Massive spinal epidural infantile hemangioma, image findings, and treatment: a case report and review of literature

Abstract

Spinal involvement of infantile hemangiomas is rare with the predilection to involve the epidural space. A proper diagnosis might be challenging due to the atypical location and variable/inconsistent use of the International Society for the Study of Vascular Anomalies (ISSVA) classification by radiologists, pathologists, and clinicians. A proper diagnosis of epidural infantile hemangioma is key due to the different aggressiveness of the treatment options with inconstant literature regarding the best available treatment. Herein, we present a case of a massive epidural infantile hemangioma successfully treated with only beta-blocker. We discuss the clinical, MRI, CT, ultrasound, and histological features of this lesion as we review the literature with the objective of addressing some of the confusion surrounding the subject.

Keywords: Beta-blockers; Classification; Epidural Infantile hemangioma; Vascular tumor.

Fig. 1

Sagittal T2 (images A and B), Sagittal T1 (image C), Coronal STIR (images D and E), axial T2 (images F and G) and axial T1 post gadolinium (image H) images of the spine showing a large infiltrative avidly enhancing (blue asterisk, image H) tumor occupying the spinal canal from T10 to S1 with a multilevel Dumble shaped extra spinal components protruding from multiple neural foramina (red asterisk image D). The mass showed high signal intensity on T2 weighted images (images A, D, F, E, G), low signal intensity on T1 weighted images (image D) and extensive flow voids (blue arrows, image G). Note is made of edema in the left psoas muscle (green asterisk, image F) and involvement of the adjacent paraspinal muscles (red arrow, image H). No signal abnormality was detected at the rest of the spinal cord

Fig. 2

Axial (image A), Coronal (image C and D) contrast enhanced CT scan of the spine with 3D reconstruction (image E) showing a high attenuation mass occupying the lower thoracic and lumber spinal canal, extending through multiple neural foramina forming a Dumble shaped appearance (image A). 3D reconstruction images show multilevel posterior elements failing to fuse in keeping with Spina bifida (image E)

Fig. 3

Transverse ultrasound images of the spine and right paraspinal region during transcutaneous biopsy. There is a hypoechoic structure occupying the pine canal (green asterisk, image D) with the vertebral body anteriority (white asterisk, image D) with a protruding component through the right neural foramina (red asterisk, image A) adjacent to the right kidney (blue asterisk, image A). The lesion shows increased flow on doppler images, comparable to that of the adjacent kidney (image B). Note is made of the biopsy needle (white arrow, image B)

Fig. 4

Histologic examination of the specimen showed lobular proliferation of capillary sized vascular spaces (green asterisks) that are lined by bland endothelial (blue arrows)

Fig. 5

Sagittal T1 (image A), Sagittal T2 (image B), Sagittal T1 post gadolinium (image C and D), and axial T1 post gadolinium T2 (image E) images of the lumber spine 6 months after beta blocker therapy showing significant decrease in size and extent of the mass with residual posterior epidural component (blue asterisk, image C) with decrease but persistent areas of foraminal extension (red asterisk, image E). Not is made of significant decrease in the flow voids seen on prior MRI