A systematic approach to vertebral hemangioma

Abstract

Vertebral hemangiomas (VHs) are a frequent and often incidental finding on computed tomography (CT) and magnetic resonance (MR) imaging of the spine. When their imaging appearance is "typical" (coarsened vertical trabeculae on radiographic and CT images, hyperintensity on T1- and T2-weighted MR images), the radiological diagnosis is straightforward. Nonetheless, VHs might also display an "atypical" appearance on MR imaging because of their histological features (amount of fat, vessels, and interstitial edema). Although the majority of VHs are asymptomatic and quiescent lesions, they can exhibit active behaviors, including growing quickly, extending beyond the vertebral body, and invading the paravertebral and/or epidural space with possible compression of the spinal cord and/or nerve roots ("aggressive" VHs). These "atypical" and "aggressive" VHs are a radiological challenge since they can mimic primary bony malignancies or metastases. CT plays a central role in the workup of atypical VHs, being the most appropriate imaging modality to highlight the polka-dot appearance that is representative of them. When aggressive VHs are suspected, both CT and MR are needed. MR is the best imaging modality to characterize the epidural and/or soft-tissue component, helping in the differential diagnosis. Angiography is a useful imaging adjunct for evaluating and even treating aggressive VHs. The primary objectives of this review article are to summarize the clinical, pathological, and imaging features of VHs, as well as the treatment options, and to provide a practical guide for the differential diagnosis, focusing on the rationale assessment of the findings from radiography, CT, and MR imaging.

Surgical treatment of aggressive vertebral hemangiomas

“…For patients with an uncertain radiological diagnosis, percutaneous biopsy should be performed to rule out lesions that can mimic an aggressive hemangioma. 29,36,45,49 For patients with aggressive vertebral hemangiomas who present with mild or slowly progressive neurological symptoms, it is reasonable to attempt nonoperative management with embolization, vertebroplasty, or radiation therapy provided the symptoms are not due to compression by a focal bony prominence, which is unlikely to resolve without surgery. For patients with severe or rapidly progressive symptoms, surgery should be considered, with preoperative embolization when possible.…”

Differentiating Atypical Hemangiomas and Metastatic Vertebral Lesions: The Role of T1-Weighted Dynamic Contrast-Enhanced MRI

“…3 While these incidentally found lesions are benign, their appearance in routine STIR, T1- and T2-weighted MR sequences often mimics that of primary bone malignancies and metastatic lesions. 8 Therefore the ability to distinguish between these commonly encountered lesions and vertebral malignancies has a direct clinical application in patient management, particularly in a patient with known malignancy.…”

Undiagnosed vertebral hemangioma causing a lumbar compression fracture and epidural hematoma in a parturient undergoing vaginal delivery under epidural analgesia: a case report

“…9 Magnetic resonance imaging is the imaging modality of choice to show the aggressive characteristics of symptomatic hemangiomas, such as the presence and extent of extraosseous soft tissue, the compression of the spinal cord and/or nerve roots, and the presence of epidural hematoma. 2 In our case, an acute compression fracture with epidural extension was diagnosed, while the presence of low-signal-intensity reinforced trabeculae in the vertebral body were suggestive of hemangioma as the underlying cause.…”

“…The lesions are characterized by erosion of the horizontal trabeculae, thus resulting in the typical radiographic finding of accentuated thickened vertical trabeculae. 2 Rarely, their enlargement within the vertebral body may produce expansion of the vertebra and pathological fracture. 2 Hemodynamic changes, as those occurring during pregnancy, may play a significant role, 6 while mechanical factors, such as bending and axial vertebral loading, can also contribute.…”

“…2 Rarely, their enlargement within the vertebral body may produce expansion of the vertebra and pathological fracture. 2 Hemodynamic changes, as those occurring during pregnancy, may play a significant role, 6 while mechanical factors, such as bending and axial vertebral loading, can also contribute. 9 Magnetic resonance imaging is the imaging modality of choice to show the aggressive characteristics of symptomatic hemangiomas, such as the presence and extent of extraosseous soft tissue, the compression of the spinal cord and/or nerve roots, and the presence of epidural hematoma.…”