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Hemangioma


KEY FACTS

Terminology

  • Most common benign neoplasm of spine

    • Vascular/fatty marrow with fewer but thicker trabeculae

Imaging

  • CT: Well-circumscribed, hypodense lesion with coarse vertical trabeculae (corduroy appearance on sagittal, “white polka dots” on axial CT)

  • MR: Circumscribed lesion, hyperintense on both T1 and T2WI, with hypointense vertical striations

    • Usually intraosseous, may have epidural component

    • Atypical hemangiomas may have reduced T1 signal due to paucity of fat

    • Strong, heterogeneous enhancement

  • Often multiple (20-30%)

  • Bone CT may supplement MR evaluation of suspected hemangioma with atypical imaging features concerning for neoplasm

Pathology

  • Histology

    • Thin-walled sinusoidal channels lined by vascular endothelium

    • Interspersed thickened bony trabeculae

    • Fatty tissue

Clinical Issues

  • Found in 10% of imaged adults

  • Usually incidental finding

  • Complications in < 1%

    • Pathologic compression fracture

    • Epidural hemangioma component with cord compression

  • No follow-up typically necessary with pathognomonic imaging with small lesions and no extraosseous extension

Sagittal graphic of the thoracolumbar junction shows the typical striated pattern of hemangioma, with thickened bony trabeculae
. It fills the entire vertebral body, but there is neither extraosseous extension nor thecal sac compromise.

Sagittal bone CT reformatted from the axial source data in a 43-year-old woman with low back pain shows the coarse, thickened vertical trabeculae
and alternating fatty hypodense areas
characteristic for vertebral hemangioma. The posterior cortex
is indistinct.

Sagittal T1WI in the same case shows the “speckled” hyperintense marrow
of the L1 vertebral body (compare with normal T12 and L1 vertebrae). Some transcortical extension into the epidural space is present
. Contrast the appearance of this hemangioma with focal fatty marrow replacement in L5
. Foci of fatty marrow are common normal findings in middle-aged and older patients.

Sagittal T2WI in the same case shows the “speckled” fatty marrow or a classic vertebral hemangioma
.

TERMINOLOGY

Definitions

  • Common benign venous malformation within vertebrae

    • Usually intraosseous, may have epidural component

    • Rare: Purely epidural spinal hemangioma

  • Typically, incidental lesion identified on imaging performed for unrelated reasons

IMAGING

General Features

  • Best diagnostic clue

    • CT: Well-circumscribed, hypodense lesion with coarse vertical trabeculae (“white polka dots” on axial CT)

    • MR: Circumscribed lesion, hyperintense on both T1 and T2WI, with hypointense vertical striations

  • Location

    • Vertebral body

      • –

        Infrequently extends into posterior elements

    • Often multiple (20-30%)

  • Size

    • Variable, may encompass whole vertebral body

  • Morphology

    • Well-circumscribed margins, thickened trabeculae

    • Infrequently, associated epidural soft tissue

Radiographic Findings

  • Radiography

    • Vertebral body lesion with coarse vertical trabeculae resembling corduroy or honeycomb

CT Findings

  • NECT

    • Hypodense vertebral lesion

    • Thickened, vertically aligned trabecula

      • –

        “Polka dot” appearance on axial images

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