Dumbbell-Shaped Thoracic Epidural Capillary Hemangioma Mimicking Schwannoma: A Case Report

Dumbbell-Shaped Thoracic Epidural Capillary Hemangioma Mimicking Schwannoma: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Dumbbell-Shaped Thoracic Epidural Capillary Hemangioma Mimicking Schwannoma: A Case Report SRIKANTH THIYAGARAJAN, SRI RAHUL, MOHAMED NALEER, JEYASELVA SENTHILKUMAR, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9318800/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background Spinal epidural hemangiomas are rare benign vascular lesions. A dumbbell configuration defined by extension through the neural foramen with both intraspinal and extraspinal components is most commonly associated with schwannomas. Dumbbell-shaped capillary hemangiomas are exceptionally rare and can pose significant diagnostic challenges. Case Presentation: A 66-year-old woman presented with a one-year history of back pain and progressive bilateral lower-limb weakness that progressed to a bedridden state. Imaging revealed a dumbbell-shaped lesion extending from D3 to D5 with a large paravertebral component measuring 4.3 × 3.6 × 5.7 cm. A combined D3–D5 laminectomy and right posterolateral thoracotomy was performed. The tumor was markedly hypervascular intraoperatively, and gross total resection was achieved. Recent coronary artery bypass grafting and dual antiplatelet therapy increased the operative hemorrhagic risk. Postoperatively, the patient demonstrated neurological improvement with restoration of bladder control and regained ambulation with a walker. Conclusions Dumbbell capillary hemangiomas can mimic schwannomas radiologically yet carry substantial hemorrhagic risk. Multidisciplinary surgical planning is essential for safe management. Spinal tumor dumbbell tumor capillary hemangioma epidural hemangioma thoracotomy Figures Figure 1 Figure 2 Introduction Vascular malformations constitute approximately 2–7% of spinal space-occupying lesions and include cavernous angiomas, arteriovenous malformations, capillary telangiectasias, and capillary hemangiomas [ 1 , 2 ]. Capillary hemangiomas most commonly involve cutaneous or mucosal tissues of the head and neck in children, whereas spinal extraosseous involvement is distinctly uncommon [ 3 ]. Primary spinal epidural hemangiomas account for approximately 4% of epidural spinal lesions [ 4 , 5 ]. Histologically, they are classified into cavernous and capillary types. Spinal epidural capillary hemangiomas are exceedingly rare, with fewer than 20 cases reported, and only a small fraction demonstrate a dumbbell configuration [ 4 , 6 , 7 ]. The term dumbbell tumor refers to lesions extending through the intervertebral foramen, connecting intraspinal and extraspinal compartments. This morphology is classically associated with schwannomas. Non-neurogenic dumbbell tumors are rare, and capillary hemangioma presenting in this form represents an exceptional diagnostic entity [ 8 , 9 ]. We report a thoracic dumbbell capillary hemangioma in a high-risk cardiac patient, emphasizing diagnostic challenges, surgical decision-making, and outcome. Case Presentation A 60-year-old female presented with a two-month history of progressive ascending weakness of both lower limbs, which progressed to complete paraplegia over six weeks. She also reported sensory loss below the D6 dermatome with urinary retention and constipation, suggestive of thoracic spinal cord compression. Neurological examination revealed spastic paraplegia with increased tone and absent voluntary motor activity in both lower limbs, with hypoesthesia below the D6 level and neurogenic bladder and bowel dysfunction. Magnetic resonance imaging of the thoracic spine demonstrated a well-defined, homogeneously enhancing dumbbell-shaped lesion centered at the D4 vertebral level with extension through the right neural foramen into the intrathoracic paravertebral space [Figure 1 , 2 ]. The intraspinal component caused severe spinal cord compression. Computed tomography showed a characteristic “honeycomb” appearance involving the D4 vertebral body, pedicle, and lamina, suggestive of a hypervascular lesion [Figure 3 ]. The patient underwent D3–D5 laminectomy with planned costotransversectomy. Intraoperatively, the lesion was identified as a purely extradural, markedly hypervascular tumor with foraminal and paravertebral extension [Figure 4 ]. Following circumferential devascularization, the intraspinal component was excised [Figure 5 ]. Due to significant bleeding and the large intrathoracic component, the procedure was modified to a right-sided mini-thoracotomy to facilitate safe resection. Postoperatively, the patient showed rapid neurological improvement and was able to stand with support