A Case Report of Multiple Cavernous Hemangiomas with Fluid-Fluid Levels: A Focus on the Radiologic Features of Dynamic MRI with Subtraction

Abstract

The radiologic features of hemangiomas are well established. The diagnostic features on contrast enhanced computed tomography (CT) or magnetic resonance imaging (MRI) include peripheral globular and gradual centripetal enhancement. In most cases, hemangiomas do not require a pathological examination. However, some hemangiomas show atypical radiologic features, such as poor gradual enhancement on sclerosing or hyalinized hemangioma and a fluid-fluid level within a hemangioma (1). The radiologic diagnosis of hemangioma with a fluid-fluid level remains problematic because the typical enhancement pattern of hemangioma is not found on CT and a fluid-fluid level can be reported in various hepatic lesions from malignant to benign tumors (2, 3). Recently, the gadolinium-enhanced dynamic MRI with subtraction has been introduced as a highly sensitive method in the depiction of a vascular pattern and subtle enhancement of focal hepatic lesions (4, 5). To the best of our knowledge, there has been no report about the imaging feature of dynamic MRI with subtraction in a hemangioma with a fluid-fluid level. Herein, multiple cavernous hemangiomas with fluidfluid levels in a patient are presented. Case ReportA 40-year-old man was referred for hepatic nodules detected on a routine health checkup. The man had no specific medical history or laboratory findings. Ultrasound (US) revealed three well-defined echogenic nodules in the right lobe of his liver (Fig. 1A). Their diameters were less than 2 cm (range; 0.9-2 cm). On multiphase enhanced CT, these nodules showed nonspecific subtle enhancement in three phases and subtle single layered attenuation difference between the inferior and superior layer. The inferior layer of all nodules showed higher attenuation than that of the superior layer ( Multiple cavernous hemangiomas with fluid-fluid levels were presented in a 40-year-old male patient. These hemangiomas showed nonspecific radiologic features on ultrasound and computed tomography, but gadolinium-enhanced magnetic resonance imaging (MRI) with subtraction revealed fluid-fluid levels with unique and different enhancement of the inferior and superior layer. This is the first case report of cavernous hemangiomas with fluid-fluid levels, containing radiologic features of dynamic MRI with subtraction.