Vertebral hemangiomas are common, so let's learn about the rare invasive hemangiomas

01

Case 1

Female, 52 years old, mainly caused by "chest and back pain with numbness in both lower extremities for 4 months, exacerbation with two stool disorder for 3 months."

02

Case 2

Female, 47 years old, mainly caused by "waist and sacral pain for more than 3 years, worsening with pain in both lower extremities for 1 week."

Past history: denial of history of hypertension, history of diabetes, history of coronary heart disease, history of no blood transfusion, history of drug allergy, history of food allergy, history of vaccination is unknown, history of surgery, history of trauma, no other.

Admission to the hospital: the patient slowly enters the ward on his own, with a slow gait, clear speech, and physical examination cooperation. Lumbar range of motion is slightly limited, no obvious sensory plane is detected, the skin sensation, muscle strength, and muscle tone of both upper extremities are normal, waist and sacral tenderness (+), percussion pain (+), no release, the skin sensation, muscle strength, and muscle tone of both lower limbs are normal, and the skin in the anus and perineum feels normal. Knee tendon reflexes and Achilles tendon reflexes are normal. Bilateral Babinski sign (-). There are no obvious abnormalities in the body.

Two cases combined with pathology and imaging were diagnosed as vertebral invasive hemangiomas

Vertebral invasive hemangioma

Spinal hemangiomas are the most common benign tumors in the spine, accounting for 10% to 12% of spinal lesions. Invasive hemangiomas are hemangiomas that grow aggressively, causing expansive changes in the vertebral body, pedicle, or lamina, destroying the bone cortex, or forming paravertebral soft tissue masses that compress the spinal cord and nerve roots, accounting for about 1% of spinal hemangiomas.

Clinical manifestations

General and clinical features of invasive hemangiomas: Spinal hemangiomas are usually asymptomatic and are mostly discovered incidentally. According to the clinical characteristics, it is divided into three categories: asymptomatic hemangiomas, local symptomatic hemangiomas such as pain only, and invasive hemangiomas. The vast majority of aggressive hemangiomas of the spine compress nerve roots, and the spinal cord eventually develops into symptomatic hemangiomas, and both patients have symptoms of spinal cord compression. Aggressive hemangiomas of the spine occur most often in the thoracic spine, accounting for 80%, followed by the cervical and lumbar vertebrae, with the least common sacrococcygeal region; can be single or multiple, mostly located in the vertebral body, can spread to the pedicle, lamina, and spinous process, and enter the spinal canal epidural and paravertebral. The incidence is higher in women than in men, and it has been reported that it can progress rapidly during pregnancy. Pathological typing: cavernous hemangiomas, capillary hemangiomas and mixed hemangiomas, and most of the aggressive hemangiomas of the spine are cavernous hemangiomas. Microscopy includes massive proliferation of capillaries and dilated blood sinuses, fat matrix, and remnants of coarse trabecular bones.

CT findings

CT manifestations of aggressive hemangiomas: lesions can involve the entire or partial vertebral body, and to varying degrees involve the pedicles, lamina, transverse process, spinous process, and vertebral joints, and even adjacent ribs. Affected vertebral body, appendages are composed of thickened trabecula and low-density fat, typical of the entire vertebral body mildly expanded in honeycomb changes, cross-sectional dot signs, sagittal and coronary positions are fence-like, and at the same time involve the adnexal, this case 1CT found that the lesion is "fence-shaped", involving part of the vertebral body, located in the posterior part of the vertebral body, with a central bone defect at the posterior edge of the vertebral body, V-shaped, sharp edges.

MRI performance

MRI manifestations of aggressive hemangiomas: the proportion of vertebral part signals to fat cells, blood vessels, and interstitial edema. The manifestations are slightly higher T1WI signal, T2WI high signal, it is speculated that it contains more vascular components, and 2 patients have T1WI and T2WI slightly higher signal, and it has been reported in the literature that it is more clinically more invasive, resulting in compression symptoms of spinal cord or nerve roots. Those with high signals on T1WI and T2WI contain more fat matrix, and the clinical manifestations are relatively stable. MrI signal of paravertebral and intraspinal lesions is generally consistent with or similar to the signal of the vertebral part, mostly in T2WI is high signal, similar to cerebrospinal fluid signal, spinal canal lesions are located outside the dural membrane, high signal in T2WI, the edge is low-signal dura, and the internal often can be seen with punctate, striped low-signal shadow, which may be related to multiple thrombosis, mechanization, calcification and so on with cavernous hemangioma. Paravertebral soft tissue masses are narrowly banded or dumbbell-shaped. After strengthening the vertebral body, paravertebral and epidural lesions are significantly strengthened, and a few reinforcements are weak, while after delay, they are significantly strengthened. The spinal cord and nerve roots are compressed by epidural and paravertebral lesions. Both cases showed significant hyperintensity and strengthening of T2WI, growing into the spinal canal.

brief summary

In summary, CT clearly shows full vertebral body, adnexal bone distension, pulverized signs in the transverse segmentation, "palisade-like" changes in the crown and sagittal positions, or V-shaped bone defects on the posterior margin of some vertebral bodies, with sharp edges. MRI shows that epidural lesions and vertebral lesions persist, showing a long T1 long T2 signal, T2WI high signal and cerebrospinal fluid signal, and paravertebral lesions are banded bulging or dumbbell-like, which are significantly strengthened after strengthening. A combination of CT and MRI can confirm the diagnosis and extent of the invasion of aggressive hemangiomas of the spine.

He is the stone of the mountain

Aggressive hemangiomas of the lumbar spine and adnexal appendages

Invasive hemangiomas of the thoracic vertebral body and adnexal appendages

Invasive hemangioma of the thoracic vertebral body

Author | Imageshine

Content planning | Little Snowball, Peng Long

Title image source | Figureworm creative

Illustration source | radiopaedia

Submission and reprint | [email protected]

References | (Swipe down)

Cloran Francis J,Pukenas Bryan A,Loevner Laurie A et al. Aggressive spinal haemangiomas: imaging correlates to clinical presentation with analysis of treatment algorithm and clinical outcomes. [J] . Br J Radiol, 2015, 88: 20140771

Pinto Denver Steven,Hoisala V Ravi,Gupta Pavan et al. Aggressive Vertebral Body Hemangioma Causing Compressive Myelopathy - Two Case Reports. [J] . J Orthop Case Rep, 2017, 7: 7-10.

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