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Neuroradiology Case of the Week

Case 434

August 2009

Hisao Nakamura, MD and P-L Westesson, MD, PhD, DDS

Clinical Presentation: Patient is a 40-year-old man who presented after two episodes of progressive numbness from the chest level down to the legs.

Imaging Findings: MR imaging showed a intramedullary lesion with mixed hyper and hypo MR signal intensity extending from T4 to T6 level. There is a characteristic peripheral hyperintensity.

Diagnosis: Cavernous hemangioma

Discussion: This patient presented with progressing numbness of the body from the chest line down. MR imaging showed a characteristic cavernous hemangioma. These are uncommon malformations in the spinal cord but more often seen intracranially. Most vascular malformations of the spinal cord are arteriovenous malformations and cavernous hemangiomas have been estimated to represent only about 10% of all spinal vascular anomalies. Most vascular abnormalities within the vertebral bodies may have extension into the epidural space.
     Intramedullary cavernous hemangiomas are rare. MR imaging characteristics are the presence of mixed subacute and chronic hemorrhage indicated by the mixture of high-and low-signal intensity. Similar MR features may be seen in intramedullary arteriovenous malformations as a post-traumatic condition. Absence of dilated vessels and a nidus negative findings on spinal angiogram excludes most arteriovenous malformations. Thrombosed or partially thrombosed arteriovenous malformation may however have a similar appearance. Intramedullary neoplasms can usually be distinguished from cavernous hemangiomas by the relative rarity of mixed subacute and chronic hemorrhage in the spinal cord itself and by the lack of significant spinal cord expansion seen in cavernous hemangiomas.

References:

1. Fontaine S, Melanson D, Cosgrove R, Bertrand G. Cavernous hemangiomas of the spinal cord: MR imaging. Radiology. 1988 Mar;166(3):839-41. PMID: 3340780 [PubMed]