eMedicine Specialties > Radiology > Gastrointestinal
Cavernous Hemangioma, Liver: Imaging
Updated: Aug 12, 2009
Computed Tomography
Findings
Hemangiomas are enhancing lesions that have characteristic dynamic features after the administration of contrast material. On nonenhanced CT scans, hemangiomas appear hypoattenuating relative to the adjacent liver. Calcification is uncommon; it may be marginal or central, spotty or chunky.16 During the arterial-dominant phase, small hemangiomas show intense and uniform contrast enhancement and retain their contrast enhancement during the portal venous phase (see Image 1).4,17,18
Contrast-enhanced computed tomography (CT) scan that was obtained during the arterial-dominant phase. This image demonstrates a hemangioma with homogeneous and intense contrast enhancement.
Wedge-shaped subcapsular or segmental perilesional enhancement may be noted adjacent to high-flow hemangiomas. These findings are possibly due to hemodynamic alterations in the liver.19 The pattern of a peripheral, discontinuous, intense nodular enhancement during the arterial-dominant phase with progressive centripetal fill-in on CT scans is considered pathognomonic for hemangiomas (see Image 2). Pathologically, the nodular areas consist of small vascular spaces that are more densely packed than the rest of the lesion.
Contrast-enhanced computed tomography (CT) scan. These images reveal the pathognomonic features of a hemangioma, namely, peripheral nodular enhancement and progressive centripetal fill-in (arrow). The smaller, peripheral lesion (circled) shows homogeneous enhancement.
Atypical features of hemangiomas include the presence of arterioportal shunts and capsular retraction.5,20 Rarely, a centrifugal pattern of contrast enhancement is seen.21
Degree of Confidence
A globular enhancement pattern on CT scans (analogous to contrast-agent puddling on angiograms) is considered a highly sensitive (88%) and specific (84-100%) feature of hemangiomas.22,23
Hemangiomas that show early, homogeneous contrast enhancement on dynamic CT scans and/or MRI may be mistaken for other hypervascular liver tumors such as hepatoma, focal nodular hyperplasia, adenoma, and hypervascular metastases. The absence of a history of cirrhosis and/or primary malignancy is an important factor in diagnosing hemangioma. The characteristic features of a hemangioma on dynamic CT scanning, red blood cell scintigraphy, and/or MRI permit confident diagnosis in more than 95% of cases.
Magnetic Resonance Imaging
Findings
MRI is more sensitive and specific than other imaging modalities in the diagnosis of hemangiomas. Hemangiomas appear as smooth, lobulated, homogeneous, sometimes septated, hypointense lesions on T1-weighted images. On T2-weighted images, they appear hyperintense relative to the liver (ie, more pronounced on fast spin-echo images), and they remain as bright as cerebrospinal fluid or bile with increased echo time (TE) (see Image 3).24,25
Magnetic resonance image (MRI) of a hemangioma. The lesion appears as a hypointense mass on T1-weighted MRIs (T1WI) and as a hyperintense mass on dual-echo T2-weighted MRIs (T2WI). Note that the signal intensity of the lesion is similar to that of the adjacent cerebrospinal fluid.
The high signal intensity on T2-weighted images is due to the extremely long T2 relaxation time of the free fluid (ie, slowly moving blood). The T2 relaxation time is directly proportional to the collective size of the hemangioma's constituent vascular spaces.26 The T2 values for hemangiomas vary between 90 and 200 msec, compared with T2 values >300 msec for cysts.
Rarely, the imaging features of heavily fibrotic (hyalinized) hemangiomas can be mistaken for those of metastases.27 With the injection of contrast material (gadolinium chelates), lesions typically demonstrate peripheral nodular enhancement with progressive, centripetal fill-in that usually appears after 5-30 minutes (see Image 4).
Dynamic gadolinium (Gd)-enhanced magnetic resonance images (MRIs). These images demonstrate the progressive, centripetal contrast enhancement in a hemangioma.
Large hemangiomas may appear cystic on images as a result of recurrent hemorrhage or myxomatous degeneration. In some hemangiomas, MRI may demonstrate fluid-fluid levels due to the sedimentation of blood products. The supernatant layer consists of unclotted serous blood, and the sediment consists of red blood cells. Definitive diagnosis is often difficult.28
Gadolinium-based contrast agents (gadopentetate dimeglumine [Magnevist], gadobenate dimeglumine [MultiHance], gadodiamide [Omniscan], gadoversetamide [OptiMARK], gadoteridol [ProHance]) have been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). For more information, see the eMedicine topic Nephrogenic Fibrosing Dermopathy. The disease has occurred in patients with moderate to end-stage renal disease after being given a gadolinium-based contrast agent to enhance MRI or MRA scans.
NSF/NFD is a debilitating and sometimes fatal disease. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the whites of the eyes; joint stiffness with trouble moving or straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness. For more information, see the FDA Public Health Advisory or Medscape.
