eMedicine Specialties > Plastic Surgery > Skin

Vascular, Hemangiomas: Workup

Author: Meir Cohen, MD, MPS, Consulting Staff, Department of Plastic Surgery, Schneider Children's Medical Center of Israel, Tel Aviv University
Coauthor(s): Eyal Raveh, MD, Consulting Staff, Department of Otolaryngology, Rabin Medical Center, Israel; Dan Ben-Amitai, MD, Head of Pediatric Dermatology Service, Lecturer, Schneider Children's Medical Center of Israel; Shimon Maimon, MD, Head of Invasive Radiology Unit, Beilinson Campus, Rabin Medical Center, Israel; Benjamin Shalev, MD, Consulting Staff, Ophthalmology Unit, Schneider Children's Medical Center of Israel; Moshe Lapidoth, MD, Head, Laser Service, Dermatology, Golda-Hasharon Hospital; Eric Bensimon, MD, Clinical Instructor, Department of Surgery, University of Montreal
Contributor Information and Disclosures

Updated: Mar 14, 2008

Workup

Imaging Studies

  • The most important imaging tool for this condition is contrast-enhanced MRI.11 This diagnostic test, which requires sedation or general anesthesia for children younger than 6 years, demonstrates the extent of the lesion and helps differentiate between hemangiomas and venous, lymphatic, and arterial lesions. It may also help differentiate between a vascular lesion and nonvascular lesions, such as those found in neurofibromatosis.  
    • MRI scans have 3 basic images: T1-weighted spin-echo image, T2-weighted spin-echo image, and contrast-enhanced (gadolinium) T1-weighted spin-echo image. T refers to the time necessary for the protons to discontinue spinning (see Image 12). T1 refers to a value of approximately 600 milliseconds and T2 refers to a value of about 4000 milliseconds. The typical findings in the 3 image modes are presented in Image 13.
    • Hemangiomas have a typical solid appearance with intermediate intensity on a T1-weighted spin-echo image, which is more intense than venous or lymphatic malformations.11
    • During the proliferative stage, hemangiomas show a relatively low intensity in a T2-weighted spin-echo image; in the involution phase, they have a very low intensity.
    • Contrast-enhanced T1-weighted MRI shows moderate intensity with prominent flow voids during the proliferative stage because of the high flow at this stage. In contrast, hemangiomas show low intensity during involution as a result of the low flow at that stage.
    • Image 14 shows a 5-year-old boy with a left intraorbital hemangioma that had caused vertical dystopia of the left globe. Image 15 shows the contrast-enhanced T1-weighted image with visible flow voids and intensity, typical for hemangiomas at the proliferative phase.
  • Doppler ultrasonography can assess the flow of hemangiomas. Generally, they are characterized by a shunt pattern with decreased arterial resistance and increased venous velocity.
  • Arteriography is rarely used for diagnosis or treatment of hemangiomas. Superselective embolization may be used in selected bleeding hemangiomas with a detectable regional nourishing vessel.

Histologic Findings

Proliferating hemangiomas are composed of clusters of rapidly dividing endothelial cells (see Image 16). With regression, endothelial activity gradually diminishes and the cells flatten and mature. Mast cells appear in the late proliferating phase and early involuting phase and interact with macrophages, fibroblasts, and other cell types.3,12 During involution, light microscopy demonstrates progressive deposition of perivascular and interlobular/intralobular fibrous tissue. Multilaminated basement membranes, an ultrastructural hallmark of a proliferative phase hemangioma, persist in the involuted phase.3,12

Most endothelial cells and pericytes express proliferating cell nuclear antigen in the proliferative and early involuting phases.9 Its expression is negligible in the involuted phase.9 The total number of mast cells is highest in the involuting phase, and the proportion of chymase-positive mast cells decreases with the progression of involution.9 Type IV collagen and the 2 chains of laminin and perlecan are detected in the basement membranes in all phases.9

More on Vascular, Hemangiomas

Overview: Vascular, Hemangiomas
Workup: Vascular, Hemangiomas
Treatment: Vascular, Hemangiomas
Follow-up: Vascular, Hemangiomas
Multimedia: Vascular, Hemangiomas
References
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References

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  2. Marler JJ, Mulliken JB. Current management of hemangiomas and vascular malformations. Clin Plastic Surg. 2005;32:99-116. [Medline].

  3. Patrice SJ, Wiss K, Mulliken JB. Pyogenic granuloma (lobular capillary hemangioma): a clinicopathologic study of 178 cases. Pediatr Dermatol. Dec 1991;8(4):267-76. [Medline].

