Radiography
Bone hemangioma. Localized view of a frontal skull radiograph shows a well-demarcated lesion in the frontal bone with a characteristic sunburst appearance or a radiating, weblike trabecular pattern.
Bone hemangioma. Lateral projection in the same patient as in Image 1 in Multimedia depicts the diagnostic appearance of a calvarial hemangioma well.
Bone hemangioma. View depicting the typical corduroy or accordion appearance of coarse, thickened vertical trabeculae in a hemangioma affecting the right side of the vertebral body at L2.
Bone hemangioma. Lateral view in the same patient as in Image 3 in Multimedia shows no obvious involvement of the posterior elements, though this is better assessed with CT and MRI. The trabecular pattern on plain images is usually better seen on this view.
Findings
Most vertebral hemangiomas are small and cannot be seen on plain radiographs. The characteristic radiographic appearance is of a sclerotic or ivory vertebra with coarse, thickened vertical trabeculae giving a corduroy, accordion, or honeycomb appearance (see Images 1-4). This appearance is due to resorption of horizontal trabeculae, caused by vascular channels and consequent reinforcement of vertical trabeculae. This finding can be differentiated from Paget disease, in which picture framing of the vertebral body is seen owing to prominent horizontal trabeculae. Similar findings may occur with lymphoma and metastases. Bulging of the posterior cortex or expansion of the vertebral body is sometimes present.
Calvarial hemangiomas are usually round, osteolytic lesions that may demonstrate the characteristic sunburst, radiating spoke-wheel, or weblike pattern of trabecular thickening. Radiographic appearances in craniofacial hemangiomas are often nonspecific. Mixed radiopacity, radiolucency, and honeycomb patterns are observed.
Long-bone hemangiomas are usually lytic, with a spiculated pattern creating a latticelike or Irish-lace appearance. A honeycomb structure can also result from bubbly bone osteolysis. Irregular bone destruction can occur, simulating malignant lesions. Reactive sclerosis may be seen at the margins of the lesions; with surface-based hemangiomas, they may mimic osteoid osteoma. Epithelioid hemangiomas characteristically demonstrate well-defined lysis, and they may also exhibit surrounding sclerosis, cortical expansion, or destruction.
Degree of Confidence
Radiographic appearances of hemangiomas can be pathognomonic, especially with vertebral and calvarial hemangiomas. CT and MRI increase diagnostic confidence in equivocal cases.
Computed Tomography
Bone hemangioma. Incidental finding of a small thoracic vertebral body hemangioma in a patient who had another lesion in the lumbar spine. Note the punctate sclerotic foci, or polka-dot appearance, which is a characteristic finding.
Findings
Vertebral hemangiomas are typified by punctate sclerotic foci representing thickened vertical trabeculae seen in cross-section and giving a polka-dot appearance (see Image 5). This finding may be absent in patients with symptomatic lesions. Bulging of the posterior cortex and paravertebral soft-tissue extension are readily assessed on CT scans, as is bone destruction with aggressive hemangiomas. CT findings in nonvertebral hemangiomas confirm plain radiographic results but give more detailed assessment of medullary, cortical bone, and extraosseous involvement.
Degree of Confidence
CT scanning is more sensitive than plain radiography.
Magnetic Resonance Imaging
Bone hemangioma. Axial T2-weighted MRI shows the MRI equivalent of the CT polka-dot appearance. The hypointense foci correspond to coarsened, thickened trabeculae.
Bone hemangioma. Sagittal T1-weighted MRI of a spinal hemangioma affecting most of the body of L2. There is hyperintense change; hypointense thickened vertical trabeculae are also visible.
Bone hemangioma. T2-weighted image in the same patient as in Images 6-7 in Multimedia demonstrates the typically high signal intensity of marrow and the low signal intensity of the vertical trabeculae.
Bone hemangioma. Sagittal T1-weighted MRI of a typical example of a thoracic hemangioma involving only part of the vertebral body.
Bone hemangioma. Sagittal T2-weighted MRI in the same patient as in Image 9 in Multimedia.
Findings
MRI features largely depend on the proportion of fat and vascularity of the lesions. With T1-weighted MRI, particularly in vertebral hemangiomas, areas of high fat content appear as areas of high signal intensity. On T2-weighted images, high signal intensity typically corresponds to the vascularity of hemangiomas (see Images 6-7). Low signal intensity on T1-weighted images indicates decreased marrow fat or a greater vascular component; such a finding may be correlated with more aggressive behavior and is also more characteristic in cases involving vertebral collapse.
Thickened trabeculae demonstrate low signal intensity on MRI obtained with all sequences (see Image 8). Extraosseous components tend not to show high signal intensity on T1-weighted images owing to the paucity or absence of adipose tissue, but avid enhancement occurs with gadolinium enhancement owing to the vascularity of the lesions. Epidural extension and neural involvement are well depicted with MRI (see Images 9-10).
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.
Lesions in flat and long bones may show serpentine vascular channels. These demonstrate low signal intensity on T1-weighted images and high signal intensity on T2-weighted images with slow blood flow; they show low signal intensity on MRI obtained with all sequences in conditions of high blood flow.11
Degree of Confidence
Complicated symptomatic spinal hemangiomas may be difficult to differentiate from malignant lesions.
Nuclear Imaging
Findings
Osseous hemangiomas usually show normal uptake on isotope bone scans, but they may also demonstrate photopenia and mildly to moderately increased activity. Scintigraphy with labeled red blood cells usually demonstrates focally increased activity.
