Rapidly involuting congenital hemangioma (RICH) - prenatally discovered

Case contributed by Francis Fortin


Scalp mass found on routine third trimester ultrasound.

Patient Data

Age: 3rd trimester fetus
Gender: Male

Large well-circumscribed soft-tissue mass in the left frontoparietal scalp that is heterogeneous on T2 imaging with large areas of signal void. No significant skull vault remodeling nor intracranial extent.

There was mildly dilated right heart cavities on the third trimester ultrasound (not shown), attributed to increased cardiac output due to the highly vascular mass.

At 7 months, proportionally to head size, the scalp mass has markedly reduced in size without treatment. The mass has solid components which are hypointense on T2WI, isointense on T1WI and avidly enhance homogeneously on post-contrast images. Areas of blooming artifact are seen on gradient echo sequences, likely due to calcifications which are frequent findings on histology of congenital hemangiomas. On time-resolved MR angiography, there is minimal early venous return caused by arteriovenous shunting within the mass. Large venous aneurysms are seen in the mass (with internal flow voids), with partial eccentric thrombus.

Case Discussion

Characteristic prenatal and post-natal MRI findings of a rapidly involuting congenital hemangioma.

Though the patient was evolving well with conservative treatment, due to the large superficial venous aneurysms at risk for hemorrhage with progressive spontaneous involution of the mass, consensus was obtained to proceed with elective partial resection of the mass with ligation of the aneurysms at 9 months of life. Histopathology confirmed a congenital hemangioma.

Case courtesy of Pr Laurent Guibaud.

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