  4. Boon LM, Enjolras O, Mulliken JB. Congenital hemangioma: evidence of accelerated involution. J Pediatr. Mar 1996;128(3):329-35. [Medline].

  5. Mulliken JB. Vascular anomalies. In: Aston SJ, Beasley RW, Thorne CHM, eds. Grabb and Smith Plastic Surgery. 5th ed. NY: Lippincott Raven Publishers; 1997.

  6. Hemangioma Investigator Group, Haggstrom AN, Drolet BA, Baselga E, Chamlin SL, Garzon MC, et al. Prospective study of infantile hemangiomas: demographic, prenatal, and perinatal characteristics. J Pediatr. Mar 2007;150(3):291-4. [Medline].

  7. Breugem CC, van Der Horst CM, Hennekam RC. Progress toward understanding vascular malformations. Plast Reconstr Surg. May 2001;107(6):1509-23. [Medline].

  8. Chang J, Most D, Bresnick S, Mehrara B, Steinbrech DS, Reinisch J, et al. Proliferative hemangiomas: analysis of cytokine gene expression and angiogenesis. Plast Reconstr Surg. Jan 1999;103(1):1-9; discussion 10. [Medline].

  9. Tan ST, Velickovic M, Ruger BM, Davis PF. Cellular and extracellular markers of hemangioma. Plast Reconstr Surg. Sep 2000;106(3):529-38. [Medline].

  10. Metry DW, Hawrot A, Altman C, Freiden IJ. Association of solitary, segmental hemangiomas of the skin with visceral hemangiomatosis. Arch Dermatol. May 2004;140(5):591-6. [Medline].

  11. Armstrong DC, ter Brugge K. Selected interventional procedures for pediatric head and neck vascular lesions. Neuroimaging Clin N Am. Feb 2000;10(1):271-92, x. [Medline].

  12. Takahashi K, Mulliken JB, Kozakewich HP, Rogers RA, Folkman J, Ezekowitz RA. Cellular markers that distinguish the phases of hemangioma during infancy and childhood. J Clin Invest. Jun 1994;93(6):2357-64. [Medline].

  13. Organek A, Cohen M, Zuker R. Interactive information kiosk improves patient knowledge and satisfaction in a busy pediatric plastic surgery clinic. Can J Plast Surg. 2000;8(3):105.

  14. Bonifazi E, Mileti F. Images in clinical medicine. Congenital hemangioma. N Engl J Med. Apr 8 1999;340(14):1080. [Medline].

  15. Sloan GM, Reinisch JF, Nichter LS, Saber WL, Lew K, Morwood DT. Intralesional corticosteroid therapy for infantile hemangiomas. Plast Reconstr Surg. Mar 1989;83(3):459-67. [Medline].

  16. Pope E, Krafchik BR, Macarthur C, Stempak D, Stephens D, Weinstein M, et al. Oral versus high-dose pulse corticosteroids for problematic infantile hemangiomas: a randomized, controlled trial. Pediatrics. Jun 2007;119(6):e1239-47. [Medline].

  17. Boon LM, MacDonald DM, Mulliken JB. Complications of systemic corticosteroid therapy for problematic hemangioma. Plast Reconstr Surg. Nov 1999;104(6):1616-23. [Medline].

  18. Ezekowitz RA, Mulliken JB, Folkman J. Interferon alfa-2a therapy for life-threatening hemangiomas of infancy. N Engl J Med. May 28 1992;326(22):1456-63. [Medline].

  19. Fawcett SL, Grant I, Hall PN, Kelsall AW, Nicholson JC. Vincristine as a treatment for a large haemangioma threatening vital functions. Br J Plast Surg. Mar 2004;57(2):168-71. [Medline].

  20. Scheepers JH, Quaba AA. Does the pulsed tunable dye laser have a role in the management of infantile hemangiomas? Observations based on 3 years' experience. Plast Reconstr Surg. Feb 1995;95(2):305-12. [Medline].

  21. Achauer BM, Celikoz B, VanderKam VM. Intralesional bare fiber laser treatment of hemangioma of infancy. Plast Reconstr Surg. Apr 1998;101(5):1212-7. [Medline].

  22. Achauer BM, Chang CJ, VanderKam VM, Boyko A. Intralesional photocoagulation of periorbital hemangiomas. Plast Reconstr Surg. Jan 1999;103(1):11-6; discussion 17-9. [Medline].

  23. Silfen R, Amir A, Regev D, Hauben DJ. Tumescence: a valuable adjunct for the excision of facial hemangiomas. Plast Reconstr Surg. Jul 2000;106(1):217-8. [Medline].

