This site is targeted at medical and radiology professionals, contains user contributed content, and material that may be confusing to a lay audience. Use of this site implies acceptance of our Terms of Use.

Hepatic haemangioma

Hepatic haemangiomas (also known as hepatic venous malformations) are benign non-neoplastic hypervascular liver lesions. They are frequently diagnosed as an incidental findings on imaging and most patients are asymptomatic. A peripheral location within the liver is most common 3.

Cavernous malformations are found throughout the body. This article focuses on hepatic cavernous haemangiomas. For a general discussion please refer to the general article on cavernous venous malformation

Terminology

It is important to note that according to newer nomenclature (ISSVA classification of vascular anomalies) these lesions are merely known as slow flow venous malformations. Having said that it is probably helpful in reports to include the word 'hemangioma' as this term is ubiquitous in the literature and most familiar to many clinicians. The remainder of this article uses the term 'hepatic hemangioma' for consistency with the majority of the existing literature. 

Pathology

Thought to be congenital in origin , non-neoplastic, and are almost always of the cavernous subtype. Blood supply is predominantly hepatic arterial, as with all liver tumours 4.

Sub types

Rarely multiple hepatic haemangiomas can also occur - see hepatic haemangiomatosis.

Associations

Radiographic features

Ultrasound

Nonspecific. They are typically well defined hyperechoic lesions. A small proportion (10%) however are hypoechoic. One reason forthese lesions to appear hypoechoic is a background of hepatic steatosis, where liver parenchyma itself is of increased echo intensity. They may or may not show peripheral feeding vessels on colour Doppler.

CT

Most lesions are relatively well defined. The dynamic enhancement pattern is related to the collective size of their vascular spaces 1.

Features of typical lesions include

  • noncontrast: often hypoattenuating relative to liver parenchyma
  • arterial phase: typically discontinuous, nodular, peripheral enhancement (small lesions may show uniform enhancement)
  • portal venous phase: progressive peripheral enhancement with more centripetal fill in
  • delayed phase: further irregular fill in and therefore iso- or hyper-attenuating to liver parenchyma

Other described features include

MRI

Typical features include

  • T1: hypointense relative to liver parenchyma
  • T2:
    • intensely hyperintense relative to liver parenchyma
    • this may give a light bulb sign
  • T1 C + (Gd): often shows peripheral nodular enhancement which progresses centripetally (inward) on delayed images.
    • haemangiomas tend to retain contrast on delayed (>5 minute) contrast-enhanced images
    • atypical haemangiomas may demonstrate slightly altered enhancement patterns
    • in general delayed (1 hour) imaging with Gd-BOPTA (a hepatobiliary-specific MR contrast agent) may not be helpful, since haemangiomas can have a variable appearance that ranges from hypointensity to diffuse and central enhancement
  • DWI: haemangiomas appear hyperintense on diffusion weighted imaging (DWI) due to T2 shine-through rather than restricted diffusion
Nuclear medicine
SPECT

99Tc RBC labelled SPECT can be sensitive for larger lesions and typically demonstrate decreased activity on initial dynamic images followed by increased activity on delayed, blood pool images.

Differential diagnosis

General imaging differential considerations for typical lesions include

There are much wider differential considerations for atypical lesions

  • hypervascular metastases
    • hypervascular metastases show marked early enhancement with a continuous ring that on later images fills in centrally and progressive centripetal fill-in may occur on delayed phases 12

Related articles

Vascular tumours and malformations

Updating… Please wait.
Loadinganimation

Alert_accept

Error Unable to process the form. Check for errors and try again.

Alert_accept Thank you for updating your details.