Vascular lesions of the lumbar epidural space: magnetic resonance imaging features of epidural cavernous hemangioma and epidural hematoma

Lesões vasculares do espaço epidural lombar: aspectos da ressonância magnética da coluna lombar no emangioma cavernoso e hematoma epidural

CASE REPORTS

VASCULAR LESIONS OF THE LUMBAR EPIDURAL SPACE: MAGNETIC RESONANCE IMAGING FEATURES OF EPIDURAL CAVERNOUS HEMANGIOMA AND EPIDURAL HEMATOMA

Roberto Basile Júnior, Laércio Alberto Rosemberg, Fernando Machado Pedrosa, Eduardo Von Uhlendorff, Claudia M. Matuoka and Pil Sun Choi

RHCFAP/2956

BASILE Jr., R. et al. - Vascular lesions of the lumbar epidural space: magnetic resonance imaging features of epidural cavernous hemangioma and epidural hematoma. Rev. Hosp. Clín. Fac. Med. S. Paulo 54 (1): 25 - 28, 1999.

SUMMARY: The authors report the magnetic resonance imaging diagnostic features in two cases with respectively lumbar epidural hematoma and cavernous hemangioma of the lumbar epidural space. Enhanced MRI T1-weighted scans show a hyperintense signal rim surrounding the vascular lesion.

Non-enhanced T2-weighted scans showed hyperintense signal.

DESCRIPTORS: Lumbar pain. Lombar epidural cavernous hemangioma. Epidural hematoma. Lumbar disk hernia. Lumbar spine magnetic resonance.

Vascular lesions of the lumbar epidural space are a rather uncommon finding. Hemangiomas of the epidural space represent only 4% of all epidural findings. On the other hand, epidural hematoma is more common according to Heihoff⁴. An epidural hematoma can be caused by the rupture of the local epidural veins. Vein rupture is usually secondary to a lumbar disk degenerative disease. In these cases, there is usually no history of significant local trauma. Therefore, it is possible that the local veins adjacent to the lumbar disk come to rupture along with the rupture of the diseased lumbar disk producing an epidural hematoma. Both types of intervertebral disk rupture; that is, annular or extrusive rupture can cause local epidural bleeding and hematoma formation. Gadolinium-enhanced magnetic resonance imaging is currently used to diagnose vascular lesions of the lumbar epidual space⁴. The diagnosis of a co-exiting vascular lesion is highly relevant for the surgical treatment approach of a suspected herniated lumbar disk because the surgical access to remove a local hematoma is usually wider than the surgical access for an herniated disk alone.

The authors report two cases presenting radicular pain in the lower limbs with mild neurological signs compatible with lumbar disk herniation. Magnetic resonance imaging disclosed the presence of an epidural cavernous hemangioma and an epidural hematoma in case one and case two respectively.

CASE REPORT

Case one: A healthy college-educated 27 year-old male developed in December 1996 symptoms radicular pain over the left buttock. Two weeks later, the patient reported that the pain spread down to the outer surface of the left leg. Pain became more severe during walking, sneezing, coughing, sitting, and during the transition from sitting to standing up. Partial pain relief was obtained upon lying down. The patient reported no history of trauma or use of any medications before the pain onset.

The physical exam demonstrated a L5 nerve root pain upon the flexion of the upper body. Neurological exam uncovered weakness of the left halux extensor (2/5), and left anterior tibialis weakness (3/5). No sensitive deficit was recorded and a positive 45 degress Lasègue's signal was obtained. Patellar and aquileus reflexes were unremarkable.

T1-weighted scans showed on the left sagittal view, a rounded low intensity signal image encroaching upon the upper surface of the L5 vertebral body. The rounded low signal image displayed a signal of similar intensity to the L5 vertebral body (arrowheads in figure 1).

The gadolinium-enhanced T1-weighted scans showed on the left sagittal view and on the axial view at the level of L5 pedicle, a rounded low intensity signal image surrounded by a hyperintensity signal halo. (arrowheads in figure2). Invasion of the L5 lateral recess and impinging on the left L5 nerve root (arrowheads in figure 3) were recorded.

T2-weighted scans showed on the left sagittal view and on the axial view at the level of L5 pedicle, a hyperintensity signal image encroaching on the upper surface of the L5 vertebral body.(arrow in figure 4). Invasion the left L4-L5 lateral recess and impinging of the left L5 nerve root (arrowheads in figure 5) were made evident.

