Thoracic Spinal Angiolipoma: A Retrospective Case Series Highlighting Heterogeneous Imaging Presentations

Spinal angiolipomas are uncommon benign epidural tumors composed of mature adipose tissue and abnormal vascular channels. Their magnetic resonance imaging (MRI) appearance depends on the relative proportions of these components, which can make preoperative diagnosis difficult. The objective of this series is to describe the clinical, radiological, surgical, and histopathological spectrum of thoracic spinal angiolipomas and to discuss the implications of their imaging heterogeneity for preoperative diagnosis. We describe three adults with progressive thoracic myelopathy caused by posterior epidural lesions: a 53-year-old man with an eight-level T1-T8 fat-signal lesion without postcontrast enhancement; a 57-year-old man with a heterogeneously enhancing T4-T6 lesion causing severe canal stenosis; and a 65-year-old woman with a T5-T6 lesion with T6 vertebral marrow signal change that initially suggested vertebral hemangioma with epidural extension. Each patient underwent posterior decompression and microsurgical excision. Histopathology demonstrated mature adipose tissue admixed with benign vascular channels in the first two patients and an angiolipomatous vascular-fatty lesion with osseocartilaginous tissue in the third. All patients improved neurologically after surgery without a documented new deficit; follow-up MRI in the second patient at four months showed no residual lesion. This series illustrates the radiologic heterogeneity of spinal angiolipomas and the uncommon occurrence of long-segment disease. Recognition of the fatty and vascular components can narrow the differential diagnosis, but histopathology remains decisive. Adequate decompression and maximal safe resection generally provide favorable early outcomes.