by postoperative day two. Histopathology demonstrated lobules of proliferating capillary-sized vessels lined by flattened endothelial cells without atypia, consistent with benign capillary hemangioma [Figure 6 ]. Discussion Dumbbell-shaped spinal tumors represent a diagnostic challenge because of their diverse etiologies. Schwannomas are the most commonly encountered lesions; however, meningiomas, neurofibromas, ganglioneuromas, hemangioblastomas, lymphomas, and Ewing’s sarcoma must also be considered [ 7 , 8 ]. Vascular tumors are infrequently included in the preoperative differential owing to their rarity and imaging similarities to more prevalent neurogenic tumors. Most spinal epidural hemangiomas are of the cavernous type, whereas epidural capillary hemangiomas are exceedingly rare, with fewer than ten cases reported to date [ 7 , 10 ]. Histologically, capillary hemangiomas are characterized by lobules of thin, endothelium-lined capillary vessels separated by fibrous septa, in contrast to cavernous hemangiomas, which consist of dilated vascular spaces [ 11 , 12 ]. Among these rare epidural capillary hemangiomas, only approximately five cases exhibiting a dumbbell configuration have been documented, highlighting the exceptional nature of this presentation [ 8 , 9 ]. MRI is the imaging modality of choice for evaluating spinal epidural lesions [ 6 ]. Capillary hemangiomas typically appear isointense on T1-weighted sequences and hyperintense on T2-weighted images, with marked homogeneous gadolinium enhancement [ 13 , 14 ]. These features closely resemble those of schwannomas and meningiomas, particularly when a dumbbell morphology is present [ 13 , 15 ]. In contrast, cavernous hemangiomas often demonstrate heterogeneous signal intensity due to hemorrhage, thrombosis, or calcification [ 5 ]. In the present case, the combination of homogeneous enhancement and classic dumbbell configuration strongly favored a preoperative diagnosis of schwannoma, delaying recognition of the vascular nature of the lesion. Definitive diagnosis relies on histopathological evaluation. Capillary hemangiomas demonstrate compact lobules of capillary-sized vessels, whereas cavernous hemangiomas show large, dilated vascular channels [11,16]. Immunohistochemical positivity for endothelial markers such as CD31, CD34, and Factor VIII further confirms the diagnosis [ 11 , 14 ]. Despite their benign histology, capillary hemangiomas can exhibit pronounced intraoperative vascularity, resulting in substantial blood loss and operative difficulty. The dumbbell variant of spinal capillary hemangioma has been reported across cervical, thoracic, and lumbar regions without a clear regional predilection [ 8 , 9 ]. Reported patients are typically middle-aged or elderly, and surgery is frequently complicated by significant intraoperative hemorrhage. Surgical excision, with or without preoperative embolization, remains the treatment of choice [ 6 ]. When suspected preoperatively, embolization may reduce blood loss and improve surgical safety; however, this option is seldom considered because these lesions are often misdiagnosed as schwannomas. Although capillary hemangiomas are benign, gross total excision provides the best long-term outcome and is associated with a low recurrence rate [ 17 , 18 ]. Complete resection may be challenging in dumbbell lesions because of extensive foraminal or paravertebral extension [ 19 ]. When subtotal resection is unavoidable, radiosurgery has been advocated for residual or recurrent disease, although long-term outcome data remain limited [ 14 , 20 ] . In the present case, extensive osseous involvement, marked hypervascularity, and intraoperative hemodynamic instability necessitated modification of the surgical strategy, shifting from a posterior-only approach to a combined laminectomy and thoracotomy. This experience underscores the importance of maintaining a broad differential diagnosis and surgical flexibility when managing dumbbell-shaped spinal lesions. Conclusion Dumbbell-shaped epidural capillary hemangioma is an exceptionally rare spinal lesion that can closely mimic schwannoma on imaging, leading to preoperative diagnostic uncertainty. Despite its benign histology, the tumor may exhibit marked hypervascularity and extensive osseous and paravertebral involvement, resulting in significant intraoperative hemorrhagic risk. Gross total excision remains the treatment of choice and is associated with favorable neurological recovery. Preoperative recognition of a possible vascular etiology, consideration of embolization, and readiness to modify the surgical approach including combined posterior and thoracic exposure are essential to ensure safe resection and optimal outcomes. Declarations