  24. Enjolras O, Mulliken JB, Boon LM, Wassef M, Kozakewich HP, Burrows PE. Noninvoluting congenital hemangioma: a rare cutaneous vascular anomaly. Plast Reconstr Surg. Jun 2001;107(7):1647-54. [Medline].

  25. Zuker MR, Cohen M. Congenital hand anomalies (discussion). In: Goldwyn RM, Cohen MN, eds. The Unfavorable Result in Plastic Surgery Avoidance and Treatment. 3rd ed. Philadelphia: Lippincott Williams and Wilkins; 2000:710-13.

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Further Reading

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Keywords

Vascular hemangioma, hemangioma, vascular lesions, skin lesion, congenital skin lesion, congenital vascular lesion, acquired skin lesion, acquired vascular lesion, hemangiomas, capillary malformation, venous malformation, lymphatic malformation, slow-flow lesions, high-flow lesions, capillary hemangioma, strawberry hemangioma, cavernous hemangioma, superficial hemangioma, deep hemangioma, mixed hemangioma, mixed type hemangioma, malignant type hemangioma, spreading hemangioma, spreading lesion, involution phase, proliferation phase, PHACES syndrome, PHACES, pyogenic granuloma, facial deformity, facial disfigurement, spontaneous involution, facial hemangioma, periorbital hemangioma, forehead hemangioma, cheek hemangioma, nasal hemangioma, upper lip hemangioma, lower lip hemangioma

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Contributor Information and Disclosures

Author

Meir Cohen, MD, MPS, Consulting Staff, Department of Plastic Surgery, Schneider Children's Medical Center of Israel, Tel Aviv University
Meir Cohen, MD, MPS is a member of the following medical societies: American Cleft Palate/Craniofacial Association and Plastic Surgery Research Council
Disclosure: Nothing to disclose.

Coauthor(s)

Eyal Raveh, MD, Consulting Staff, Department of Otolaryngology, Rabin Medical Center, Israel
Disclosure: Nothing to disclose.

Dan Ben-Amitai, MD, Head of Pediatric Dermatology Service, Lecturer, Schneider Children's Medical Center of Israel
Dan Ben-Amitai, MD is a member of the following medical societies: Israel Medical Association
Disclosure: Nothing to disclose.

Shimon Maimon, MD, Head of Invasive Radiology Unit, Beilinson Campus, Rabin Medical Center, Israel
Disclosure: Nothing to disclose.

Benjamin Shalev, MD, Consulting Staff, Ophthalmology Unit, Schneider Children's Medical Center of Israel
Disclosure: Nothing to disclose.

Moshe Lapidoth, MD, Head, Laser Service, Dermatology, Golda-Hasharon Hospital
Disclosure: Nothing to disclose.

Eric Bensimon, MD, Clinical Instructor, Department of Surgery, University of Montreal
Eric Bensimon, MD is a member of the following medical societies: American Society of Plastic Surgeons, Canadian Society of Plastic Surgeons, Quebec Medical Association, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Medical Editor

Shahin Javaheri, MD, Chief, Department of Plastic Surgery, Martinez Veterans Affairs Outpatient Clinic; Consulting Staff, Advanced Aesthetic Plastic & Reconstructive Surgery
Shahin Javaheri, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery and American Society of Plastic Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Wayne Stadelmann, MD, Stadelmann Plastic Surgery, PC
Wayne Stadelmann, MD is a member of the following medical societies: Alpha Omega Alpha, New Hampshire Medical Society, Northeastern Society of Plastic Surgeons, and Phi Beta Kappa
Disclosure: Nothing to disclose.

CME Editor

Nicolas (Nick) G Slenkovich, MD, Practice Director, Colorado Plastic Surgery Center at Swedish Medical Center
Nicolas (Nick) G Slenkovich, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, American Society of Plastic Surgeons, and Colorado Medical Society
Disclosure: Nothing to disclose.

Chief Editor

Jorge I de la Torre, MD, FACS, Professor of Surgery and Physical Medicine and Rehabilitation, Residency Program Director, Division of Plastic Surgery, University of Alabama at Birmingham; Director, Center for Advanced Surgical Aesthetics
Jorge I de la Torre, MD, FACS is a member of the following medical societies: American Association of Plastic Surgeons, American Burn Association, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Society for Reconstructive Microsurgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Association for Academic Surgery, and Medical Association of the State of Alabama
Disclosure: Nothing to disclose.

 
 
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