contents TIB Introduction Vertebral haemangioma is the most common benign tumour of the spine.1 The prevalence of spinal haemangiomas varies from 10% to 12% from postmortem and radiographic studies.1,2 Sixty per cent of patients with haemangiomas are asympto- matic and are discovered as incidental find- ings on imaging.3 Twenty per cent of patients present with pain, which is usually not related to the spinal haemangioma.3 However approximately 20% of patients become symptomatic with increasing pain related to the haemangioma, or less com- monly with progressive neurological signs with or without signs of spinal cord com- pression.3,4 We present 4 cases to demon- strate the clinical spectrum and imaging findings of spinal haemangiomas. Case 1 A 32-year-old man presented with a long history of backache. Clinical examina- tion was unremarkable. Focal sclerosis in the T6 vertebral body was detected on the thoracic spine radiographs (Fig 1a). MR demonstrated replacement of the T6 body by a heterogeneous hyperdense lesion with vertical hypodense striations on both T1 and T2-weighted images (Figs 1b,c). A smaller identical focal lesion was detected in the T5 body. A diagnosis of multiple spinal haemangiomas was made. The patient responded well to analgesics. Case 2 A 52-year-old man complained of localised severe upper lumbar backache and episodes of rectal bleeding. Clinical examination was normal. A barium enema demonstrated sigmoid diverticular disease. The thoracic spine radiographs were unre- markable. A technetium 99m pyrophos- phate bone scan demonstrated a focus of increased activity in the left pedicle of the L1 vertebra and solitary metastasis was sus- pected. A MR scan demonstrated a focal lesion in the left body, pedicle and trans- verse process of L1. The lesion was hyper- intense on both T1 and T2-weighted images with a heterogeneous speckled appearance on both axial and sagittal images (Figs 2a-c). These features were considered typical of spinal haemangioma. The patient’s pain settled on analgesics and physiotherapy. A repeat study 8 weeks later demonstrated no interval change in the appearance of the haemangioma. CASE SERIES 22 SA JOURNAL OF RADIOLOGY • October 2005 Imaging of vertebral haeman- giomas - contribution of MR imaging P Corr FFRad (D)SA MD F Lockhat FCRad (D) SA Department of Radiology Inkosi Albert Luthuli Hospital and Nelson Mandela Medical School Durban Fig.1a. In case 1 lateral thoracic radiograph demonstrates typical vertical sclerotic striated pattern of a haemangioma. Fig. 1c. Fig. 1b,c. In case 1 on T1 and T2-weighted sagittal scans there are hyperdense striated lesions in the body of T5 and T6 typical of hae- mangiomas. Figs 2a-c. In case 2 on T1 and T2-weighted MR scans the heterogeneous hyperdense haemangioma is noted replacing the left side of the L1 body, pedicle and transverse process. This is best visualised on the trans- verse image on Fig.2c. pg22-24 TIB 10/9/05 9:50 AM Page 22 CASE SERIES 23 SA JOURNAL OF RADIOLOGY • October 2005 Case 3 A 36-year-old painter fell off a step lad- der, injuring his back. He complained of severe upper lumbar back pain with diffi- culty walking. Clinically he had severe localised spinal tenderness over L1 with decreased power (2/5) and reflexes in both legs. Spine radiographs demonstrated an ill-defined sclerotic lesion in the body of L1. MR imaging demonstrated a hyperin- tense lesion replacing the whole of the L1 body, with vertical hypointense striations on T1 and T2-weighted images. There was an extradural haematoma causing thecal sac and conus compression (Figs 3a-c). A diagnosis of a pathological fracture of a vertebral haemangioma was made. This patient underwent a laminectomy and spinal fusion. Case 4 A 25-year-old man presented with gradual onset of paraparesis. Clinical examination confirmed weakness in the lower limbs. Subcutaneous telangectasia were noted over the chest. T1 and T2- weighted MR images of the spine (Figs 4a and b) demonstrated a low signal intensity lesion in the C6 vertebral body on T1 and a high intensity signal on T2. The lesion had the classic celery-stalk appearance on the axial T2-weighted image (Figs 4a-d) with contrast enhancement following gadolini- um enhancement (Fig. 4d). There was a focal intramedullary lesion at T1 with a heterogeneous appearance on T2 in keep- ing with a spinal cord haemangioma. Fig. 2c. Fig. 2b. Fig. 3c. Figs 3a-c. In case 3 on T1 and T2 images a pathological fracture of the L1 body haeman- gioma is noted with intraosseus and extradur- al haematoma (arrows) causing thecal com- pression. Figs 4a-d. In case 4 on T1 and T2 images an ‘aggressive haemangioma’ with low intensity on T1 and high intensity on T2 is demon- strated