Ethics approval and consent to participate: Not applicable for single case reports. Consent for publication: Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of the journal upon request. Availability of data and materials: The data supporting the findings of this study are available from the corresponding author upon reasonable request. Competing interests: The authors declare no competing interests. Funding: No external funding was received. Clinical trial number: Clinical trial number: not applicable. Authors’ contributions: S. Thiyagarajan: Conceptualization, Data curation, Investigation, Writing – original draft, Correspondence. S. Rahul: Investigation, Surgical management, Data curation, Writing – review and editing. M. Naleer: Methodology, Surgical supervision, Validation, Writing – review and editing. J. Senthilkumar: Supervision, Project administration, Validation, Writing – review and editing. M. Rathore: Data curation, Literature review, Writing – review and editing. All authors have read and approved the final version of the manuscript. Acknowledgements: The authors would like to express their sincere gratitude to the entire Surgery team for their unwavering dedication, expertise, and compassionate care provided to the patients throughout the course of this study. The authors deeply appreciate the team's role not only in delivering high-quality patient care but also in supporting the broader goals of this research endeavour. The authors gratefully acknowledge the financial support by “SRM Medical College Hospital and Research Centre, Faculty of medicine and health sciences, SRMIST, kattankulathur, for bearing the defrayed cost of publishing this article. References Nowak DA, Gumprecht H, Stolzle A, Lumenta CB. Intraneural growth of a capillary haemangioma of the cauda equina. Acta Neurochir. 2000;142:463–7. Nowak DA, Widenka DC. Spinal intradural capillary haemangioma: A review. Eur Spine J. 2001;10:464–72. Roncaroli F, Scheithauer BW, Krauss WE. Hemangioma of spinal nerve root. J Neurosurg. 1999;91(2 Suppl):S175–80. Hasan A, Guiot MC, Torres C, Marcoux J. A case of a spinal epidural capillary hemangioma: case report. Neurosurgery. 2011;68(3):E850–3. Wu S, Sharma KK, Ho CL. Lumbar spinal epidural capillary hemangioma: a case report and literature review. Am J Case Rep. 2022;23:e936181. Gencpinar P, Acikbaş SC, Nur BG, Karaali K, Arslan M, Gurer EI, et al. Epidural capillary hemangioma: a review of the literature. Clin Neurol Neurosurg. 2014;126:99–102. Rajeev MP, Waykule PY, Pavitharan VM, Nandeesh BN. Spinal epidural capillary hemangioma: a rare case report with a review of literature. Surg Neurol Int. 2017;8:123. Badinand B, Morel C, Kopp N, Tran Min VA, Cotton F. Dumbbell-shaped epidural capillary hemangioma. AJNR Am J Neuroradiol. 2003;24(2):190–2. Yim B, Lee Y-J, Park DW, Lee JY, Park CK, Paik SS. Spinal capillary hemangioma involving the lumbar epidural and paraspinal spaces: case report. J Korean Soc Radiol. 2015;73(1):36–40. Benevello C, Laaidi A, Peeters S, Moiraghi A, Tauziede-Espariat A, Oppenheim C, et al. Spinal epidural capillary hemangioma: a systematic literature review and an illustrative case. Neurochirurgie. 2022;68(6):697–701. Niznick N, Nguyen TB, Bourque PR. Spinal capillary hemangioma: a rare benign extradural tumour. Can J Neurol Sci. 2020;47:549–50. Iannelli A, Lupi G, Castagna M, Valleriani A, Becherini F. Intramedullary capillary hemangioma associated with hydrocephalus in an infant. J Neurosurg. 2005;103(3 Suppl):272-6. 10.3171/ped.2005.103 .3.0272. Erratum in: J Neurosurg. 2007;106(5 Suppl):419. Bacherini, Francesca [corrected to Becherini, Francesca]. PMID: 16238083. Shin JH, Lee HK, Jeon SR, Park SH. Spinal intradural capillary hemangioma: MR findings. AJNR Am J Neuroradiol. 2000;21(5):954–6. PMID: 10815676; PMCID: PMC7976756. Liu JJ, Lee DJ, Jin L, Kim KD. Intradural extramedullary capillary hemangioma of the cauda equina: case report and literature review. Surg Neurol Int., Ganapathy S, Kleiner LI, Mirkin LD, Hall L. Intradural capillary hemangioma of the cauda equina. Pediatr Radiol. 2008;38(11):1235-8. 10.1007/s00247-008-0947-1 . Epub 2008 Jul 29. PMID: 18663441. Benevello C, Laaidi A, Peeters S, Moiraghi A, Tauziede-Espariat A, Oppenheim C, et al. Spinal epidural capillary hemangioma: a systematic literature review and an illustrative case. Neurochirurgie. 2022;68(6):697–701. Roncaroli F, Scheithauer BW, Krauss WE. Capillary hemangioma of the spinal cord. Report of four cases. J Neurosurg. 2000;93(1, Suppl):148–51. Kasukurthi R, Ray WZ, Blackburn SL, Lusis EA, Santiago P. Intra-medullary capillary hemangioma of the thoracic spine: case report and review of the literature. Rare Tumors. 