Soft tissue venous malformations

Last revised by Ashesh Ishwarlal Ranchod on 4 Oct 2023

Soft tissue venous malformations, commonly known as soft tissue hemangiomas, are location-dependent benign vascular soft tissue tumors.

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 to include the word 'hemangioma' in reports as this term is ubiquitous in the literature and most familiar to many clinicians. The remainder of this article uses the terms 'soft tissue hemangioma' and 'soft tissue venous malformation' interchangeably.

They are the most common angiomatous lesions and represent up to 7% of all benign soft-tissue tumors 2. There may be a greater female predilection. In the pediatric population, hemangiomas tend to be the most frequently diagnosed soft-tissue neoplasm.

Soft tissue hemangiomas may be classified into five histological subtypes.

This classification is dependant on the predominant type of vascular channel identified within them:

  • capillary: commonest type; tend to predominate in the pediatric population.

  • cavernous

  • arteriovenous

  • venous

  • mixed

They can arise in various anatomic locations, including striated muscle, skin, subcutaneous tissue, and synovial tissue (synovial hemangioma).

Small lesions may be occult on plain radiographs, while large lesions may show evidence of a focal soft tissue swelling +/- associated phleboliths.

Can have a variable appearance. Typically seen as an ill-defined or well-defined hypoechoic mass of heterogeneous echotexture with multiple cystic spaces within. On color Doppler, there may be no detectable signal or only weak signal 13.

On unenhanced CT, it may appear as an ill-defined mass of similar attenuation to muscle. CT may also show the presence of associated phleboliths.

Hemangiomas are typically well-defined, lobulated and heterogeneous with no features of local invasion.

While many sequences show a rather heterogeneous signal intensity "mass", certain signal characteristics tend to dominate.

  • T1

    • overall signal is often intermediate to slightly high (relative to skeletal muscle) 6

    • some focal high signal areas is present in a large proportion of lesions (up to 70% 5,9)

  • T2: high signal intensity tends to dominate on T2-weighted images

  • gradient echo: the presence of phleboliths may show blooming artifact 10

  • T1 C+ (Gd): lesions show marked signal enhancement in parts of the areas which were both of high and low T2 8

Some intramuscular hemangiomas may also be associated with atrophic changes in muscles.

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