Hemangioma of the spine

1. Vertebral Hemangioma
Upper Chesapeake Medical Center Spine Conference
January 5th, 2018

2. 67 yo man cc: LBP B sciatica HPI: sx for months PMH: depression, sleep apnea, gastric ulcer, R
partial KR, L RC repair, cardiac stents 2009, cardiac angioplasty 2011, CAD, R eye resected for
carcinoma 2014, colon surgery 2002, HTN, Chol, TIA 2017 MEDS: fluoxetine, rosuvastatin, Toprol,
omeprazole, vit E, vit C, coQ, ASA Exam: 5’10” 242 lb, stiff

4. Rule out paget’s disease, coarse trabeculae, obscuring of the cortical cancellous
border, irregular bone formation, enlargement of the bone and deformity

6. Pre gad
Post gad

9. Post gad

13. Polka dot, jail bar, corduroy cloth
Coarsened trabeculae; resorbed horizontal trab
Increased signal in both T1&T2
1% become asymptomatic
Typical, atypical, and aggressive

19. Incidence: >10-12% in autopsy studies, most common in 5th decade of life,
but any age including children and pregnant women
2:3 men to women
Rx: intra-arterial embolization, vertebroplasty, radiotherapy, intralesional
ethanol
Dx: CT honeycomb pattern
Active lesions: bone expansion, fracture, bleed, soft tissue extension
High in fat lesions are quiescent
Aggressive VH: are more vascular and less fat, 55% axial pain, 45%
neurological compression; usually compressive are thoracic and young
adults; atypical VH have very high T2 signal and irregular vertical trabeculae;
Location: thoracic and lumbar
Bone scan results are equivocal sometimes positive/negative

20. Gross: soft, well demarcated dark red mass

21. Microscopic histology: thin walled blood filled vessels lined in a single layer of flat endothelial cell
loose edematous stroma; the vessels permeate the bone marrow and trabeculae; adipocytes, vess
interstitial edema make up the tumor

22. Cavernous hemangioma have large sinusoidal spaces

23. l vascular channels

24. 1998-2008; Israel; 10 year f/u; Preop arterial embolization 4/6;2
vertebroplasty alone;

28. Destroy the endothelium
Shrink tumor
Elicit thrombosus
Can recur

29. Radiotherapy:
Malignant transformation
Delayed onset of pain relief
Best for reduced recurrence after subtotal resection of aggressive VH

30. • U Penn
• Quantitative signal intensity in T2 fat saturation
sequences can differentiate aggressive v asx
• Aggressive hemangiomas are low T1 signal and
have extraosseous component, vertebral expansion
• Benign hemangiomas are high signal both T1&T2

31. T1
T2 T1

33. Aggressive hemangiomas have less fat content and are more vascular. The lesion is irregular and

34. Aggressive VH:
1. entire body involved
2. extension into neural arch
3. cortical expansion
4. T3T9
5. irregular honeycomb pattern
6. soft tissue mass
Poorly defined/expanded cortex, bone collapse, pedicle erosion, lysis, ballooning,
intact cortex adjacent to a paraspinal mass, maintained body height

35. Atypical aggressive VH with polka dots on CT

37. Aggressive VH T8
42 yo woman

38. DDX
• Myeloma
• Lymphoma
• Metastasis(common in pedicle)
• Plasmocytoma
• Epithelioid hemangioendothelioma
• chordoma

39. Plasmacytoma minibrain appearance

41. thanks