2009;1:e10. Hasan A, Guiot MC, Torres C, Marcoux J. A case of a spinal epidural capillary hemangioma: case report. Neurosurgery. 2011;68:E850–3. Kliea M, Alsultan M, Chatty E, Qatleesh S, Hamzeh G. Spontaneous hemorrhage of spinal epidural capillary hemangioma resulting in hyperacute neurologic deficit: a case report. Med (Baltim). 2023;102(42):e35606. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 01 May, 2026 Reviews received at journal 30 Apr, 2026 Reviewers agreed at journal 25 Apr, 2026 Reviewers agreed at journal 23 Apr, 2026 Reviewers agreed at journal 22 Apr, 2026 Reviewers invited by journal 22 Apr, 2026 Editor assigned by journal 07 Apr, 2026 Submission checks completed at journal 07 Apr, 2026 First submitted to journal 04 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9318800","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":618960607,"identity":"c1d34bfe-8079-4a8c-8c3b-e045db93e704","order_by":0,"name":"SRIKANTH THIYAGARAJAN","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5klEQVRIie2PsQrCMBCGrxQ6FVyvlOIrBArqIPZVGgR9hY4BIS7iKAo+hI9w0MGl6Cp0qQjOBVdRT7qJtro55CM5LnAf9wfAYPhD2qp1Kbxbn1tLQVWr5iOCoCN6zqgapq8UPpg4afUiaJp/Kj7F4uDuo+4inVxK6AcbsnVR+5d5TMcl5nKdS40Eo3BD1lTUrsksFaLIY/Sl5mCpZEVjvWKDf413ESuTkuD+jeIAIpG19KXiYNSsiMx1hKeGkhWNmRiGq7RBac9cu/DUgIONT2WSDIL5dnquD/aylK/9w7zBYDAY3vMAlSFM3KBsMX4AAAAASUVORK5CYII=","orcid":"","institution":"Department of general surgery, SRM Medical College Hospital and Research Centre, Faculty of medicine and health sciences, SRM institute of science and Technology","correspondingAuthor":true,"prefix":"","firstName":"SRIKANTH","middleName":"","lastName":"THIYAGARAJAN","suffix":""},{"id":618960608,"identity":"16a8f116-1b4c-4009-bdf2-ad1e016ddb45","order_by":1,"name":"SRI RAHUL","email":"","orcid":"","institution":"Department of Neurosurgery, SRM Medical College Hospital and Research Centre, Faculty of medicine and health sciences, SRM institute of science and Technology","correspondingAuthor":false,"prefix":"","firstName":"SRI","middleName":"","lastName":"RAHUL","suffix":""},{"id":618960611,"identity":"b961f5c2-1a68-4b56-a41c-b0205d3d3d8f","order_by":2,"name":"MOHAMED NALEER","email":"","orcid":"","institution":"Department of Neurosurgery, SRM Medical College Hospital and Research Centre, Faculty of medicine and health sciences, SRM institute of science and Technology","correspondingAuthor":false,"prefix":"","firstName":"MOHAMED","middleName":"","lastName":"NALEER","suffix":""},{"id":618960612,"identity":"6493f186-d342-4093-8908-6a5363634ae1","order_by":3,"name":"JEYASELVA SENTHILKUMAR","email":"","orcid":"","institution":"Department of Neurosurgery, SRM Medical College Hospital and Research Centre, Faculty of medicine and health sciences, SRM institute of science and Technology","correspondingAuthor":false,"prefix":"","firstName":"JEYASELVA","middleName":"","lastName":"SENTHILKUMAR","suffix":""},{"id":618960613,"identity":"b6a75a90-fc03-4445-8aa5-f0184fc2a799","order_by":4,"name":"MANISHA RATHORE","email":"","orcid":"","institution":"Department of Neurosurgery, SRM Medical College Hospital and Research Centre, Faculty of medicine and health sciences, SRM institute of science and Technology","correspondingAuthor":false,"prefix":"","firstName":"MANISHA","middleName":"","lastName":"RATHORE","suffix":""}],"badges":[],"createdAt":"2026-04-04 08:23:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9318800/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9318800/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106877946,"identity":"99f10c46-bbf2-47c1-8e6b-c9952252a9ce","added_by":"auto","created_at":"2026-04-14 10:42:55","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":19099,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative Imaging of the Thoracic Dumbbell Capillary Hemangioma. Sagittal T2-weighted MRI showing the hyperintense, lobulated, dumbbell-shaped epidural mass causing severe compression of the spinal cord at the D3-D5 level.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9318800/v1/510915debc06759be309f446.jpg"},{"id":106877947,"identity":"697f9df0-b595-4592-8712-52ff81b42da0","added_by":"auto","created_at":"2026-04-14 10:42:55","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":30769,"visible":true,"origin":"","legend":"\u003cp\u003eAxial T1-weighted post-contrast MRI demonstrating the intensely enhancing, dumbbell-shaped lesion, highlighting the large extraspinal paravertebral component and the smaller intraspinal component.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9318800/v1/bb09beaa2e591047dfe66495.jpg"},{"id":106877983,"identity":"10d60c38-ce7a-451b-aab9-d8587130d290","added_by":"auto","created_at":"2026-04-14 10:43:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":418873,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9318800/v1/c7e290ca-7803-4f2c-92b4-014d89e5df99.