Age / Sex : 56 / F

Chief complaint: back pain for seven months

What is your impression?

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

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Courtesy: Byeong Seong Kang, Ulsan University Hospital

Aggressive vertebral hemangioma

Discussion

Findings:

1) Plain radiography

- Lateral view radiograph of the thoracolumbar spines reveals coarse trabecular striations within the T12 vertebral body.

2) CT

- Axial unenhanced CT demonstrates the ‘honeycombing’ pattern and erosion of the posterior vertebral wall. The lesion involves the entire vertebral body and bilateral pedicles with expansion into the spinal canal.

3) MR

- Sagittal T2-weighted MR image shows a high-signal intensity lesion that involves the entire vertebral body. The associated vertebral body expansion and epidural extension results in severe circumferential cord compression with abnormal cord signal. Axial contrast-enhanced T1-weighted MR image shows diffuse enhancement of the lesion.

Differential Diagnosis:

Aggressive vertebral hemangioma / Metastasis / Plasmacytoma

Diagnosis: Aggressive vertebral hemangioma

Discussion:

Aggressive vertebral hemangiomas frequently have an atypical radiological appearance on any imaging modality. Radiography may not detect abnormalities or show nonspecific findings, such as osteoporosis, poorly defined or expanded cortex, vertebral collapse, pedicle erosion, or vertical trabecular pattern irregularities that are associated with lytic areas of varying size. Although CT provides a more detailed study of the microstructure of the lesion, it may show nonspecific findings as ballooning or lysis of the cortex or extraosseous soft tissue extension. However, the typical “polka-dot” sign should always be sought on axial CT images, even in the more aggressive/destructive lesions, because it can guide the correct diagnosis.

Aggressive vertebral hemangiomas typically contain less fat and more vascular stroma thereby producing a low MR signal on T1-weighted images. This appearance may resemble a metastatic lesion, however, metastatic lesions usually have low signal on T1-weighted images and high signal on T2-weighted images. In addition, the morphology, including the presence of coarsened trabeculae can be used for differentiation. Aggressive vertebral hemangiomas most often occur between T3 and T9 vertebral segments. They generally occupy the entire vertebral body, extend into the neural arch, expand the osseous margins, and contain a soft tissue component. Cord compression and subsequent myelopathy may result from either encroachment of extradural soft tissue, pathologic fracture, or hemorrhage.

References:

1. Gaudino S, Martucci M, Colantonio R, et al. A systematic approach to vertebral hemangioma. Skeletal Radiol 2015;44:25-36

2. Schrock WB, Wetzel RJ, Tanner SC, Khan MA. Aggressive hemangioma of the thoracic spine. J Radiol Case Rep 2011;5:7-13