Aggressive vertebral hemangiomata are a rare form of vertebral hemangiomata where significant vertebral expansion, extra-osseous component with epidural extension, disturbance of blood flow, and occasionally compression fractures can be present causing spinal cord and/or nerve root compression 1,2.
It can occur at any age, with peak prevalence in young adults. They represent approximately 1% of spinal hemangiomas and are usually symptomatic 1. 75% of these lesions occur in the thoracic spine between T3 and T9 vertebral segments 3.
Unlike typical vertebral hemangiomas which are almost always asymptomatic, aggressive type 'always' present with neurological manifestations due to the mass effect of the epidural component upon the spinal cord, nerve roots or both, leading to compressive myelopathy and/or radiculopathy 2.
They are composed of blood vessels with slow flowing, dilated venous channels surrounded by fat, infiltrating the medullary cavity 4.
They appear as hypodense expansile vertebral masses, with cortical defects and soft tissue extension and spinal cord/nerve root compression. The classic “polka dot” and “corduroy” signs of the vertebral body due to thickened vertebral trabeculae are also helpful 1. They generally occupy the entire vertebral body, extend into the neural arch, expand the osseous margins, and contain a soft tissue component 1.
Thickened trabeculae appear as low signal areas in both T1 and T2 images. The extraosseous component typically follows usual hemangioma in all pulse sequences with high T1 and T2 signals as well as uniform post-contrast enhancement. MRI is excellent at the assessment of cord or nerve root compression 1.
Chemical shift imaging can be helpful to look for signal drop out to indicate intralesional fat.
Treatment and prognosis
Accurate preoperative diagnosis is essential because they are highly vascular with high tendency of intraoperative bleeding. Surgery is required in cases of rapid or progressive neurological symptoms like compressive myelopathy or radiculopathy. Endovascular embolization prior to surgery to minimize intraoperative blood loss. Radiotherapy can be used in patients with slow progressive neurological deficits. Other emerging options in cases of aggressive hemangiomas include radiofrequency ablation with a hemostatic agent (FLOSEAL, Baxter, USA), and bone autograft placement 6. Minimally-invasive procedures may be successful in smaller lesions 5.
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- 2. Schrock WB, Wetzel RJ, Tanner SC, Khan MA. Aggressive hemangioma of the thoracic spine. (2011) Journal of radiology case reports. 5 (10): 7-13. doi:10.3941/jrcr.v5i10.828 - Pubmed
- 3. Friedman DP. Symptomatic vertebral hemangiomas: MR findings. (1996) AJR. American journal of roentgenology. 167 (2): 359-64. doi:10.2214/ajr.167.2.8686604 - Pubmed
- 4. Alexander J, Meir A, Vrodos N, Yau YH. Vertebral hemangioma: an important differential in the evaluation of locally aggressive spinal lesions. (2010) Spine. 35 (18): E917-20. Pubmed
- 5. Vasudeva VS, Chi JH, Groff MW. Surgical treatment of aggressive vertebral hemangiomas. (2016) Neurosurgical focus. 41 (2): E7. doi:10.3171/2016.5.FOCUS16169 - Pubmed
- 6. Canbay S, Kayalar AE, Gel G, Sabuncuoğlu H. A novel surgical technique for aggressive vertebral hemangiomas. (2019) Neurocirugia (Asturias, Spain). 30 (5): 233-237. doi:10.1016/j.neucir.2018.08.003 - Pubmed