Age / Sex : 63 / F

Chief complaint: Back and both buttock pain for 10 months

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Two weeks later, you can see the final diagnosis with a brief discussion of this case.

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Courtesy: Sung Hwan Hong, Seoul National University hospital

Aggressive vertebral hemangioma

Discussion

Findings:

MRI

- Expansile bone lesion in T11 posterior elements with partial involvement of the vertebral body

- T2 hyperintense lesion with diffuse and strong enhancement

- Serpentine low-signal structures more likely indicative of hypertrophied trabeculae

- Epidural mass formation resulting in spinal cord compression

- Tail-like enhancement along the posterior dura

CT

- Expansile osteolytic bone lesion with hypertrophied trabeculae

- Partial cortical penetration and epidural mass formation

Differential Diagnosis:

1. Vertebral hemangioma

2. Metastasis

3. Plasmacytoma

Diagnosis: Aggressive vertebral hemangioma

Discussion:

Vertebral hemangiomas are common benign lesions of the spinal column that often are discovered incidentally. Rarely, vertebral hemangiomas behave as aggressive neoplasms that directly or indirectly compress adjacent neural structures. These small but significant subset of symptomatic lesions are known as aggressive hemangiomas and are characterized by bone expansion, extraosseous extension of tumor, disturbance of local blood flow, and rarely compression fractures. Approximately 45% of aggressive hemangiomas are associated with neurologic deficits, the others only characterized by pain.

Vertebral hemangiomas are classically characterized by sparing and thickening of vertically striated trabeculae which preserve the functional capability of the vertebral body to withstand an axial load. This appearance has been described on radiographs and CT as polka-dot or corduroy cloth. Aggressive hemangiomas typically contain less fat and more vascular stroma thereby producing a low MR signal on T1-weighted images. On T2-weighted images, the signal intensity increases due to high water content. In addition, the morphology, including the presence of coarsened trabeculae can be used for differentiation. 

Conservative surgical strategies are appropriate for most symptomatic hemangiomas causing cord compression without instability or deformity. Even so, complete intralesional spondylectomy following embolization of aggressive vertebral hemangiomas with circumferential vertebral involvement can be safely accomplished. Transarterial embolization without decompression is an effective treatment for painful intraosseous hemangiomas. Radiation therapy may be used in those cases of subtotal resection. Vertebroplasty is useful for improving pain symptoms, especially when vertebral body compression fracture has occurred in patients without neurological deficit, but is less effective in providing long-term pain relief.

References:

1. Friedman DP. Symptomatic vertebral hemangiomas: MR findings. AJR 1996;167:359-364

2. Schrock WB, Wetzel RJ, Tanner SC, Khan MA. Aggressive hemangioma of the thoracic spine. J Radiol Case Rep 2011;5:17-13

3. Acosta FL Jr, Sanai N, Chi JH, Dowd CF, Chin C, Tihan T, Chou D, Weinstein PR, Ames CP. Comprehensive management of symptomatic and aggressive vertebral hemangiomas. Neurosurg Clin N Am 2008;19:17-29