Brian Sorensen, MD, and P-L Westesson, MD, PhD, DDS
Clinical
Presentation: A
42-year old female presented with a 2-year history of right shoulder and arm pain. Her symptoms progressed to include throbbing neck pain, intermittent bilateral upper extremity numbness, and right third and fourth digit weakness.
Imaging Findings: T1-weighted MR images demonstrate a heterogeneous, low-signal intraosseous lesion and intermediate-signal extradural mass at the level of C6 vertebra. The lesion extends posterolaterally from C6 vertebral body to the right C5-C6 intervertebral foramen with anterolateral impression on the thecal sac. Contrast-enhanced T1WIs reveal avid lesional enhancement with intraosseous punctate regions of low attenuation. The mass exhibits high T2 signal. CT myelography reveals an extradural ventral defect at the C5-C6 level. Post-myelogram CT images show a C6 honeycomb lytic lesion and posterior body erosion with a soft tissue epidural component. CT-guided biopsy was performed as depicted below.
Figure 1: T1-weighted sagittal image of the cervical spine.
Figure 2A.Contrast-enhanced T1-weighted sagittal image of the cervical spine.
Figure 2B. Contrast-enhanced T1-weighted axial image at the C6 level.
Figure 3A: T2-weighted sagittal image of the cervical spine.
Figure 3B:T2-weighted axial image at the C6 level.
Figure 4: Proton-density sagittal image of the cervical spine.
Figure 5. Gradient echo axial image at the C6 level.
Figure 6. Myelogram of the cervical spine in the sagittal plane.
Figure 7A. Post-myelogram sagittal CT image of the cervical spine.
Figure 7B. Post-myelogram axial CT image at the C6 level.
Figures 8. Axial CT-guided biopsy image.
Diagnosis: Vertebral hemangioma with extraosseous extension
Discussion: Hemangiomas are the most common benign vertebral tumor, typically occurring in the lower thoracic and upper lumbar regions. Most hemangiomas are discovered incidentally with peak incidence in the 5th decade of life. Although malignant degeneration is extremely uncommon, rare "aggressive hemangiomas" may mimic malignancy, presenting with localized spinal pain, fracture, myelopathy, or radiculopathy.
Most hemangiomas are too small to be detected radiographically. When visualized, a hemangioma characteristically presents as a well-demarcated hypodense lesion with coarse vertical trabeculae, appearing longitudinally and transversely in a "corduroy" and "polka dot" pattern, respectively. MR findings depend upon the proportion of fat and vascularity of the tumor. Fat content corresponds with T1 hyperintensity, whereas vascularity correlates with high T2 signal and contrast enhancement. Aggressive hemangiomas present iso/hypointense to bone on T1WIs and hyperintense on T2WI, making differentiation from metastasis difficult. CT is helpful in identifying extraosseous extension and differentiating hemangioma from metastasis. The differential diagnosis for vertebral hemangioma also includes focal fatty marrow, Paget disease, severe disc degeneration, and post-radiation changes.
Benign "fatty" hemangiomas carry an excellent prognosis with no need for follow-up. Annual radiography is performed to follow symptomatic hemangiomas. In the case of aggressive hemangioma, treatment is dictated by degree of osseous destruction/collapse and neural compromise. Surgical resection and reconstruction are reserved for cases of neural compression. Prior to decompression, transarterial embolization is performed to reduce tumor burden and intraoperative blood loss. Radiation therapy is commonly administered for primary pain management, reossification, and postoperative relapse prevention. In the absence of cord and posterior element involvement, vertebroplasty is an excellent alternative for management of pain associated with compression fracture.
References:
Acosta FL Jr, Dowd CF, Chin C, Tihan T, Ames CP, Weinstein PR. Current treatment strategies and outcomes in the management of symptomatic vertebral hemangiomas. Neurosurgery. 2006 Feb;58(2):287-95; discussion 287-95. [Medline]
