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Research paper
Clinical presentation, natural history and outcomes of intramedullary spinal cord cavernous malformations
  1. Anshit Goyal1,
  2. Lorenzo Rinaldo1,
  3. Redab Alkhataybeh1,
  4. Panagiotis Kerezoudis1,
  5. Mohammed Ali Alvi1,
  6. Kelly D Flemming2,
  7. Lindsy Williams2,
  8. Felix Diehn3,
  9. Mohamad Bydon1
  1. 1 Neurosurgery, Mayo Clinic, Rochester, New York, USA
  2. 2 Neurology, Mayo Clinic, Rochester, New York, USA
  3. 3 Radiology, Mayo Clinic, Rochester, New York, USA
  1. Correspondence to Dr Mohamad Bydon, Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA; bydon.mohamad{at}


Objective There is a paucity of literature investigating the clinical course of patients with spinal intramedullary cavernous malformations (ISCMs). We present a large case series of ISCMs to describe clinical presentation, natural history and outcomes of both surgical and conservative management.

Methods We retrospectively reviewed the clinical course of patients diagnosed with ISCMs at our institution between 1995 and 2016. Haemorrhage was defined as clinical worsening in tandem with imaging changes visualised on follow-up MRI. Outcomes assessed included neurological status and annual haemorrhage rates.

Results A total of 107 patients met inclusion criteria. Follow-up data were available for 85 patients. While 21 (24.7%) patients underwent immediate surgical resection, 64 (75.3%) were initially managed conservatively. Among this latter group, 16 (25.0%) suffered a haemorrhage during follow-up and 11 (17.2%) required surgical resection due to interval bleeding or neurological worsening. The overall annual risk of haemorrhage was 5.5% per person year. The rate among patients who were symptomatic and asymptomatic on presentation was 9.5% and 0.8%, respectively. Median time to haemorrhage was 2.3 years (0.1–12.3). Univariate analysis identified higher ISCM size (p=0.024), history of prior haemorrhage (p=0.013) and presence of symptoms (p=0.003) as risk factors for subsequent haemorrhage. Multivariable proportional hazards analysis revealed presence of symptoms to be independently associated with haemorrhage during follow-up (HR 9.39, CI 1.86 to 170.8, p=0.013).

Conclusion Large, symptomatic ISCMs appear to be at increased risk for subsequent haemorrhage. Surgery may be considered in such lesions to prevent rebleeding and subsequent neurological worsening.

  • spinal cord
  • cavernoma
  • intramedullary
  • cavernous malformation
  • natural history
  • surgical resection
  • neurologic outcomes
  • hemorrhage
  • bleeding risk

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  • AG and LR contributed equally.

  • Contributors AG, LR: conceptualisation and design, data collection, analysis and drafting of manuscript. RA: data collection. PK, MAA, KDF, LW: reviewing and revising original draft. FD: data collection, reviewing and revising original draft. MB: study supervision, reviewing and revising original draft.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval Institutional Review Board (IRB) approval was obtained (IRB #15-006838).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement All available data provided in the manuscript and as supplement.