Hemangioma (Vertebral)

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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

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

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

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