Degree of Confidence
MRI is more sensitive and specific than other imaging modalities in the diagnosis of hemangiomas. On the basis of liver hemangioma characteristics on T2-weighted images (both morphologic and quantitative T2 values), MRI has a sensitivity of 100%, a specificity of 92%, and an accuracy rate of 97%.
Hemangiomas that show early, homogeneous contrast enhancement on dynamic CT scans and/or MRI may be mistaken for other hypervascular liver tumors such as hepatoma, focal nodular hyperplasia, adenoma, and hypervascular metastases. The absence of a history of cirrhosis and/or primary malignancy is an important factor in diagnosing hemangioma. The characteristic features of a hemangioma on dynamic CT scans, red blood cell scintigraphy, and/or MRI permit confident diagnosis in more than 95% of cases.
Ultrasonography
Findings
At ultrasonography, hemangiomas appear as well-circumscribed, uniformly hyperechoic lesions (see Image 5). The increased echogenicity has been postulated to be caused by multiple interfaces between the walls of the cavernous spaces and the blood within them.29 In a study by Taboury et al, more than 75% of hemangiomas had posterior acoustic enhancement that the authors believed was correlated with hypervascularity at angiography.30 In large hemangiomas, heterogeneous areas are interspersed within the hyperechoic mass. Atypical features include hypoechoic lesions with a thin hyperechoic rim or a thick rind and scalloped borders.4 Note that hemangiomas may appear hypoechoic in fatty livers.31
Gray-scale and Doppler ultrasonographic (US) images. These sonograms show a well-defined, uniformly hyperechoic liver mass with peripheral feeder vessels that are characteristic of a hemangioma.
Color power or duplex Doppler ultrasound examinations have a limited role in the specific diagnosis of hemangioma.32 Occasionally, a kilohertz shift in the low to mid range may be observed in the peripheral and central blood vessels in the hemangiomas.33
Nuclear Imaging
Findings
Red blood cell-tagged technetium-99m (99m Tc) scintigraphy with single photon emission CT (SPECT) scanning permits a specific diagnosis of hemangiomas.34 The lesions characteristically show decreased activity on early dynamic images and delayed filling from the periphery of the lesion.
Degree of Confidence
The reported sensitivity is 97%, specificity 83%, and accuracy 96% for red blood cell-tagged99m Tc scintigraphy in the diagnosis of hemangiomas.
Hemangiomas that show early, homogeneous contrast enhancement during dynamic CT scanning and/or MRI may be mistaken for other hypervascular liver tumors such as hepatoma, focal nodular hyperplasia, adenoma, and hypervascular metastases. The absence of a history of cirrhosis and/or primary malignancy is an important factor in diagnosing hemangioma. The characteristic features of a hemangioma on dynamic CT scans, red blood cell scintigraphy, and/or MRI permit confident diagnosis in more than 95% of cases.
Angiography
Findings
At angiography, the feeding vessels of the hemangioma are of normal caliber, except those in the large tumors. During the late arterial/hepatic parenchymal phases, a dense, nodular pattern of opacification of the dilated vascular spaces persists into the venous phase.35
Degree of Confidence
Although hemangiomas have characteristic angiographic features, the use of angiography is not warranted in the diagnosis of hemangioma, given the diagnostic capabilities of less invasive techniques, such as helical CT scanning and MRI.
More on Cavernous Hemangioma, Liver |
| Overview: Cavernous Hemangioma, Liver |
 Imaging: Cavernous Hemangioma, Liver |
| Follow-up: Cavernous Hemangioma, Liver |
| Multimedia: Cavernous Hemangioma, Liver |
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Further Reading
Related eMedicine topics
Hemangiomas, Hepatic
Hemangioma, Cavernous
Kasabach-Merritt Syndrome (Hematology)
Kasabach-Merritt Syndrome (Pediatrics)
Budd-Chiari Syndrome
Clinical guidelines
AASLD practice guidelines: evaluation of the patient for liver transplantation. American Association for the Study of Liver Diseases - Private Nonprofit Research Organization. 2000 Jan (revised 2005 Jun). 26 pages. NGC:004333
ACR Appropriateness Criteria® liver lesion characterization. American College of Radiology - Medical Specialty Society. 1998 (revised 2006). 7 pages. NGC:005115
Surgery for hepatic colorectal metastases. Society for Surgery of the Alimentary Tract, Inc - Medical Specialty Society. 2004 May 15. 3 pages. NGC:003837
Clinical trials
Incidence of Hepatic Hemangiomatosis in Patients With Cutaneous Hemangiomas
A Comparison of Contrast Enhanced Ultrasound (CEUS) and Contrast Enhanced Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) for Characterization of Focal Liver Masses
Keywords
cavernous hemangioma of liver, hepatic cavernous hemangioma, hepatic hemangioma, hemangioma of the liver, giant hemangioma of the liver, primary liver tumor, focal nodular hyperplasia, Kasabach-Merritt syndrome
