Haemangioma, an uncommon cause of an extradural or intradural extramedullary mass: case series with radiological pathological correlation

Abstract

Haemangiomas of the vertebrae, usually regarded as having little or no consequence, may display aggressive features, including extension into the extradural space, and cause significant neurological symptoms and signs necessitating treatment. Extraosseous haemangiomas in an extradural or intradural extramedullary location are a rare entity. Here we review our radiologic and pathologic experience of osseous haemangiomas with extradural extension and primary extradural and intradural extramedullary haemangiomas. Magnetic resonance imaging plays a pivotal role in the characterisation of spinal haemangiomas, with typical imaging features including T1 and T2 signal hyperintensity. Atypical and aggressive imaging features are also described. Spinal angiography may be required to differentiate haemangiomas from non-vascular lesions. This is a rare and unusual entity, and should be considered as a differential diagnosis for some extramedullary masses.Teaching points• Osseous haemangiomas can display aggressive features and cause neurologic symptoms needing treatment.• Haemangioma extension into the extradural space is an imaging feature of aggressiveness.• Extraosseous haemangiomas are a rare but important differential diagnosis for extramedullary masses.• Extraosseous extramedullary haemangiomas most frequently present with progressive myelopathy.• MRI is pivitol in characterising spinal haemangiomas; imaging characteristics can vary.

Differentiating Atypical Hemangiomas and Metastatic Vertebral Lesions: The Role of T1-Weighted Dynamic Contrast-Enhanced MRI

“…2 VHs are more frequently found in women, especially in the fourth to sixth decades of life. 3 These lesions can affect a segment or the entirety of the vertebral body, and they are multiple in roughly one-third of patients. 4 The vast majority is stable and asymptomatic, but can become clinically relevant with atypical imaging characteristics when establishing the presence of metastatic disease or when dealing with an aggressive/symptomatic hemangioma which can induce pain, fractures, and neurologic manifestations due to spinal cord compression.…”

“…Vessels are scattered surrounded by fatty matrix and vertically oriented trabeculae of bone, probably causing resorption of underlying bone and thickening of the remaining trabeculae. 3 The characteristic radiologic appearance is defined by its histological architecture demonstrating parallel striated pattern “corduroy cloth” on plain film and on sagittal or coronal CT and spotted appearance “polka dot” on axial CT. 3,6 MRI appearance is also influenced by the proportion of the histological components. Autopsy specimens of VHs have been examined with MRI and correlated histologically demonstrating that the signal intensity on T1- and T2-weighted imaging is associated with the fraction of the lesion occupied by adipocytes, vessels and edema.…”

“…7 Typical VHs are hyperintense on T1 and T2, especially on FSE sequences, because of their fatty stroma and vascular components, demonstrating variable enhancement, lower in lesions with a larger fatty content. 3 . On the other hand, atypical VHs have low fat content and high vascularity displaying an iso/hypointense signal on T1 and hyperintense signal on T2-weighted images with elevated contrast enhancement.…”

“…Cortical erosion, extradural soft tissue, expansion to the posterior elements and even invasion of the spinal canal, are radiologic signs of aggressiveness. 3 While these incidentally found lesions are benign, their appearance in routine STIR, T1- and T2-weighted MR sequences often mimics that of primary bone malignancies and metastatic lesions. 8 Therefore the ability to distinguish between these commonly encountered lesions and vertebral malignancies has a direct clinical application in patient management, particularly in a patient with known malignancy.…”

French Multidisciplinary Approach for the Treatment of MSK Tumors

“…VHs are the most common benign vertebral tumors accounting for 2 to 3% of all spine tumors. [34][35][36] Commonly considered benign, VHs are post-capillary low-flow vascular malformations containing venous vessels and fat, muscular, and fibrotic tissue in different proportions. They are frequently located in the thoracic vertebrae, within the body or less commonly within pedicles and the other elements of the posterior neural arch.…”