CASE 1961 Published on 25.10.2005

Intradural extramedullary capillary haemangioma

Section

Neuroradiology

Case Type

Clinical Cases

Authors

Vilanova JC, Barceló J, Villalón M

Patient

78 years, male

Categories
No Area of Interest ; Imaging Technique MR, MR, MR, MR, MR-Angiography
Clinical History
A 78-year-old male patient presented with a three-month history of progressive motor weakness of both the lower extremities.
Imaging Findings
The 78-year-old male patient presented with a three-month history of progressive motor weakness of both the lower extremities. A neurological examination which was done, revealed decreased motor strength of both the lower extremities, with grade 2 severity, and bilateral hypoaesthesia below the level of T11–T12. There was hyperreflexia of the left lower extremity and hyporreflexia of the right one as well. An MRI examination was performed, which showed the presence of a well-circumscribed intradural mass at the level of T10–T11, displacing and compressing the spinal cord. The mass was isointense relative to the spinal cord on T1-weighted images (Fig. 1) and hyperintense on T2-weighted images (Fig. 2). Sagittal T2-weighted imaging revealed the presence of the intradural mass with retromedullary serpiginous areas of signal void (Fig. 3). The lesion enhanced intensely and homogeneously (Fig. 4). An MRA examination was performed which demonstrated the presence of vascular lesions with a multilobular and septate pattern, with extensive retromedullary serpiginous vessels (Fig. 5). A vascular lesion was suspected and the most likely preoperative diagnoses were those of a haemangioma or a haemangioblastoma. The tumour was totally excised and the patient's neurological deficits progressively improved after surgery. The pathological examination exhibited the presence of small capillary-sized vessels, indicating a capillary haemangioma (Fig. 6).
Discussion
Spinal intradural extramedullary haemangiomas are rare occurrences. Haemangiomas may arise from the blood vessels of the nerve roots in the cauda equina, the inner surface of the dura, or the pial surface of the spinal cord (1–3). In this case, the site of origin was the inner surface of the dura mater. Both capillary and cavernous haemangiomas behave as space-occupying masses, producing chronic progressive myelopathy or radiculopathy leading to motor and sensory deficits (4). There is also a significant risk of bleeding. The MR imaging findings of a spinal intradural extramedullary capillary haemangioma have been described as being either homogeneous or heterogeneous on T1- and T2-weighted images; however they always show a strong enhancement (1–3). The most outstanding finding in this case was seen on MRA, which corresponded to the macro- and microscopic appearance of lobules separated with septa and composed of small capillaries without haemorrhage. The most common intradural extramedullary tumours are neurinomas and meningiomas, both of which show a marked enhancement on contrast-enhanced T1-weighted images. Usually, the signal intensity is hypointense rather than isointense. Cystic changes are not infrequently found in neurinomas. Meningiomas are usually only slighty hyperintense on T2-weighted images. The signal intensity may be helpul in differentiating between a meningioma and haemangioma. Intradural arteriovenous malformations show a vascular flow void within the lesion. It is difficult to distinguish between a haemangioma and a haemangioblastoma by MR imaging, when the lesion presents without a cystic component. Other intradural extramedullary tumours include paraganglioma, filum terminale ependymoma, metastases, sarcoidosis and lymphoma. Paraganglioma may show a heterogenous "salt and pepper" appearance. Ependymoma may be seen with a lower degree of enhancement. Metastases usually appear as multiple nodular lesions. Sarcoidosis and lymphoma frequently appear as multifocal patchy or linear enhancing lesions (5). It is important, whenever a suspected vascular lesion is found in the spine, to add an MRA study in order to achieve a more accurate diagnosis and evaluation, as in the case reported.
Differential Diagnosis List
Intradural extramedullary capillary haemangioma.
Final Diagnosis
Intradural extramedullary capillary haemangioma.
Case information
URL: https://www.eurorad.org/case/1961
DOI: 10.1594/EURORAD/CASE.1961
ISSN: 1563-4086