Thoracic extraosseous, epidural, cavernous hemangioma: Case report and review of literature
A 40-year-old male presented with a band-like feeling of constriction at the nipple level for eight months, followed by numbness to all modalities of sensation below this level. During the last month, progressive ascending spastic paraparesis had rendered him wheelchair-bound. There was no history of trauma, fever, deformity, tenderness over the spine, weight loss, or bowel or bladder dysfunction. He had no neurocutaneous markers. He had grade 3/5 medical Research Council (MRC) spastic paraparesis, exaggerated bilateral knee and ankle reflexes, and sustained ankle clonus on the left side. There was a graded sensory impairment to all modalities below the fourth thoracic dermatome. His hematological and biochemical investigations were within normal limits. The chest skiagram was normal.\nMagnetic resonance imaging (MRI) of the thoracic spine revealed an extradural lesion, opposite the T2-T4 vertebral bodies, which was homogenously isointense on T1- and hyperintense on T2-weighted images. The lesion was located dorsally and had compressed the thoracic cords ventrally. The axial sections revealed that the mass was located eccentrically; more on the patient's left side, with a small projection into the intervertebral foramen. The spinal cord at that level could be seen displaced ventrally and to the right. A central hyperintensity on T2-weighted imaging, within the cord substance, was also observed. Of note was the presence of a remote intraosseous T8 vertebral hemangioma. The lesion enhanced avidly and homogenously with contrast []. Computerized tomography (CT) of the upper dorsal spine did not reveal any bony destruction or widening of the intervertebral foramen. A radiological differential of an extradural schwannoma or meningioma was considered.\nThe patient underwent a T2-T4 laminectomy. Intraoperatively, the mass was encountered within the epidural fat and immediately beneath the laminae. It was reddish in color, firm, friable, and highly vascular. It was located epidurally, mostly dorsal to the thecal sac, but also extended laterally to the left, along the left T2 nerve root sheath. Its blood supply was derived from the intervertebral foramina on both sides. Initially, the tumor's dorsal surface was devascularized, with bipolar cautery, under the operating microscope. Its arterial feeders were then sequentially cauterized and interrupted, just medial to the intervertebral foramina, taking care not to injure the dorsal nerve roots. The lesion was then peeled off the surface of the dura and the adjacent nerve sheaths. The lesion was excised en bloc. The underlying dura was then opened, taking care to preserve the arachnoid, to ensure total microsurgical excision.\nThe patient was discharged 48 hours after surgery. His postoperative course was significant for a subjective improvement in spasticity and numbness. The histopathological examination indicated a CH []. On the last follow-up, 12 months after surgery, a check craniospinal MRI confirmed complete excision, with no recurrence at the operative site and no other new lesions. His power and sensations were nearly normal and he had returned to work.