Prognostic factors for the outcome of surgical and conservative treatment of symptomatic spinal cord cavernous malformations: a review of a series of 20 patients

Abstract

Object In this study, the authors present a review of a series of 20 intramedullary spinal cord cavernous malformations (SCCMs) with particular focus on MR imaging and prognostic factors. Methods Between 1994 and 2009, 20 patients with SCCM were treated under the care of the senior author. The diagnosis was made in all patients after the onset of clinical symptoms. The age of the 9 men and 11 women ranged between 26 and 71 years (median 38.5 years). The duration of symptoms prior to referral ranged from 1 week to 9 years (median 6.5 months). At the time of referral, 4 patients had no significant neurological deficits, 10 patients suffered significant functional restrictions, and 6 patients presented with severe paraparesis and loss of functional strength. None of the patients had complete paraplegia. Seventeen patients underwent microsurgical removal, while 3 patients opted for conservative therapy. For the present analysis, the medical records and MR images and/or reports were reviewed. Classification of length of history, pretreatment status, MR imaging pattern, and treatment modality was done and correlated with outcome. Results The cavernoma was located at the cervical level in 8 patients and between T-1 and L-1 in 12 patients. The cavernoma appeared as mainly T2 hyperintense on MR images in 7 patients, mainly T2 hypointense in 2 patients, and mixed in the remaining 10 patients. The craniocaudal extension of the core varied between 5 and 45 mm. In 2 patients with cervical cavernomas, a distinct T2 signal of the spinal cord cranial and distal to the cavernoma was seen, and in a patient with a large thoracic cavernoma, T2 extinction cranial and caudal to the cavernoma was seen as a sign of hemosiderosis. Neurological deficits improved postoperatively in 12 of the surgically treated patients, remained stable in 2, and deteriorated in 3. The 3 patients who were conservatively treated remained stable over a follow-up of 3–9 years. Postoperative improvement was seen in 5 of 7 surgical patients with a history of symptoms of 2 months or less, 5 of 6 patients with a history of 2–24 months, and in 2 of 4 patients with a history of more than 2 years. Two of the 3 patients with postoperative deterioration had a history of more than 2 years and the third a short history of 1 month. Conclusions Although a satisfactory outcome can be achieved through surgical treatment of SCCMs, some patients worsen after surgery or during the postoperative course. Long-term stability is possible in oligosymptomatic conservatively treated patients. The prevalence and pathophysiological importance of segmental spinal cord edema and hemosiderosis is incompletely understood at the present time.