Hemangioma (Vertebral)

Diagnosis Definition

• Hemangiomas of the spine are venous vascular malformations
• Most are incidental findings and unrelated to patient symptoms
• When symptomatic, they can cause pain and myelopathy by intra-spinal bleeding, bony expansion or extra-osseous extension into surrounding soft tissue or the posterior neural elements
• Multiple hemangiomas are seen in the same patient in up to 60% of cases
• 10-12% of patients have vertebral hemangiomas at autopsy

Imaging Findings

• The classic CT appearance of a hemangioma is a well-circumscribed lesion with a sharp transition zone and sclerotic margin within the vertebral body; the lesion is hypoattenuating with a “polka-dot” pattern (due to a cross-section of reinforced trabeculae) or “corduroy” appearance (due to rarefaction with vertical striations) on axial images
• On MRI, they are typically hyperintense on T1 and T2-weighted images due to fat; the signal intensity varies on fat-saturated sequences depending on the amount of fat in the lesion relative to vascularity and interstitial edema
• Enhancement patterns are variable, but a mild degree of heterogeneous enhancement is common

KEY IMAGES

Pearls

• Atypical hemangiomas may demonstrate hypointense signal on T1 and hyperintense signal on T2-weighted images and be difficult to distinguish from a malignant process; the morphology as seen on CT can often clarify the diagnosis
• The main differential diagnosis is focal fat in the vertebra, however, focal fat should not enhance whereas hemangiomas (even with fat in them) do; if the lesion is completely suppressed on a STIR sequence it is considered to be focal fat
• Hemangiomas are benign “do not touch” lesions, although if they abut the endplate or cortical bone, they can result in a pathologic fracture

References

1. Ross JS, Masaryk TJ, Modic MT, et al. Vertebral hemangiomas: MR imaging. Radiology 1987; 165(1):165-169
2. Baudrez V, Galant C, Vande Berg BC. Benign vertebral hemangioma: MR-histological correlation. Skeletal Radiol 2001; 30(8):442-446