Clinical Reasoning: 63-Year-old woman with thoracic cavernous malformation and delayed worsening myelopathy

A 63-year-old woman presented with marked, progressive worsening of lower extremity spasticity and decreased upper extremity strength. In 1980, she developed lower extremity paresthesias and was found to have an intramedullary hemorrhagic lesion at T3. She underwent a laminectomy at T1-T4 and partial resection of a cavernous malformation (CM). Apart from a single, transient worsening of lower extremity sensory symptoms in 1985 (due to CM rebleeding), she did not experience any further exacerbations. At the time of evaluation at our institution, she had noticed worsening leg spasms and difficulty with her gait, as well as decreased muscle bulk, most pronounced in the quadriceps. These symptoms had developed over several months. She also reported worsening strength and endurance in the upper extremities, difficulties with fine motor movements, and dysphagia. She did not report new sensory deficits in her upper extremities or bowel or bladder dysfunction. On examination, she had a spastic gait but was able to walk with a cane. She had mild weakness, Medical Research Council grade 4, in the lower extremities and normal strength in the upper extremities, except for mild weakness, about 4/5 strength, in finger and wrist extension, in the interossei, and proximally. She had 3+ patellar and ankle reflexes, normal reflexes in the upper extremities, and extensor plantar responses bilaterally. Jaw jerk was not assessed. She had marked spasticity in the lower extremities with normal tone in the upper extremities. She had a T5 sensory level to temperature.