Aggressive hemangioma of the thoracic spine

Abstract

Vertebral hemangiomas are common lesions and usually considered benign. A rare subset of them, however, are characterized by extra-osseous extension, bone expansion, disturbance of blood flow, and occasionally compression fractures and thereby referred to as aggressive hemangiomas. We present a case of a 67-year-old woman with progressive paraplegia and an infiltrative mass of T4 vertebra causing mass effect on the spinal cord. Multiple conventional imaging modalities were utilized to suggest the diagnosis of aggressive hemangioma. Final pathologic diagnosis after decompressive surgery confirmed the diagnosis of an osseous hemangioma.

Keywords: Aggressive hemangioma; Cord compression; Vertebral body.

Figure 1:

67-year-old woman with aggressive hemangioma of the thoracic spine and progressive paraplegia. GE Signa Excite 1.5 Tesla magnet. Precontrast axial (TR: 366, TE: 14) (a) and sagittal (TR: 500, TE:14) (b) T1 weighted images depicting an initially hypointense soft tissue mass which enhances greatly after intravenous injection of 15cc OptiMARK (gadoversetamide) as seen on postcontrast axial (TR: 467, TE: 14) (c) and fat-suppressed sagittal (TR: 400, TE: 14) (d) T1 weighted images. The mass involves the T4 vertebral body (asterisks) with extension into the spinal canal (arrows), postererior elements (curved arrows), and left paraspinous soft tissues (arrow heads). Sagittal T2 weighted (TR: 4866, TE: 113) (e) and Short T1 Inversion Recovery (STIR) (TR: 4900, TE: 54) (f) images demonstrating high signal within the spinal cord at the level of T4 consistent with spinal cord edema (open arrowheads).

Figure 2:

67-year-old woman with aggressive hemangioma of the thoracic spine and progressive paraplegia. Noncontrast CT images depicting an expansile lesion of T4 vertebral body (arrows) with trabecular thickening and intervening decreased density giving the characteristic “polka dot” appearance on axial image (a) and “corduroy cloth/jail bar” appearance on coronal (b) and sagittal (c) images compatible with an osseous hemangioma. Note the aggressive nature with soft tissue component extending and involving the spinal canal (arrowheads) and posterior elements (curved arrows). (Scanner: GE LightSpeed Pro16; Protocol: Source axial image slice thickness: 0.63mm, kVp 120, mA 631)

Figure 3:

67-year-old woman with aggressive hemangioma of the thoracic spine and progressive paraplegia. Selected digital subtraction angiography (DSA) images at the T3–T4 vertebral level demonstrating abnormal pooling of contrast (white arrows) in the T4 vertebral body on early phase (a) with accumulation of contrast on more delayed phases (b) consistent with a hemangioma. The blood supply was mainly from the right supreme intercostal artery (black arrows).

Figure 4:

67-year-old woman with aggressive hemangioma of the thoracic spine and progressive paraplegia. Histology is from surgical biopsy of the mass. Haematoxylin & Eosin stain, 40x magnification. Thin-walled blood vessels of various size (asterisks) filled with blood and serous fluid extend through the bony trabeculae (arrows) of the vertebral body, replacing the normal marrow; consistent with osseous hemangioma.