BRIEF COMMUNICATIONS 75

present study showed that HPV 16 and HPV 18 are the most common
types associated with cases of invasive cervical cancer in Jordan.
Conflict of interest
The authors have no conflicts of interest.
References
[1] Agosti JM, Goldie SJ. Introducing HPV vaccine in developing countries – key
challenges and issues. N Engl J Med 2007;10;356(19):1908–10.
[2] Muñoz N, Bosch FX, de Sanjosé S, Herrero R, Castellsagué X, Shah KV, et al.
Epidemiologic classification of human papillomavirus types associated with
cervical cancer. N Engl J Med 2003;6;348(6):518–27.
[3] Smith JS, Lindsay L, Hoots B, Keys J, Franceschi S, Winer R, et al. Human
papillomavirus type distribution in invasive cervical cancer and high-grade cervical
lesions: a meta-analysis update. Int J Cancer 2007;121(3):621–32.
[4] Hammouda D, Muñoz N, Herrero R, Arslan A, Bouhadef A, Oublil M, et al. Cervical
carcinoma in Algiers, Algeria: human papillomavirus and lifestyle risk factors. Int J
Cancer 2005;113(3):483–9.
[5] Lalaoui K. El Mzibri M, Amrani M, Belabbas MA, Lazo PA. Human papillomavirus
DNA in cervical lesions from Morocco and its implications for cancer control. Clin
Microbiol Infect 2003;9(2):144–8.
[6] Cuschieri KS, Cubie HA, Whitley MW, Seagar AL, Arends MJ, Moore C, et al. Multiple
high risk HPV infections are common in cervical neoplasia and young women in a
cervical screening population. J Clin Pathol 2004;57(1):68–72.

0020-7292/$ – see front matter © 2009 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
doi:10.1016./j.ijgo.2009.08.025

Acute postpartum paraplegia caused by spinal extradural capillary hemangioma

Ali Akhaddar a,⁎, Mohamed Oukabli b, Hassan En-nouali c, Mohamed Boucetta a
a
Department of Neurosurgery, Mohammed V Military Teaching Hospital, University of King Mohammed V-Souissi, Rabat, Morocco
b
Department of Pathology, Mohammed V Military Teaching Hospital, University of King Mohammed V-Souissi, Rabat, Morocco
c
Department of Radiology, Mohammed V Military Teaching Hospital, University of King Mohammed V-Souissi, Rabat, Morocco

a r t i c l e i n f o epidural mass at the T5-vertebral level with extension to the right

T5–T6 foramen (Fig. 1a, b). A preoperative diagnosis of neuroma or
Article history:
angiolipoma was made. Emergent T5–T6 laminectomy revealed a
Received 22 July 2009
Received in revised form 28 July 2009 red–purple hemorrhagic well-circumscribed epidural mass. Macro-
Accepted 24 August 2009 scopic total excision was achieved (Fig. 1c). Microscopic examina-
tion showed a vascular lesion composed of thin and irregular
Keywords: capillary vessels suggestive of a capillary hemangioma (Fig. 1d). The
Gonadotropin-releasing
Capillary hemangioma hormone agonist
patient demonstrated dramatic improvement in her lower extremity
Infertility
Extradural
In vitro fertilization
Postpartum strength and sensation on the first postoperative day and almost
Leuprolide
Spinal cord compression total neurologic and functional recovery occurred after the first
week.
Pregnancy is a known risk factor for symptomatic conversion of
previously dormant vertebral hemangiomas, especially in the third
trimester of gestation [1]. However, purely extradural hemangiomas
Back pain is common in pregnancy. A 19-year-old woman pre-
are rare and most are of the cavernous type [2,3]. Three plausible
sented in her first pregnancy at 35 weeks of gestation with back pain
mechanisms that may explain compression of the spinal cord during
and progressive gait disturbance. The pain, well tolerated at first,
pregnancy from epidural hemangioma are: (1) increased venous
increased progressively and was attributed to normal pregnancy; the
pressure due to obstruction of the inferior vena cava by the enlarged
patient was treated symptomatically.
uterus; (2) estrogenic hormonal effect on the endothelium leading to
At 38 weeks of gestation the patient presented in active labor and
an increase in size of the hemangioma; and (3) blood volume increase
cesarean delivery was performed under general anesthesia for fetal
during pregnancy distending abnormal angiomatous blood vessels
distress. The patient delivered a healthy female neonate weighing
[1,2].
3800 g with an Apgar score of 8. In the immediate postpartum period
Spinal epidural hemangioma can cause dramatic neurological
the patient developed sudden paresthesia and complete neurologic
deficits, which can be successfully reversed if diagnosed and treated
palsy of both legs, and was transferred to our institution. On
without delay [4]. Physicians should be aware of spinal epidural
admission, the patient was paraplegic with urinary retention and
hemangioma in patients presenting with back pain and new-onset
diminished sensory function below the T6-vertebral level. Spinal MRI
neurological deficits, particularly in the third trimester of pregnancy.
showed a well-circumscribed, homogeneously-enhanced, posterior
A spinal MRI as an appropriate diagnostic modality should be
performed immediately.

⁎ Corresponding author. Bloc V2, appt 5, Av Kamal Zebdi, Secteur 21, Hay Riyad,
Conflict of interest
10100, Rabat, Morocco. Tel.: +212 670 94 77 39; fax: +212 537 71 60 44.
E-mail address: akhaddar@hotmail.fr (A. Akhaddar). No conflicts of interest exist.
76 BRIEF COMMUNICATIONS

Fig. 1. Spinal MRI on T1 weighted images after gadolinium injection, axial (a) and sagittal (b) views. The spinal cord was compressed by a well-circumscribed, homogeneously-enhanced,
posterior epidural mass (star) at the T5-vertebral level with extension to the right T5–T6 foramen (arrow). The epidural vascular lesion after total excision (c). Photomicrograph of the
lesion showing thin and irregular capillary vessels suggestive of a capillary hemangioma (d) (hematoxylin-eosin, original magnification x200).

References
[1] Vijay K, Shetty AP, Rajasekaran S. Symptomatic vertebral hemangioma in pregnancy
treated antepartum. A case report with review of literature. Eur Spine J 2008;17
(Suppl 2):S299–303.
[2] Hakan T, Demir M, Aker F, Berkman M. Pregnancy-related spinal epidural capillary-
cavernous haemangioma: magnetic resonance imaging and differential diagnosis.
Australas Radiol 2007;51:B6–9.
[3] Badinand B, Morel C, Kopp N, Tran Min VA, Cotton F. Dumbbell-shaped epidural
capillary hemangioma. Am J Neuroradiol 2003;24(2):190–2.
[4] Akhaddar A, Albouzidi A, Elmostarchid B, Gazzaz M, Boucetta M. Sudden onset of
paraplegia caused by hemorrhagic spinal epidural angiolipoma. A case report. Eur
Spine J 2008;17(Suppl 2):S296–8.

0020-7292/$ – see front matter © 2009 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijgo.2009.08.012