Adjuvant multimodal treatment for spinal intradural extramedullary capillary hemangioma with subpial growth: illustrative case

Abstract

Background: Spinal intradural extramedullary capillary hemangiomas are rare vascular lesions. Although total resection is the first treatment, the efficacy of adjuvant therapies, such as steroid or radiation therapy, has not been investigated.

Observations: A 74-year-old man presented with progressive back pain, gait disturbance, and left chest pain. Spinal magnetic resonance imaging (MRI) revealed an intradural extramedullary lesion at the middle thoracic level. Preoperatively, systemic steroid administration improved his chest pain and reduced the tumor size. The authors performed tumor extirpation. Because the tumor strongly adhered to the pia matter, in short, the tumor accompanied with partial subpial growth, subtotal resection was performed, leaving a thin layer of the tumor. A pathological examination revealed capillary hemangioma. His gait disturbance showed rapid improvement. Stereotactic cyber knife treatment was performed for the residual tumor at 1 month after the operation. Serial MRI showed a gradual decrease in the tumor size and no recurrence at 2 years after the operation.

Lessons: When a tumor adheres to the spinal cord or nerve root, immoderate total resection should not be performed to avoid exacerbating the clinical symptoms. Adjuvant therapies, such as a systemic steroid administration or radiation therapy, may provide satisfactory control of spinal capillary hemangiomas.

Keywords: capillary hemangioma; intradural extramedullary tumor; radiation therapy; spine; steroid.

FIG. 1.

Preoperative MRI. An intradural extramedullary lesion showing isointensity on a T1-weighted image (A) and relative hyperintensity accompanied by spinal cord edema on a T2-weighted image (B). The mass lesion showed homogeneous contrast enhancement on a T1-weighted image, accompanied by the dural tail sign (C) and spinal cord compression (D). The intradural extradural lesion showing a decrease in tumor size and improvement in spinal edema after systemic steroid administration (E and F). Th6 = 6th thoracic vertebrae.

FIG. 2.

After the dura was opened, a dark-reddish mass lesion was seen on the dorsal surface of the spinal cord (A). A thin layer of the tumor was left on the dorsal surface of the spinal cord (B). The pathological diagnosis after surgery suggested capillary hemangioma (hematoxylin and eosin, C) with a positive reaction for CD31 (D). Original magnification ×200 (C and D).

FIG. 3.

Planning images for the Cyber Knife treatment based on computed tomography (A and B). Postoperative follow-up MRI 1 week after surgery showed a thin layer of residual tumor on the dorsal surface of the spinal cord (C and D). MRI 2 months after Cyber Knife treatment showed shrinkage of the residual tumor (E and F). MRI 2 years after Cyber Knife treatment showed gradual regression of the tumor (G and H). Th6 = 6th thoracic vertebrae.