Management of Aggressive Vertebral Haemangioma and Assessment of Differentiating Pointers Between Aggressive Vertebral Haemangioma and Metastases – A Systematic Review

Abstract

Study Design Systematic review. Objectives Vertebral haemangioma has been classified into typical and aggressive vertebral haemangioma (AVH). Management options for AVH are many and the clinician has decision dilemma in choosing the right one. Metastases mimic AVH in clinical and radiological presentation. Differentiating pointers between them has not been clearly delineated in literature. Aim of our review is to identify treatment options; to formulate a management algorithm for AVH based on clinical presentation and to identify radiological differentiating pointers between them. Methods Systematic review was conducted according to PRISMA guidelines. We systematically reviewed all available literature from the year 2001 to 2020. Relevant articles were identified as per laid down criteria from the medical databases. After inclusion, first and second authors went through full text of each included article. Results Of 139 studies reviewed, eight met our criteria for review of management and three separate studies for radiological differentiating pointers. 99 patients with 88 AVH had undergone treatment. Back pain with myelopathy is the presenting symptom in majority of patients. Patients with backpain - myelopathic symptoms had improved following surgery; patients with back pain alone had improved with either percutaneous vertebroplasty or CT guided alcohol ablation. Dynamic contrast MRI, Diffusion weighted MRI and ratio of signal intensity between T1w and fat suppression T1w MR help the clinician in differentiating them. Conclusion Management of AVH can be based on the patient’s clinical presentation. Patients presenting with AVH and back pain can be managed with either Percutaneous vertebroplasty or CT guided alcohol ablation. Patients presenting with AVH and neurological symptoms could be managed with surgery. Dynamic contrast enhanced MR, Diffusion weighted MR, ratio of signal intensity between T1w and Fat suppression T1w MR imaging could help the clinician in differentiating the two before contemplating biopsy. Grade Practice Recommendation C

Surgical Options for Aggressive Vertebral Hemangiomas：A case series, literature review and treatment recommendations

“…He promotes surgery in patients who have failed on the preceding lines of treatment, even if they are neurologically intact, and considers post-operative radiation therapy in all AVH patients who have developed significant or quickly progressing neurological deficits. After classifying the patient as having AVH based on radiological parameters, Subramaniam et al [ 42 ] suggested an algorithm based on the patient's clinical presentation in the most recent published systematic review. Percutaneous vertebroplasty, guided alcohol ablation, or external beam radiation can be used to treat individuals with localized back pain who are not responding to medicinal treatment, as well as patients with back pain and radicular symptoms.…”

Vertebral hemangiomas: a review on diagnosis and management

“…Other symptomatic patients have a wide variety of treatment options available including sclerotherapy, embolization, radiotherapy, and/or vertebroplasty [1,5,23]. The best approach in managing an individual patient with a symptomatic VH has not been elucidated and there have been different management algorithms suggested based on varying institutional experiences [1,5,24,25]. This article will review what is currently known regarding VHs.…”

Ethanol Sclerosis Therapy for Aggressive Vertebral Hemangioma of the Spine: A Narrative Review

“…The presence of more than three of the following six characteristics is reported to increase the likelihood that a venous hemangioma will be symptomatic: (1) location between T3 and T9; (2) including the entire vertebral body; (3) expanding to the laminas; (4) cortex expansion with an unclear margin; (5) honeycomb pattern; and (6) expanding into the soft tissues [ 1 ]. Various therapeutic approaches have been proposed and used to manage symptomatic hemangiomas of the spine [ 3 , 4 ], including vertebroplasty using cement [ 5 , 6 ], radiation therapy [ 7 , 8 ], transarterial embolization [ 9 ], and complete tumor resection [ 10 , 11 ]. Ethanol sclerosis therapy was first reported by Heiss et al in 1994 [ 12 ].…”

“…If ethanol sclerosis therapy has more advantages than disadvantages, it would be a good treatment option. Systematic reviews concerning the management of aggressive vertebral hemangiomas have been published extensively [ 2 , 3 ]. However, reviews focusing on ethanol sclerosis therapy for the spine have not been published.…”