Spinal Cord Cavernoma

Diagnosis

Spinal cord cavernoma. Vascular lesions in the right cerebellar hemisphere, presumed to be cerebellar cavernomas. 

Response from neurosurgeon Professor Martin Scholz

I have reviewed both sets of imaging files. The spinal MRI reveals a large cavernous angioma of the spinal cord at the level of the second cervical vertebra (C2), predominantly on the right side and arising from the dorsal aspect of the spinal canal. The lesion exerts significant pressure on the spinal cord, displacing it anteriorly. The patient’s clinical symptoms are most likely attributable to this compression.

Surgical resection of the angioma is feasible, although it requires exceptional precision and caution. At our center, such procedures are performed with the patient in a seated position. Prior to surgery, a transesophageal echocardiography (TEE) is mandatory to rule out the presence of a patent foramen ovale (PFO), which could pose a risk during the operation.

To safeguard the integrity of spinal cord pathways intraoperatively, we employ continuous neurophysiological monitoring, including somatosensory and motor-evoked potentials (SSEPs and MEPs). This technique significantly reduces the risk of postoperative neurological deficits.

This case carries inherent risks, including the possibility of developing a transverse myelopathy syndrome (paraplegia). However, a conservative “wait-and-see” approach also entails substantial danger: a hemorrhage into the spinal cord could equally result in paraplegia—or even respiratory paralysis if the lesion affects high cervical segments. Therefore, a thorough risk–benefit analysis is essential.

According to current literature and our institutional data, the overall risk of postoperative complications in such surgeries is approximately 10–12%, distributed as follows:  

• Risk of permanent paraplegia: <1%  
• Transient neurological worsening (e.g., motor or sensory deficits): 5–6%  
• Postoperative anemia (often requiring transfusion): -5–6%  
• Surgical site infection: 1–2%  
• Cerebrospinal fluid (CSF) leak/fistula: 2–3%  
• Secondary hemorrhage: 1–2%  

In my assessment, the surgery is technically feasible because the cavernoma protrudes slightly from the spinal cord parenchyma, affording better surgical access. Should intraoperative monitoring show a significant drop in evoked potential amplitudes, resection is immediately halted to preserve neurological function, even if it means leaving a small residual portion of the lesion.

Regarding the cranial MRI scans (second disc), multiple small cavernous malformations (a few millimeters in size) are visible in the right cerebellar hemisphere, clustered closely together. Additionally, a small occipital cavernoma (<10 mm) is present but exerts no mass effect on adjacent brain tissue. These supratentorial and infratentorial lesions can safely be managed conservatively with regular MRI follow-up.

The annual risk of hemorrhage from cavernous malformations is reported variably in the literature, ranging from 0.3% to 0.5% per year. Given the patient’s young age (29 years) and an estimated life expectancy of approximately 60 additional years, her cumulative lifetime risk of hemorrhage reaches 25–30%. This further supports the consideration of surgical intervention for the symptomatic spinal lesion.

It should also be noted that cavernous angiomas are venous malformations that grow not through cellular proliferation but by the progressive accumulation of blood within dilated vascular channels. This can lead to gradual enlargement and increasing compression of neural structures over time.

Lastly, the provided spinal MRI study ends at the level of the fourth thoracic vertebra (T4). A complete evaluation necessitates extended MRI imaging of the entire thoracic and lumbar spine to exclude additional cavernomas, which are not uncommon in multifocal cases.

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