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Dumbbell-Shaped Thoracic Epidural Capillary Hemangioma Mimicking Schwannoma: A Case Report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eVascular malformations constitute approximately 2\u0026ndash;7% of spinal space-occupying lesions and include cavernous angiomas, arteriovenous malformations, capillary telangiectasias, and capillary hemangiomas [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Capillary hemangiomas most commonly involve cutaneous or mucosal tissues of the head and neck in children, whereas spinal extraosseous involvement is distinctly uncommon [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePrimary spinal epidural hemangiomas account for approximately 4% of epidural spinal lesions [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Histologically, they are classified into cavernous and capillary types. Spinal epidural capillary hemangiomas are exceedingly rare, with fewer than 20 cases reported, and only a small fraction demonstrate a dumbbell configuration [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe term dumbbell tumor refers to lesions extending through the intervertebral foramen, connecting intraspinal and extraspinal compartments. This morphology is classically associated with schwannomas. Non-neurogenic dumbbell tumors are rare, and capillary hemangioma presenting in this form represents an exceptional diagnostic entity [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. We report a thoracic dumbbell capillary hemangioma in a high-risk cardiac patient, emphasizing diagnostic challenges, surgical decision-making, and outcome.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 60-year-old female presented with a two-month history of progressive ascending weakness of both lower limbs, which progressed to complete paraplegia over six weeks. She also reported sensory loss below the D6 dermatome with urinary retention and constipation, suggestive of thoracic spinal cord compression. Neurological examination revealed spastic paraplegia with increased tone and absent voluntary motor activity in both lower limbs, with hypoesthesia below the D6 level and neurogenic bladder and bowel dysfunction.\u003c/p\u003e \u003cp\u003eMagnetic resonance imaging of the thoracic spine demonstrated a well-defined, homogeneously enhancing dumbbell-shaped lesion centered at the D4 vertebral level with extension through the right neural foramen into the intrathoracic paravertebral space [Figure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e,\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e]. The intraspinal component caused severe spinal cord compression. Computed tomography showed a characteristic \u0026ldquo;honeycomb\u0026rdquo; appearance involving the D4 vertebral body, pedicle, and lamina, suggestive of a hypervascular lesion [Figure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe patient underwent D3\u0026ndash;D5 laminectomy with planned costotransversectomy. Intraoperatively, the lesion was identified as a purely extradural, markedly hypervascular tumor with foraminal and paravertebral extension [Figure \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e]. Following circumferential devascularization, the intraspinal component was excised [Figure \u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e]. Due to significant bleeding and the large intrathoracic component, the procedure was modified to a right-sided mini-thoracotomy to facilitate safe resection. Postoperatively, the patient showed rapid neurological improvement and was able to stand with support by postoperative day two. Histopathology demonstrated lobules of proliferating capillary-sized vessels lined by flattened endothelial cells without atypia, consistent with benign capillary hemangioma [Figure \u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eDumbbell-shaped spinal tumors represent a diagnostic challenge because of their diverse etiologies. Schwannomas are the most commonly encountered lesions; however, meningiomas, neurofibromas, ganglioneuromas, hemangioblastomas, lymphomas, and Ewing\u0026rsquo;s sarcoma must also be considered [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Vascular tumors are infrequently included in the preoperative differential owing to their rarity and imaging similarities to more prevalent neurogenic tumors.