Transient high density vertebral bone lesions

Abstract

DiagnosisBone marrow enhancement by retrograde contrast filling through collateral veins due to a left brachiocephalic vein thrombosis. DiscussionThe contrast-enhanced CT examination revealed sclerotic-like lesions associated with consecutive anterior and posterior elements from the fourth cervical vertebra to the fifth thoracic vertebra, without any lytic components, which could at first be considered as bony metastases (Fig. 1a-b). CT scan also highlighted significant collateral venous circulation secondary to a brachiocephalic left venous thrombosis. A PET-CT performed at the same time was negative. A non-contrast CT scan performed 10 days later did not reveal the initially noted bone lesions (Fig. 2a-b) and suggested diagnosis of intraosseous venous contrast media. The 1-year non-contrast CT follow-up did not show any progression of the disease.Given the lack of corresponding findings on the unenhanced CT, in the setting of central venous obstruction and collateral pathway formation, the high-attenuation lesions seen on the enhanced CT examination can be explained by the presence of intraosseous venous collaterals. In fact, the left brachiocephalic vein obstruction was responsible for the development of an extensive collateral venous pathway (Fig. 2c-d) involving the mediastinum, anterior jugular veins, anterior, and basivertebral venous plexi. The venous pressure in the dilated capillaries allowed marrow enhancement through the anastomosis capillary sites: basivertebral veins bed (between the anterior external plexus and the posterior internal plexi) and pedicular sites (between the intervertebral veins and the vertebral plexi) (Fig. 3a-b). Our patient remained asymptomatic despite the huge collateral venous substitution. The rate of injection of contrast and the time of image acquisition following contrast injection might be factors influencing the appearance of these findings.