Acute bleeding of a cavernous malformation of the conus medullaris

A 29-year old arabian man was admitted to the hospital with a progressive sensory loss to light touch, pin prick and vibration of the right and in a lesser extent of the left leg without any association to a particular dermatome. He additionally presented with paraesthesias in both legs, unsteady gait and incipient bladder- and bowl incontinence starting approximately one week prior to admission. Examination of reflexes revealed a diminished achilles tendon reflex in combination with a hyperactive patellar tendon reflex bilaterally. Cerebral spinal fluid (CSF) analysis showed 8 cells/µl, 39mg/dl protein, and 64mg/dl glucose. No immunological evidence for viral, bacterial or fungal infection could be found.

Subsequently performed spinal MRI showed a central intramedullary lesion approximately 1cm in diameter located within the conus medullaris suspicious for an intramedullary cavernous malformation (A-E). The lesion was accompanied by a perifocal edema and showed an inhomogeneous hypointense core on T2WI consistent with an cavernous hemorrhage (A,D,E). Application of contrast agent showed a slight enhancement in the edematous region (C) (Figure 1).

Cavernous malformations may be localized in every region of the CNS. Spinal cord cavernous malformations (SCCM) have been diagnosed more frequently since magnetic resonance imaging (MRI) has become more widely available. While the true incidence of SCCM remains unknown, they represent about 5–12% of all spinal vascular abnormalities1. They are rarely found in the conus medullaris representing only around 3% of all intramedullary cavernomas. Most are asymptomatic. The treatment of choice for symptomatic spinal cord cavernous malformations appears to be surgical excision in order to avoid recurrent bleeding. Consequently, the patient was referred to the department of neurosurgery with following total surgical excision. He had complete functional recovery after approximately four weeks.