\u003c/p\u003e \u003cp\u003eMost spinal epidural hemangiomas are of the cavernous type, whereas epidural capillary hemangiomas are exceedingly rare, with fewer than ten cases reported to date [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Histologically, capillary hemangiomas are characterized by lobules of thin, endothelium-lined capillary vessels separated by fibrous septa, in contrast to cavernous hemangiomas, which consist of dilated vascular spaces [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Among these rare epidural capillary hemangiomas, only approximately five cases exhibiting a dumbbell configuration have been documented, highlighting the exceptional nature of this presentation [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMRI is the imaging modality of choice for evaluating spinal epidural lesions [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Capillary hemangiomas typically appear isointense on T1-weighted sequences and hyperintense on T2-weighted images, with marked homogeneous gadolinium enhancement [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. These features closely resemble those of schwannomas and meningiomas, particularly when a dumbbell morphology is present [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In contrast, cavernous hemangiomas often demonstrate heterogeneous signal intensity due to hemorrhage, thrombosis, or calcification [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In the present case, the combination of homogeneous enhancement and classic dumbbell configuration strongly favored a preoperative diagnosis of schwannoma, delaying recognition of the vascular nature of the lesion.\u003c/p\u003e \u003cp\u003eDefinitive diagnosis relies on histopathological evaluation. Capillary hemangiomas demonstrate compact lobules of capillary-sized vessels, whereas cavernous hemangiomas show large, dilated vascular channels [11,16]. Immunohistochemical positivity for endothelial markers such as CD31, CD34, and Factor VIII further confirms the diagnosis [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Despite their benign histology, capillary hemangiomas can exhibit pronounced intraoperative vascularity, resulting in substantial blood loss and operative difficulty.\u003c/p\u003e \u003cp\u003eThe dumbbell variant of spinal capillary hemangioma has been reported across cervical, thoracic, and lumbar regions without a clear regional predilection [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Reported patients are typically middle-aged or elderly, and surgery is frequently complicated by significant intraoperative hemorrhage. Surgical excision, with or without preoperative embolization, remains the treatment of choice [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. When suspected preoperatively, embolization may reduce blood loss and improve surgical safety; however, this option is seldom considered because these lesions are often misdiagnosed as schwannomas.\u003c/p\u003e \u003cp\u003eAlthough capillary hemangiomas are benign, gross total excision provides the best long-term outcome and is associated with a low recurrence rate [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Complete resection may be challenging in dumbbell lesions because of extensive foraminal or paravertebral extension [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. When subtotal resection is unavoidable, radiosurgery has been advocated for residual or recurrent disease, although long-term outcome data remain limited [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e20\u003c/span\u003e] .\u003c/p\u003e \u003cp\u003eIn the present case, extensive osseous involvement, marked hypervascularity, and intraoperative hemodynamic instability necessitated modification of the surgical strategy, shifting from a posterior-only approach to a combined laminectomy and thoracotomy. This experience underscores the importance of maintaining a broad differential diagnosis and surgical flexibility when managing dumbbell-shaped spinal lesions.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eDumbbell-shaped epidural capillary hemangioma is an exceptionally rare spinal lesion that can closely mimic schwannoma on imaging, leading to preoperative diagnostic uncertainty. Despite its benign histology, the tumor may exhibit marked hypervascularity and extensive osseous and paravertebral involvement, resulting in significant intraoperative hemorrhagic risk. Gross total excision remains the treatment of choice and is associated with favorable neurological recovery. Preoperative recognition of a possible vascular etiology, consideration of embolization, and readiness to modify the surgical approach including combined posterior and thoracic exposure are essential to ensure safe resection and optimal outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable for single case reports.