The patient was submitted to a left L4-L5 laminectomy on December 30th 1997. Surgical procedure disclosed a reddish mass impinging the left L5 nerve root. The removal of the mass produced a profuse bleeding from epidural vessels requiring immediate cauterization. Lumbar 4-5 disk was unremarkable. Histological analysis revealed a cavernous hemangioma. The patient became asymptomatic with normal left anterior tibialis and left halux extensor muscle power and unremarkable neurological exam at one year medical follow-up.

Case 2: A 38 year-old healthy businessman reported an 8 month-long history of a radicular pain over the right buttock, which become more severe in the last 30 days prior to the initial medical evaluation. Thereafter, the pain spread down to the posterior surface of the right leg, flaring up during the transition from standing up to sitting and sitting to standing up becoming continuos even lying down.

The patient reported no history of trauma and the use of medications before the pain onset.

The physical exam demonstrated a limitation of the flexion of lumbar spine. Neurological exam was unremarkable. However, a right lower limb 45 degrees positive Lasègue's sign was obtained. Contralateral limb Lasègue's sign was also elicited.

T1-weighted scans showed on the right sagittal view and on the axial view at the level of L5-S1 disk, a rounded low intensity signal image with a hyperintensity signal surrounding its lower rim. This image was found to encroach on the L5-S1 disk and on the upper posterior surface of the S1 vertebral body (aarowheads in figure 6). Invasion of the right L5-S1 lateral recess L5 and impinging of the the left S1 nerve root (arrowhead in figure 7) were recorded.

Gadolinium-enhanced T1-weighted scans showed on the right sagittal and axial views, a low intensity signal image surrounded by a hyperintensity signal halo in the upper posterior S1 surface (arrowheads in figure 8) encroaching on the S1 lateral recess, impinging the right S1 nerve root (see arrowhead in figure 9).

T2-weighted scans showed on the right sagittal view and on axial view at the level of L5-S1 disk, a hyperintensity signal image encroaching on the upper surface of the S1 vertebral body (arrowhead in figure 10). Invasion of the right L5-S1 lateral recess and impinging on the right S1 nerve root (arrowhead in figure 11) became apparent.

The subject was submitted to a right L5-S1 laminectomy on August 10 1998.

Surgical procedure disclosed a reddish mass surrounded by a capsule forming a hematoma that impinged on the right S1 nerve root. Hematoma removal produced a profuse bleeding from epidural vessels.

The L5-S1 disk was removed because of an extruded disk herniation on the right. Histological analysis confirmed hematoma and herniated disk. The patient became completely asymptomatic after the surgical treatment.

DISCUSSION

Cavernous epidural hemangioma is an infrequent vascular neoplasm^1,2,3. It is more frequently recorded in the thoracic segment of the spinal column. It usually emerges within the vertebral canal progressing into a clinical picture with features of a mielopathy⁸. However, a cavernous epidural hemangioma may mimic an acute lumbar herniated disk condition if the hemangioma is located in the lumbar segment of the spinal column. Microscopic bleeding within the hemangioma is usually the factor leading to hemangioma growth and deterioration of the symptoms and neurolgical findings.

The MRI findings of a lumbar epidural cavernous hemangioma has only been reported for the first time in 1995 by Harrigton et al³. Yet, the reason why only a few cases of lumbar epidural cavernous hemangioma have been reported in the current literature is likely due to a failure to reach a proper diagnosis of this condition. The caring radiologist's lack of diagnostic suspicion or failure in recognizing the characteristic MRI features may lead to lumbar epidural cavernous hemangioma diagnosis failure⁴.

According to several authors, the essential MRI features of the epidural hemangioma are the lack of the hemosiderin deposition halo in T1- and T2-weighted scans and the presence of a T2-weighted hyperintensity signal^4,8. Epidural hemangioma can be mistaken for epidural fat, atypical schwannoma, neurofibroma, venous plexus or local scarring⁸. However, the neurofibroma and schwannoma usually produce a remarkable enlargement of the vertebral notch. The cavernous hemangioma in case one, displays the characteristic MRI T2-weighted hyperintensity signal as reported elsewhere in the literature.

