb;9(1):97-101.

    10) Greenberg MS. Bone tumors of the spine. In: Handbook of neurosurgery. 6th Edition New York, Thieme 2006, Pages 277-284

    11) Healy M, Herz DA, Pearl LL: Spinal hemangiomas. Neurosurg 1983, 13: 689-691

    12) Heiss JD, Doppman JL, Oldfield EH : Treatment of vertebral hemangioma by intralesional injection of absolute ethanol. N Engl J Med 1994; 331: 508-511.

    13) Hemmy DC, Geem MC, Armbrust FM, Larsons J: Resection of a vertebral hemangioma after preoperative embolization. J Neurosurg 1977, 47: 282-285

    14) Laredo JD, Assouline E, Gelbert F, Wybier-Merland JJ, Tubiana JM: Vertebral hemangiomas: Fat content as a sign of aggressiveness. Radiol 1990, 177: 467-472

    15) Murugan L, Samson RS, Chandy MJ.Management of symptomatic vertebral hemangiomas: review of 13 patients. Neurol India. 2002 Sep;50(3):300-5.

    16) Nguyen JP, Djindjian M, Badiane S: Hemangiomes vertebraux avec signes neurologiques: Le contexte clinique, Resultats de l’enquete de la SNCLF. Neurochirurg 1989, 35: 270-274

    17) Nguyen JP, Djindjian M, Gaston A, Ghardi R, Behaiem N, Garon JP, Poirier J: Vertebral angiomas presenting with neurological symptoms. Surg Neurol 1987, 27: 391-397

    18) Ross JS, Masaryk TJ, Modie MT, Carter JR, Mapstone T, Dengel FM: Vertebral hemangiomas MR Imaging. Radiol 1987, 165: 165-169

    19) Schmorl G, Junghanns H. The human spine in health and disease. Besemann EF, trans-ed. 2nd ed. New York, NY: Grune & Stratton, 1971.

    20) Yang ZY, Zhang LJ, Chen ZX et al : Hemangioma of the vertebral column. A report of twenty-three patients with special reference to functional recovery after radiation therapy. Acta Radiol Oncol 1985; 24: 129-132.

  • Top
  • Summary
  • Introduction
  • Case Presentation
  • Discussion
  • Conclusion
  • References
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