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of the journal upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data supporting the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo external funding was received.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClinical trial number: not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eS. Thiyagarajan: Conceptualization, Data curation, Investigation, Writing – original draft, Correspondence.\u003c/p\u003e\n\u003cp\u003eS. Rahul: Investigation, Surgical management, Data curation, Writing – review and editing.\u003c/p\u003e\n\u003cp\u003eM. Naleer: Methodology, Surgical supervision, Validation, Writing – review and editing.\u003c/p\u003e\n\u003cp\u003eJ. Senthilkumar: Supervision, Project administration, Validation, Writing – review and editing.\u003c/p\u003e\n\u003cp\u003eM. Rathore: Data curation, Literature review, Writing – review and editing.\u003c/p\u003e\n\u003cp\u003eAll authors have read and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to express their sincere gratitude to the entire Surgery team for their unwavering dedication, expertise, and compassionate care provided to the patients throughout the course of this study. The authors deeply appreciate the team's role not only in delivering high-quality patient care but also in supporting the broader goals of this research endeavour. The authors gratefully acknowledge the financial support by “SRM Medical College Hospital and Research Centre, Faculty of medicine and health sciences, SRMIST, kattankulathur, for bearing the defrayed cost of publishing this article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNowak DA, Gumprecht H, Stolzle A, Lumenta CB. Intraneural growth of a capillary haemangioma of the cauda equina. Acta Neurochir. 2000;142:463\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNowak DA, Widenka DC. Spinal intradural capillary haemangioma: A review. Eur Spine J. 2001;10:464\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoncaroli F, Scheithauer BW, Krauss WE. Hemangioma of spinal nerve root. J Neurosurg. 1999;91(2 Suppl):S175\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHasan A, Guiot MC, Torres C, Marcoux J. A case of a spinal epidural capillary hemangioma: case report. Neurosurgery. 2011;68(3):E850\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWu S, Sharma KK, Ho CL. Lumbar spinal epidural capillary hemangioma: a case report and literature review. Am J Case Rep. 2022;23:e936181.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGencpinar P, Acikbaş SC, Nur BG, Karaali K, Arslan M, Gurer EI, et al. Epidural capillary hemangioma: a review of the literature. Clin Neurol Neurosurg. 2014;126:99\u0026ndash;102.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRajeev MP, Waykule PY, Pavitharan VM, Nandeesh BN. Spinal epidural capillary hemangioma: a rare case report with a review of literature. Surg Neurol Int. 2017;8:123.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBadinand B, Morel C, Kopp N, Tran Min VA, Cotton F. Dumbbell-shaped epidural capillary hemangioma. AJNR Am J Neuroradiol. 2003;24(2):190\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYim B, Lee Y-J, Park DW, Lee JY, Park CK, Paik SS. Spinal capillary hemangioma involving the lumbar epidural and paraspinal spaces: case report. J Korean Soc Radiol. 2015;73(1):36\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBenevello C, Laaidi A, Peeters S, Moiraghi A, Tauziede-Espariat A, Oppenheim C, et al. Spinal epidural capillary hemangioma: a systematic literature review and an illustrative case. Neurochirurgie. 2022;68(6):697\u0026ndash;701.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNiznick N, Nguyen TB, Bourque PR. Spinal capillary hemangioma: a rare benign extradural tumour. Can J Neurol Sci. 2020;47:549\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIannelli A, Lupi G, Castagna M, Valleriani A, Becherini F. Intramedullary capillary hemangioma associated with hydrocephalus in an infant. J Neurosurg. 2005;103(3 Suppl):272-6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3171/ped.2005.103\u003c/span\u003e\u003cspan address=\"10.3171/ped.2005.103\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.3.0272. Erratum in: J Neurosurg. 2007;106(5 Suppl):419. Bacherini, Francesca [corrected to Becherini, Francesca]. PMID: 16238083.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShin JH, Lee HK, Jeon SR, Park SH. Spinal intradural capillary hemangioma: MR findings. AJNR Am J Neuroradiol. 2000;21(5):954\u0026ndash;6. PMID: 10815676; PMCID: PMC7976756.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu JJ, Lee DJ, Jin L, Kim KD. Intradural extramedullary capillary hemangioma of the cauda equina: case report and literature review. Surg Neurol Int., Ganapathy S, Kleiner LI, Mirkin LD, Hall L. Intradural capillary hemangioma of the cauda equina. Pediatr Radiol. 