Aggressive giant dumbell-shaped thoracic vertebral hemangioma: illustrative case

Abstract

Background: Vertebral hemangioma is the most common benign tumor of the spine, diagnosed incidentally in most cases. In 0.4% of patients, the lesion is considered aggressive, causing neurological deficits. This subtype of hemangioma is characterized by strong postcontrast enhancement, cortical lysis, and epidural extension causing myelopathy and/or radiculopathy.

Observations: A 52-year-old man presented with myelopathy symptoms, namely lower-limb hypoesthesia up to the T4-5 sensory level, right leg hyposthenia, and urinary incontinence. Imaging studies revealed a giant dumbbell-shaped lesion causing spinal cord compression, associated with signal alteration of the T3 vertebral body. The diagnosis of schwannoma was not certain given the radiological features, so a biopsy was planned and confirmed the diagnosis of vertebral hemangioma. Preoperative embolization, spinal fusion, and gross-total resection of the extravertebral component of the lesion were performed.

Lessons: This report should raise awareness of the differential diagnosis of dumbbell-shaped spinal tumors and the therapeutic strategies available for aggressive vertebral hemangiomas, a rare lesion that should be managed in a multidisciplinary setting. https://thejns.org/doi/10.3171/CASE24190.

Keywords: aggressive vertebral hemangioma; case report; dumbell-shaped spinal tumor.

FIG. 1.

Preoperative MRI showing a dumbbell-shaped lesion originating from the T3 vertebral body with an extradural component and an extracanalicular portion with expansion in the thoracic cavity. The lesion appeared hypointense on T1-weighted sequences and strongly hyperintense on T2-weighted sequences (A–C) and showed homogeneous contrast enhancement on postcontrast T1-weighted sequences (B). A hyperintense signal on T2-weighted images could be appreciated in the medullary cord at the T3 level, consistent with myelopathy due to medullary cord compression.

FIG. 2.

Preoperative CT scan showing a dumbbell-shaped lesion originating from the T3 vertebral body with an extracanalicular portion expanding into the thoracic cavity (A). The bone acquisition setting shows the typical “polka dot sign,” an imaging feature specific for VH (B).

FIG. 3.

Angiograms obtained before the embolization procedure show an evident contrast-medium blush with no clear spinal anastomoses (A and B). Postembolization angiograms show effective closure of the afferent branches to the lesion (C and D).

FIG. 4.

Postoperative MRI (A and B) and radiography (C) showing complete resection of the extravertebral component of the VH with the resolution of medullary cord compression and the correct positioning of spinal fusion hardware.