Imaging of infantile hemangiomas: a pictorial essay

Abstract

Infantile hemangioma (IH) is a common benign vascular neoplasm with a characteristic pattern of progression: at birth, it is not fully developed; in the first days or weeks of life, it grows; and its growth peaks at around one year of age, after which there is spontaneous regression. Although most IHs are superficial and therefore obvious on physical examination, they can also affect deeper planes or other organs, in which case they are best assessed with imaging examinations. Methods such as ultrasound and magnetic resonance imaging can help differentiate IHs from vascular malformations, other benign tumors, and malignant tumors. The aim of this pictorial essay is to demonstrate the various presentations of IHs through illustrative cases, with an emphasis on imaging findings.

Keywords: Hemangioma; Hemangioma, capillary; Infant; Magnetic resonance imaging; Ultrasonography.

Figure 1

Cutaneous IH. A one-month-old infant with a reddish tumor on the anterior surface of the chest. A: Ultrasound image obtained with a high-frequency transducer, showing a slightly exophytic, hypoechoic, expansile formation restricted to the cutaneous planes, with well-defined margins and lobulated edges. B: Color Doppler showing intense vascularization and an arterial flow pattern with a low (0.53) resistance index (RI). These findings are characteristic of a cutaneous IH.

Figure 2

Purely subcutaneous IH. A three-month-old infant with a palpable nodule in the left sternoclavicular region. A: High-frequency ultrasound image showing an expansile, hypoechoic formation restricted to the subcutaneous planes, with well-defined margins. B: Color Doppler showing intense vascularization, which is consistent with purely subcutaneous IH.

Figure 3

Mixed IH. A two-month-old infant with a reddish bulging/expansile lesion on the right side of the face. MRI scans showing an expansile lesion with the center affecting the cutaneous and subcutaneous planes of the right face, involving the zygomaticomaxillary, preseptal/palpebral, and nasal regions, extending slightly into the medial extraconal postseptal space of the orbit. It was characterized by a predominantly hyperintense signal on T2-weighted/T1-weighted sequences (T2/TIMRI, in A) and intense contrast enhancement on contrast-enhanced T1-weighted sequences with digital subtraction (T1+C+subtraction, in B), findings that are consistent with a mixed IH.

Figure 4

Orbital IH. A two-week-old infant with progressive left-eye proptosis. A: Ultrasound of the orbit, showing an expansile intraorbital lesion, with homogeneous echotexture and well-defined margins, near the globe (asterisk) and the optic nerve (arrow). B: Color Doppler showing signs of intense vascularization, a set of findings that are consistent with orbital IH.

Figure 5

Airway IH. A four-month-old infant with progressive respiratory dysfunction, admitted to the hospital with cough, subcostal retraction, and peripheral oxygen saturation of 95%. Chest X-ray showing asymmetric lung volumes, with hyperexpansion of the left lung and mediastinal shift to the right (R, in A), the initial diagnostic hypotheses being congenital lobar emphysema and foreign body aspiration. Further investigation with unenhanced chest CT (B) showed a 1.0-cm nodular opacity significantly reducing the lumen of the right main bronchus (arrow), and direct endoscopic evaluation was indicated.

Figure 6

Airway IH. Fiberoptic bronchoscopy image showing a sessile lesion covered by vascularized mucosa, completely obstructing the lumen of the left main bronchus (arrow). For diagnostic and therapeutic purposes, the bronchial lumen was partially opened and the endobronchial tumor was biopsied. After the biopsy, there was significant bleeding, which was contained with cold saline and adrenaline.

Figure 7

irway IH. Histopathologic findings after biopsy by fiberoptic bronchoscopy demonstrated vascular channels lined by round endothelial cells, with discrete or imperceptible lumens. Photomicrograph demonstrating immunoexpression of the glucose transporter type 1 protein, characterized by intense, diffuse brown staining in the endothelial cells of blood vessels, a finding that helps differentiate IHs from other vascular lesions.

Figure 8

Parotid IH. A three-month-old infant with a progressive volumetric increase in the right cervical region. An outpatient ultrasound evaluation showed an expansile lesion in the cervical region, and MRI was performed to assess its relationship with deep planes. The MRI sequences showed an expansile lesion with lobulated contours, presenting a hyperintense signal on an axial T2-weighted short-tau inversion recovery sequence (T2/STIR, in A), as well as intense enhancement on a coronal T1-weighted gadolinium contrast-enhanced sequence (T1+C, in B), findings consistent with an IH, in the right parotid gland. Oral propranolol was administered, with a satisfactory response on physical examination, confirmed by a follow-up MRI scan (C), which showed a significant reduction in the size of the IH, with heterogeneous signal intensity (arrow), secondary to fatty replacement of the lesion.

Figure 9

Hepatic IHs. A one-week-old infant with hepatomegaly on the prenatal examination. High-frequency ultrasound showing numerous small hypoechoic nodules in the liver parenchyma (arrows), characteristic of IHs, in contrast with hepatic hemangiomas in adults, which are typically hyperechoic.

Figure 10

Hepatic IHs. Further CT investigation to evaluate nodules. Multiphasic CT showing an enlarged liver, due to several hypodense nodules that present early peripheral contrast enhancement and gradual, progressive centripetal filling, with a tendency toward homogenization in relation to the hepatic parenchyma in late acquisitions, findings consistent with infantile hepatic hemangiomatosis.