2008;38(11):1235-8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00247-008-0947-1\u003c/span\u003e\u003cspan address=\"10.1007/s00247-008-0947-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2008 Jul 29. PMID: 18663441.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBenevello C, Laaidi A, Peeters S, Moiraghi A, Tauziede-Espariat A, Oppenheim C, et al. Spinal epidural capillary hemangioma: a systematic literature review and an illustrative case. Neurochirurgie. 2022;68(6):697\u0026ndash;701.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoncaroli F, Scheithauer BW, Krauss WE. Capillary hemangioma of the spinal cord. Report of four cases. J Neurosurg. 2000;93(1, Suppl):148\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKasukurthi R, Ray WZ, Blackburn SL, Lusis EA, Santiago P. Intra-medullary capillary hemangioma of the thoracic spine: case report and review of the literature. Rare Tumors. 2009;1:e10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHasan A, Guiot MC, Torres C, Marcoux J. A case of a spinal epidural capillary hemangioma: case report. Neurosurgery. 2011;68:E850\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKliea M, Alsultan M, Chatty E, Qatleesh S, Hamzeh G. Spontaneous hemorrhage of spinal epidural capillary hemangioma resulting in hyperacute neurologic deficit: a case report. Med (Baltim). 2023;102(42):e35606.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Spinal tumor, dumbbell tumor, capillary hemangioma, epidural hemangioma, thoracotomy","lastPublishedDoi":"10.21203/rs.3.rs-9318800/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9318800/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSpinal epidural hemangiomas are rare benign vascular lesions. A dumbbell configuration defined by extension through the neural foramen with both intraspinal and extraspinal components is most commonly associated with schwannomas. Dumbbell-shaped capillary hemangiomas are exceptionally rare and can pose significant diagnostic challenges.\u003c/p\u003e\u003ch2\u003eCase Presentation:\u003c/h2\u003e \u003cp\u003eA 66-year-old woman presented with a one-year history of back pain and progressive bilateral lower-limb weakness that progressed to a bedridden state. Imaging revealed a dumbbell-shaped lesion extending from D3 to D5 with a large paravertebral component measuring 4.3 \u0026times; 3.6 \u0026times; 5.7 cm. A combined D3\u0026ndash;D5 laminectomy and right posterolateral thoracotomy was performed. The tumor was markedly hypervascular intraoperatively, and gross total resection was achieved. Recent coronary artery bypass grafting and dual antiplatelet therapy increased the operative hemorrhagic risk. Postoperatively, the patient demonstrated neurological improvement with restoration of bladder control and regained ambulation with a walker.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eDumbbell capillary hemangiomas can mimic schwannomas radiologically yet carry substantial hemorrhagic risk. Multidisciplinary surgical planning is essential for safe management.\u003c/p\u003e","manuscriptTitle":"Dumbbell-Shaped Thoracic Epidural Capillary Hemangioma Mimicking Schwannoma: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-14 10:42:45","doi":"10.21203/rs.3.rs-9318800/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-01T08:58:37+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-30T19:51:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"304411071332307029007216010907013996215","date":"2026-04-25T17:16:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"175973584588091602776341387504165387738","date":"2026-04-23T07:50:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"137018927849939184233705949050611640356","date":"2026-04-22T19:36:38+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-22T18:26:57+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-07T12:47:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-07T12:47:01+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cardiothoracic Surgery","date":"2026-04-04T08:15:56+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b3de30f7-0d39-4fee-854a-dfe45b8584a3","owner":[],"postedDate":"April 14th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-01T08:58:37+00:00","index":52,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-30T19:51:41+00:00","index":51,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-22T18:38:35+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-14 10:42:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9318800","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9318800","identity":"rs-9318800","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}