Degree of Confidence
Single-photon emission CT images are more sensitive than planar images in depicting abnormal activity.12
Angiography
Findings
Angiographic findings confirm the hypervascularity of the lesions. Angiography usually is performed in conjunction with embolization of symptomatic hemangiomas prior to surgery.13
More on Hemangioma, Bone |
| Overview: Hemangioma, Bone |
 Imaging: Hemangioma, Bone |
| Follow-up: Hemangioma, Bone |
| Multimedia: Hemangioma, Bone |
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| Further Reading |
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References
Dahnert W. Haemangioma, bone. In: Radiology Review Manual. 4th ed. 1999: 76-7.
Resnik D, Kyriakos M, Greenway GD. Tumors and tumor-like lesions of bone. 4th ed. Diagnosis of Bone and Joint Disorders;. 2002:3979-85.
Devaney K, Vinh TN, Sweet DE. Surface-based hemangiomas of bone: a review of 11 cases. Clin Orthop. Mar 1994;233-40. [Medline].
Calianeller T, Ozdemir O, Yildirim E, Kiyici H, Altinörs N. Cavernous hemangioma of temporalis muscle: report of a case and review of the literature. Turk Neurosurg. 2007;17(1):33-6. Review. [Medline].
Magliulo G, Parrotto D, Sardella B, Della Rocca C, Re M. Cavernous hemangioma of the tympanic membrane and external ear canal. Am J Otolaryngol. May-Jun 2007;28(3):180-3. Review. [Medline].
Naama O, Gazzaz M, Akhaddar A, Belhachmi A, Asri A, Elmostarchid B, et al. Cavernous hemangioma of the skull: 3 case reports. Surg Neurol. Jan 18 2008;[Epub ahead of print]:[Medline].
Madge SN, Simon S, Abidin Z, Ghabrial R, Davis G, McNab A, et al. Primary orbital intraosseous hemangioma. Ophthal Plast Reconstr Surg. Jan-Feb 2009;25(1):37-41. [Medline].
Nielsen GP, Srivastava A, Kattapuram S, Deshpande V, O'Connell JX, Mangham CD, et al. Epithelioid hemangioma of bone revisited: a study of 50 cases. Am J Surg Pathol. Feb 2009;33(2):270-7. [Medline].
Khanam H, Lipper MH, Wolf CL, Lopes MB. Calvarial haemangiomas: report of two cases and review of the literature. Surg Neurol. 2001;55(1):63-67. [Medline].
Choi JJ, Murphey MD. Angiomatous skeletal lesions. Semin Musculoskeletal Radiology. 2000;4(1):103-12. [Medline].
Ross JS, Masaryk TJ, Modic MT, et al. Vertebral haemangiomas: MR imaging. Radiology. 1987;165(1):165-9.
Han BK, Ryu JS, Moon DH, et al. Bone SPECT imaging of vertebral haemangioma correlation with MR imaging and symptoms. Clin Nucl Med. 1995;20(10):916-21.
Kahana A, Lucarelli MJ, Grayev AM, Van Buren JJ, Burkat CN, Gentry LR. Noninvasive dynamic magnetic resonance angiography with Time-Resolved Imaging of Contrast KineticS (TRICKS) in the evaluation of orbital vascular lesions. Arch Ophthalmol. Dec 2007;125(12):1635-42. [Medline].
Acosta FL Jr, Sanai N, Chi JH, Dowd CF, Chin C, Tihan T, et al. Comprehensive management of symptomatic and aggressive vertebral hemangiomas. Review. Neurosurg Clin N Am. Jan; 2008;19(1):17-29. [Medline].
Bandiera S, Gasbarrini A, De lure F, et al. Symptomatic vertebral hemangioma; the treatment of 23 cases and a review of the literature. Chir Organi Mov. 2002;87(1):1-15. [Medline].
Cortet B, Cotten A, Deprex X, et al. Value of vertebroplasty combined with surgical decompression in the treatment of aggressive spinal angioma. Apropos of 3 cases. Revue du Rhumatisme. Edition Francaise. 1994;61:16-22.
Ide C, Gangi A, Rimmelin A, et al. Vertebral Haemangiomas with spinal cord compression: the place of preoperative percutaneous vertebroplasty with methyl methacrylate. Neuroradiology. 1996;38(6):585-9.
Feydy A, Cognard C, Miaux Y, et al. Acrylic vertebroplasty in symptomatic cervical vertebral haemangiomas: report of 2 cases. Neuroradiology. 1996;38:389-91.
Further Reading
Related eMedicine topics
Hemangioma
Hemangiomas, Hepatic
Vascular, Hemangiomas
Hemangioma, Cavernous
Hemangioma, Capillary
Clinical Trials
Genetic Basis of Hemangiomas
Hemangioma Associated With High Rates of Morbidity
Hemangioma Growth During the First 6 Months of Life
A Prospective Study Comparing the Incidence of Infantile Hemangiomas Following Normal Pregnancies Versus Pregnancies Complicated by Placental Abnormalities
Clinical guidelines
ACR Appropriateness Criteria® bone tumors. American College of Radiology - Medical Specialty Society. 1995 (revised 2005). 5 pages. NGC:004783
ACR Appropriateness Criteria® metastatic bone disease. American College of Radiology - Medical Specialty Society. 1995 (revised 2005). 11 pages. NGC:004630
Keywords
bone hemangioma, hemangioma, hemangioma of bone, osseous hemangioma, cavernous hemangioma, capillary hemangioma
