OBJECT Intramedullary spinal cavernoma (ISC) is a rare entity and accounts for approximately 5%−12% of all spinal vascular pathologies. The purpose of the present study was to examine the influence of clinical presentation, localization, and different surgical approaches on long-term outcome in patients treated for ISC. METHODS The authors performed a retrospective single-center study of 48 cases of ISC treated microsurgically over the past 28 years. Analyzed factors included preoperative clinical history, microsurgical strategies, neurological outcome (American Spinal Injury Association [ASIA] grade, Epstein and Cooper grade), and the occurrence of postoperative spinal ataxia. Univariate analysis was performed to identify factors influencing long-term outcome. RESULTS Preoperatively, 18.8% of all patients experienced a slow, progressive decline in neurological function and 33.3% suffered repetitive episodes of acute neurological deterioration over a time frame of months to years. Moreover, 16.7% noted the sudden onset of a severe neurological deficit, whereas 25% experienced the sudden onset of symptoms with a subsequent gradually progressive decline in neurological function. On long-term follow-up after treatment (mean ± SD, 79.3 ± 35.2 months), 70.8% of patients showed no change in neurological function, 6.3% suffered from a decline, and 22.9% improved neurologically. Thoracolumbar localization (p = 0.043), low preoperative Epstein and Cooper grade for the lower extremities (p < 0.001), and a low preoperative ASIA grade (p < 0.001) were identified as factors associated with an unfavorable outcome (ASIA Grade A-C). The rate of spinal ataxia related to surgical approach was 16.7%. CONCLUSION Postoperative neurological function in ISC patients is determined by the preoperative neurological status. On long-term follow-up after microsurgical treatment, 93.7% of patients presented with a stable or improved condition (ASIA grade); thus, definite microsurgical treatment should be considered as long as patients present with only mild symptoms after the diagnosis of symptomatic ISC.

Patients with neurologic deficit because of spinal bone metastases benefit from early operative intervention. Urgent surgery is indicated in patients with less than 3 days of neurologic deficit.

The aim of this study was to determine the frequency of aneurysms associated with arteriovenous malformations (AVMs) of the posterior fossa and their relation to hemorrhagic presentation in comparison to supratentorial AVMs. We performed a retrospective analysis of 474 patients with intracranial AVMs treated in our center from 1990 to 2010. Patients were analyzed for AVM size, drainage type and their clinical course with focus on vessel anomalies including AVM-associated aneurysms. Seventeen (30%) of 57 posterior fossa AVMs versus 46 (11%) of 417 supratentorial AVMs were associated with aneurysms. In six (10.5%) versus seven (1.7%) patients, respectively, flow-associated aneurysms were the source of hemorrhage. Infratentorial location of an AVM was a significant risk factor for the incidence (p < 0.001) and rupture (p < 0.001) of AVM-associated aneurysms. Feeding artery aneurysms in particular represented a risk factor for hemorrhage in the overall group of AVM patients, independently of the location (p < 0.001). The majority of patients with a posterior fossa AVM were treated by combined embolization and surgical removal within one procedure (n = 33, 58%). Feeding artery aneurysms were excluded by endovascular coiling or surgical clipping whenever feasible. Overall treatment-associated permanent morbidity in the subgroup of posterior fossa AVMs was 11% (n = 6) and mortality 4% (n = 2). Posterior fossa AVMs display a significantly higher frequency of associated aneurysms of the adjacent vessels that are correlated to the high bleeding rate compared to AVMs of the supratentorial compartment. We therefore recommend aggressive AVM treatment including the exclusion of associated aneurysms as a minimal therapeutic goal whenever possible.

Patient's age >70 years, patients with a preoperative neurological deficit, and patients with heavily bleeding metastases are at high risk for complications. The dorsoventral/dorsolateral approach had the highest complication rate.