Flash filling hepatic hemangioma

Last revised by Bruno Di Muzio on 22 Apr 2023

Flash filling hepatic hemangiomas, also known as flash filling hepatic venous malformations, are a type of atypical hepatic hemangioma, which due to its imaging features often raises the concern of a malignant process rather than a benign one. 

It is important to note that according to newer nomenclature (ISSVA classification of vascular anomalies) these lesions are known as venous malformations 5. 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 terms 'flash filling hemangioma' and 'flash filling hepatic venous malformation' interchangeably. 

They may account for 16% of all hepatic hemangiomas 3.

Being a subtype of hepatic hemangioma, it is also composed of dilated endothelial lined vascular channels and fibrous stroma.

Most are small in size (<2 cm). 

On ultrasound, most are hyperechoic - same as the typical hemangiomas. 

During CEUS these lesions show rapid, homogeneous hyperenhancement followed by hyper/isoenhancement relative to the adjacent liver due to the retention of contrast until the late phase without washout 4

On CT, these lesions are normally iso- to hypodense on unenhanced scans. There is a quick, intense and homogeneous enhancement of the lesion in the arterial phase itself, hence the name "flash filling". In the rest of the phases, it retains the contrast and remains isodense to the adjacent vascular pool. 

  • T1: hypointense 
  • T2: markedly hyperintense
  • C+ (Gd): prompt enhancement but no washout

At times the venous matrix of these hemangiomas may develop phleboliths, which when recognized should be promptly associated with hemangioma. 

Due to the atypical feature of quick, brilliant arterial phase enhancement, these lesions have to be differentiated from:

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