On the other hand, the epidural hematoma is more frequent. Heithoff⁴ states that the epidural hematoma accounts for the lumbar disk hernia resorption. Radiculopathy signs and symptoms may become reduced over a short period of time on account of the epidural hematoma resorption. The epidural hematoma is frequently mistaken for a fragment of an extruded disk herniation. According to Heitoff⁴, Saal and Saal's case series analysis demonstrated spontaneous resorption of lumbar herniated disk in several cases. This finding was in fact due to the resorption of an epidural hematoma. Definitive recognition and the differential diagnosis of the epidural hematoma with herniated disk is essential because both conditions share similar symptoms but the herniated disk disease clinical prognosis is somewhat more favorable⁵.

Extruded disk herniation is the main differential diagnosis with lumbar epidural vascular conditions. The fragments of the herniated disk show a low intensity signal in the T1- and T2-weigheted MR imaging⁴.

Wiltse et al.⁷ suggest that the epidural hematoma may co-exist with a herniated disk. Wiltse's analysed the membrane which connects the deep layer of the posterior longitudinal ligament and the Batson plexus. The Batson plexus is located posterior to this membrane and feeds the vertebral body. This took place in the case number two where the epidural hematoma was associated with the lumbar herniated disk.

The surgical approach for either epidural cavernous hemangioma or epidural hematoma is different from the surgical approach for the treatment of herniated disk alone. The former conditions require a wider surgical field.

The intra-operative diagnosis of a vascular epidural condition makes the complete removal of the vascular lesion more difficult because of the profuse epidural bleeding it usually produces.

RESUMO

RHCFAP/2956

BASILE Jr., R. e col. - Lesões vasculares do espaço epidural lombar: aspectos da ressonância magnética da coluna lombar no emangioma cavernoso e hematoma epidural. Rev. Hosp. Clín. Fac. Med. S. Paulo 54 (1): 25 - 28, 1999.

São descritas as características do diagnóstico de imagem pela ressonância magnética da coluna lombar em dois casos de lesões vasculares do espaço epidural - hemangioma cavernoso e hematoma epidural lombar. A ressonância magnética com contraste mostra nas imagens pesadas em T1, halo de alto sinal ao redor da lesão vascular. Nas imagens pesadas em T2 as lesões vasculares mostram aspecto de alto sinal.

DESCRITORES: Lombociatalgia. Hemangioma cavernoso epidural lombar. Hematoma epidural lombar. Hérnia do disco lombar. Ressonância magnética da coluna lombar.

Received of publication on the 05/10/98

From "Instituto de Ortopedia e Traumatologia do Hospital das Clínicas" University of São Paulo.

• ¹
  GAIANI, L. & CANED, L. - Angioma epidurale: descricione di un caso. Chir Organi Mov, 1996; 81: 331-334.
• ²
  GRAZIANI, N. et al. - Cavernous hemangioma and arterious venous mal formations of the spinal epidural space: report of 11 cases. Neurosurgery 1994; 35: 856-861.
• ³
  HARRINGTON, F.J.; KHAN, A. & GRUNUET, M. - Spinal epidural cavernous hemangioma presenting as a lumbar radiculopathy with analysis of magnetic ressonance imaging characteristics: case report. Neurosurgery 1995; 36: 581-584.
• ⁴
  HEITHOFF, K.B. - Myelography and computed tomography of the lumbar spine. In: WIESEL, S.W. et al. - Lumbar Spine. Philadelphia , Saunders, 1996. p. 376-428.
• ⁵
  NOBUYOSHI, W.K. et al. - Epidural hematoma of the lumbar spine simulating extruded disk herniation: clinical, discographic and enhanced magnetic ressonance imaging features. Spine 1997; 22: 105-109.
• ⁶
  SAAL, J.A. & SAAL, J.S. - The non operative treatment of herniated nucleus pulposus with radiculopathy. A autcome study. Spine 1989; 14: 431-437.
• ⁷
  WILTSE, L.L.; FONSECA, A.S. & AMSTER, J. - Relationship of the dura, Hofmann's ligaments, Batson plexus and a fibrovascular membrane lying on the posterior surface of the vertebral bodies and attaching to the layer of the posterior longitudinal ligament.. Spine 1993; 18: 1030-43.
• ⁸
  ZEVGARIDIS, D. et al. - Spinal epidural carvenous hemangiomas. J Neurosurgery 1998; 88: 903-908.

Publication Dates

• Publication in this collection
  12 Sept 2000
• Date of issue
  Feb 1999

History

• Received
  05 Oct 1998