at the C6 level with an associated spinal cord haemagioma at T1. Fig. 4b. Fig. 3b. pg22-24 TIB 10/8/05 11:41 AM Page 23 Discussion The importance of making a radiologi- cal diagnosis of spinal haemangioma is that the majority of lesions, as in cases 1 and 2, require no further investigation or any form of treatment. The MR findings are characteristic with a heterogeneous hyper- dense appearance on both T1 and T2- weighted scans.5 There is often vertical hypodense striations on sagittal MR and a celery-stalk appearance on axial images which are characteristic. These represent thickened vertical bony trabeculae within the haemangioma.6 Spinal metastases are the main differential diagnosis, however they usually extend into the pedicles unlike haemangiomas, and are hypodense on T1- weighted images while asymptomatic hae- mangiomas are usually hyperdense on T1- weighted images. Focal fatty marrow may be round and conspicuous on MR imaging and could be confused with haeman- giomas, however there are no vertical low- density striations within the fatty marrow and they normally become very hypointense on a fat saturation sequence. On histological examination most spinal haemangiomas are cavernous but can also be capillary or venous in origin.6 They are usually thin-walled endothelium- lined sinuses interspersed with bony tra- beculae and fat. They are most common in the thoracic spine involving the whole or part of a vertebral body while posterior ele- ment or pedicle involvement is uncommon (10 - 15%).6 Multiple involvement is com- mon in the thoracic spine, occurring in 25 - 30% of patients.7 Symptomatic or ‘aggressive’ spinal hae- mangiomas present with intense localised pain, myelopathy and/or radiculopathy from osseous expansion, pathological frac- ture or extradural haematoma. Symptoms are often acute with sudden haemorrhage and mass effect. These tumours usually contain less fat and more vascular stroma than asymptomatic haemangiomas. They tend to be more hypodense on T1-weight- ed and hyperdense on T2-weighted images due to the presence of interstitial oedema.5 This pattern is demonstrated in case 4. Treatment options for symptomatic haemangiomas include: surgical decom- pression, radiotherapy, endovascular embolisation using particles, direct CT- guided alcohol injection and vertebroplas- ty.3,8-10 Surgical decompression is necessary when there is compression of the spinal cord although embolisation is usually required to reduce intra-operative blood loss. In the largest series of 86 patients,8 there was a 6% mortality due to haemor- rhage. Vertebroplasty using methyl methacrylate glue has been used with some success although no large series are avail- able at this time.10 Haemangiomas are the commonest benign tumour of the spine that are often confused with spinal metastases. Uncommonly they may bleed or cause a pathological fracture resulting in spinal cord compression. Imaging with MR, although an expensive investigation, will usually give the correct diagnosis and pre- vent the patient from undergoing unneces- sary further investigations including spinal biopsy. References 1. Yocum TR, Lile RL, Schultz GD. Acquired spinal stenosis secondary to an expanding thoracic verte- bral hemangioma. Spine 1993; 18: 299-305. 2. Hemmy DC. Vertebral hemangiomas. In: Wilkins RH, Rengachary SS, eds. Neurosurgery. New York: McGraw Hill, 1996: 1827-1829. 3. Fox MW, Onofrio BM. The natural history and management of symptomatic and asymptomatic vertebral hemangiomas. J Neurosurg 1993; 78: 36- 45. 4. Nguyen JP, Djindjian M, Gaston A. Vertebral hemangiomas presenting with neurologic symp- toms. Surg Neurol 1987; 27: 391-397. 5. Baudrez V, Galant C, Van de Berg BC. Benign ver- tebral hemangioma: MR-histological correlation. Skeletal Radiol 2001; 30: 442-446. 6. Osborn AG. Tumors, cysts and tumor like lesions of the spine and spinal cord. In: Osborn AG, ed. Diagnostic Neuroradiology. St Louis: Mosby, 1994: 876-918. 7. Djindjian M, Nguyen JP, Gaston A Multiple verte- bral hemangiomas with neurologic signs. J Neurosurg 1992; 76: 1025-1028. 8. Pastushyn AI, Slin’ko EL, Mirzoyeva GM. Vertebral hemangiomas: diagnosis, management, natural history and clinicopathological correlates in 86 patients. Surg Neurol 1998; 50: 535-547. 9. Smith TP, Koci T, Mehringer CM, et al. Transarterial embolization of vertebral heman- gioma. J Vasc Interv Radiol 1993; 4: 681-685. 10. Ide C, Gangi A, Rimmelin A, et al. Vertebral hemangiomas with spinal compression: the place of preoperative percutaneous vertebroplasty with methyl methacrylate. Neuroradiology 1996; 38: 585-589. CASE SERIES 24 SA JOURNAL OF RADIOLOGY • October 2005 Fig. 4c. Fig. 4d. pg22-24 TIB 10/8/05 11:50 AM Page 24