What’s the Diagnosis – Case 127
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What’s the Diagnosis – Case 127
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Findings Dating back to the 2005 CT, there is a sclerotic focus of the S1 vertebral body with focal areas of thickened/sclerotic trabeculae and an associated soft tissue mass. The area shows increased radiotracer uptake on the delayed images of the SPECT-CT. On later imaging of 2018, the S1 vertebrae shows areas of high and low signal on the T1 pulse sequence, high signal on the IR sequence, and a prominent soft tissue mass on the T2 sagittal sequence. The S1 vertebrae and soft tissue mass show a prominent amount of enhancement. The axial T2 images show the soft tissue mass causes compression of the S1 proximal nerve roots. The follow up CT study shows findings with similar architecture to the prior study but with the soft tissue mass being larger.
What’s the Diagnosis – Case 127
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Diagnosis: Aggressive Vertebral Hemangioma Vertebral hemangioma (VH) is a very common entity seen while reading CT or MRI of the spine and especially the lumbar spine. VH are described radiographicaly as typical, atypical, or aggressive. VH pathologically have blood vessels interspersed with fatty tissue, interstitial edema, and thickened/coarsened bony trabeculae. Particularly, these thickened trabeculae account for the “polka-dot” appearance seen on axial CT images and the “corduroy” appearance seen on sagittal and coronal reformations. Typical hemangioma have a greater amount of fatty tissue giving the typical high T1 signal. The atypical hemangioma has less fatty tissue and will have less or no high T1 signal and will appear similar to many other processes with low T1/high T2 characteristics. This makes evaluation of the atypical hemangioma difficult on MRI as it can mimic many entities including metastases, myeloma, or lymphoma. However, on CT, the “polka-dot” and “corduroy” appearance will still be appreciated allowing an accurate diagnosis. The aggressive hemangioma typically has similar MRI characteristics to the atypical hemangioma but has broken through the bone and has an associated soft tissue mass. Hence on MRI these masses look very aggressive but when a CT is performed, the “polka-dot” or “corduroy” architecture is typically still able to be identified to render an accurate diagnosis. At times as in this case, aggressive hemangioma may have some fatty tissue accounting for high T1 signal but often no high T1 signal at all can be identified. Because this mass has such an aggressive appearance, biopsy is frequently performed. In fact, in this case a biopsy was performed in 2005 to help come to the appropriate diagnosis.
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Diagnosis: Aggressive Vertebral Hemangioma As seen in this case, the soft tissue mass can cause mass effect on the thecal sac or neural elements and produce radicular symptoms as seen in disc herniations and degenerative disc disease. The treatment of these aggressive hemangioma is still debated but with percutaneous techniques such as arterial embolization or intralesional ethanol injections currently being favored. Given the symptoms for this patient, they are being referred to an interventional radiology practice for treatment. As an aside, the abdominal pain in this patient was not thought to be related to the increased size of the hemangioma and increased mass effect on the S1 nerve roots but to an unrelated GI issue.
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References Differentiating Atypical Hemangiomas and Metastatic Vertebral Lesions: The Role of T1-Weighted Dynamic Contrast-Enhanced MRI. K.A. Morales, J. Arevalo-Perez, K.K. Peck, A.I. Holodny, E. Lis and S. Karimi. American Journal of Neuroradiology April 2018, DOI: https://doi.org/10.3174/ajnr.A5630 A systematic approach to vertebral hemangioma. Gaudino S, Martucci M, Colantonio R, Lozupone E, Visconti E, Leone A, Colosimo C. Skeletal Radiol. 2015 Jan;44(1):25-36. doi: 10.1007/s00256-014-2035-y. Epub 2014 Oct 28.
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