Journal of Chalmeda Anand Rao Institute of Medical Sciences Vol 7 Issue 1 January - June 2014 1Journal of Chalmeda Anand Rao Institute of Medical Sciences Vol 9 Issue 1 January - June 2015 ISSN (Print) : 2278-5310 45

Lumbar Intradural Extramedullary

Haemangioma

Kishore PVK1, Hemaratnan A2, Sreenivas V3, Sandeep Goud4, Varun

Babu A4, Prashanth S4

1 Assoc. Professor of Neurosurgery2 Professor of Neurosurgery3 Professor of PathologyDepartment of NeurosurgeryDepartment of Pathology4 PG StudentChalmeda AnandRaoInstitute of Medical SciencesKarimnagar - 505 001Telangana, India.

CORROSPONDENCE :

1Dr. P.V.K Kishore M.Ch.Assoc.ProfessorDepartment of Neuro SurgeryChalmeda Anand RaoInstitute of Medical SciencesKarimnagar - 505 001Telangana State, India.E-mail: puttetikali@yahoo.com

Case Report

INTRODUCTION

Vascular malformations of the spine are classicallydivided into four groups, each with different patholo gicaland radiological properties. This widely acceptedclassification includes venous, cavernous, arteriovenousand capillary malformations. However, some authorsrecently reported cases of vascular malformationsexhibiting pathological features of more than one discretemalformation type within the same lesion. These lesionsare rare and are named as "mixed vascular malformations.

CASE REPORT

A 22-year-old male patient presented with a 4-monthhistory of progressive lower back pain. The patient had

ABSTRACT

Vascular malformations with histopathological features of more than a single type ofmalformation present within the same lesion have been previously described. These lesionsare very rare and named as mixed vascular malformations. So far only 57 cases have beenreported in the literature. We report a case of a lumbar intradural extramedullary capillaryhemangioma due to its rarity.

Keywords: vascular malformation, capillary haemangioma, haemangioma

recently developed difficulty with walking. No historyof trauma, fever, loss of weight and loss of appetite. Onexamination no neurological deficits noted. Because hewas not relieved with medical management, X-ray lumbarspine and MRI spine was advised. MRI showed peanutsized solid tumor at L-4/L-5 level.

After preoperative workup patient has been submittedfor surgery and noted a 0.5 x 0.75cm oblong swellingattached to root of L-4. There were no abnormal vesselsand total excision of mass was achieved and sent forhistopathological examination. Patient recovered wellafter surgery, relieved of pain without any neurologicaldeficits. Histopathological report showed mixed capillaryvenous angioma.

Kishore PVK et. al

Journal of Chalmeda Anand Rao Institute of Medical Sciences Vol 9 Issue 1 January - June 2015 46

Figure 1: T2 sagittal view showing well circumscribed

intrdural extramedullary lesion at L4-L5 level

Figure-2: T2 axial view showing hyperinense mass lesion

with obliterated spinal canal and nerve roots

Figure 3: Sections studied showing capillary vascular

spaces admixed with cavernous spaces dilated with blood

Figure 4: Intraoperative image showing excised tumor

mass

DISCUSSION

The differential diagnosis for enhancing intraduralextrameduallary lesions in the spinal canal is long andincludes meningioma, hemangioma, schwannoma,hemangioblastoma, and paraganglioma. Theidentification of draining veins on MR images may helpin differentiating the hypervascular lesions such ashemangioma, hemangioblastoma, and paragangliomafrom the other nonhypervascular lesions and suggest theneed for preoperative angiography and embolization ifnecessary.

Capillary hemangiomas, which are uncommon in thespinal canal, [1-3] contain capillary networks surroundedby collagenous stroma without hemosider in deposition.To the best of our knowledge, the presence of enlargeddraining perimedullary veins has not been reported

previously. They may have been overlooked on initialassessment. These enlarged draining veins would alsobe expected in other vascular lesions such ashemangioblastoma or paraganglioma.

This lesion will be hypervascular at angiography anddemonstrates an early tumor like blush withinhomogeneous peripheral enhancement that rapidlybecomes more intense and homogeneous as thehemangioma filled in from the periphery to the center.The tumor stain persists throughout the venous phase.Also there will be rapid opacification of perimedullarycoronal plexus of veins dorsal to the spinal cord abovethe lesion.

When enlarged draining veins are associated with anintraspinal mass on MR images, the possibility of anextremely vascular tumor or vascular malformation

Lumbar Intradural Extramedullary Haemangioma

Journal of Chalmeda Anand Rao Institute of Medical Sciences Vol 9 Issue 1 January - June 2015 47

should be entertained, and preoperative spinalarteriography or contrast-enhanced MR angiographyshould be considered. In addition, preoperativeembolization may aid in the surgical resection of thesevascular lesions, although in our case this was not done.MRI films are suggestive of schwannoma by statisticalincidence.

CONCLUSION

Radiological presentation could be confusing in a purelyintradural cavernous haemangioma. Awareness of thecharacteristics of the lesion will facilitate diagnosis andtreatment of the lesion.

CONFLICT OF INTERESTThe authors declared no conflict of interest.FUNDING: None.

REFERENCES1. Cosgrove GR, Bertrand G, Fontaine S, Robitaille Y, Melanson D.

Cavernous angiomas of the spinal cord. J Neurosurg. 1988; 68 :31–36

2. Heimberger K, Schnaberth G, Koos W, Pendl G, Auff E. Spinalcavernous hemangiomas (intradural-extramedullary) underlyingrepeated subarachnoid haemorrhage. J Neurol. 1982; 226: 289 -293.

3. Richardson RR, Cerullo LJ. Spinal epidural cavernoushemangioma. Surg Neurol. 1979; 12: 266–8.