Hepatic hemangioma

Last revised by Joel Hng on 28 Feb 2023

Hepatic hemangiomas or hepatic venous malformations are the most common benign vascular liver lesions. They are frequently diagnosed as an incidental finding on imaging, and most patients are asymptomatic. From a radiologic perspective, it is important to differentiate hemangiomas from hepatic malignancy. 

It is important to note that according to newer nomenclature, these lesions are known as venous malformations (ISSVA classification of vascular anomalies) 20. Having said that, it is probably helpful to include the word 'hemangioma' in reports, as this term is ubiquitous in the literature and more familiar to many clinicians. The remainder of this article uses the terms 'hepatic hemangioma' and 'hepatic venous malformation' interchangeably. 

Hepatic hemangiomas are much more common in females, with an F:M of up to 5:1 17. They are rarely seen in young children, but infantile hepatic hemangioma is the most common, benign hepatic vascular tumor in infants.

Hepatic hemangiomas are thought to be congenital in origin, non-neoplastic, and are almost always of the cavernous subtype. Blood supply is predominantly hepatic arterial, similar to other liver tumors. A peripheral location within the liver is most common 3.

The presence of a few hepatic hemangiomas in the liver is not uncommon, but rarely a large number of hepatic hemangiomas may occur (see hepatic haemangiomatosis).

  • typically well-defined hyperechoic lesions

  • a small proportion (10%) are hypoechoic, which may be due to a background of hepatic steatosis, where the liver parenchyma itself is of increased echogenicity

  • color Doppler: may show peripheral feeding vessels 

  • contrast-enhanced ultrasound

    • arterial phase: peripheral nodular discontinuous enhancement

    • portal venous and delayed phases: continued "filling in" of the lesion, until the entire hemangioma is hyperechoic relative to background liver

    • central hemorrhagic portions of cavernous hemangiomas remain non-enhancing

See hyperechoic liver lesions for a further differential.

Most hemangiomas are relatively well-defined. The dynamic enhancement pattern is related to the size of its vascular space 1. Features of typical lesions include:

  • non-contrast: Often homogeneous hypoattenuating (<20 Hounsfield units) relative to liver parenchyma 23

  • late arterial phase: typically show 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:

Typical features include:

  • T1: hypointense relative to liver parenchyma

  • T2: hyperintense relative to liver parenchyma, but less than the intensity of CSF or of a hepatic cyst

  • T1 C + (Gd): often shows peripheral nodular discontinuous enhancement which progresses centripetally (inward) on delayed images

    • hemangiomas tend to retain contrast on delayed (>5 minutes) contrast-enhanced images

    • atypical hemangiomas may demonstrate slightly altered enhancement patterns

  • T1 C + (hepatobiliary contrast, Eovist):

    • hemangiomas show a wide range of appearances on delayed imaging so this is less useful

    • high-flow hemangiomas may show 'pseudo washout' 21 - this is thought to be due to increased contrast uptake from the adjacent liver parenchyma and should not be confused with true washout

  • DWI: hyperintense on diffusion-weighted imaging even with high b-values due to slow blood flow and can be hyperintense or mixed (hyper and hypointense regions) on ADC map 16

Tc-99m RBCs labeled 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.

They are benign lesions. Recommendations for patients with no known risk factors for hepatic malignancy can range from center to center from performing confirmatory examinations (MRI, triphasic CT or scintigraphy) to considering follow-up ultrasound in 6 months to confirm stability, to performing no further imaging evaluation 13.

Some authors propose surgical resection for patients with progressive abdominal pain in combination with a size greater than 5 cm 14.

The diagnosis of hemangioma can usually be made with high specificity if the imaging characteristics are typical. General imaging differential considerations for a hemangioma depend on the imaging modality and the patient's history, but may include:

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Cases and figures

  • Case 1: arterial phase
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  • Case 2
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  • Case 4: MRI T2
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  • Case 5: venous phase
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  • Case 6
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  • Case 7: with sonographic contrast
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  • Case 8
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  • Case 9
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  • Case 10
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  • Case 11
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  • Case 12: slow filling hemangioma (CEUS)
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  • Case 13
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  • Case 14: multifocal
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  • Case 15
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  • Case 16
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  • Case 17
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  • Case 18: flash filling hemangioma
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  • Case 19
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  • Case 20
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  • Case 21
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  • Case 22: on ultrasound
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  • Case 23
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  • Case 24: on a fatty liver
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  • Case 25
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  • Case 26: slow filling hemangioma (CEUS)
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  • Case 27: cavernous type
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  • Case 28: hypoechoic
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  • Case 29: hepatic hemangiomas - focal nodular hyperplasia
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  • Case 30: in fatty liver
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  • Case 31: Hepatic hemangiomas
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