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Neuroradiology Case of the Week
Case 281
Ashwani Sharma, MD
and P-L Westesson, MD, PhD, DDS
Clinical
Presentation: Patient is a 45-year-old female who presented with progressive history of neck pain, numbness and weakness of the right arm for 1-11/2 years. The precipitating event is unknown. Since it started it is progressively getting worse. She rates it as a 5/10. She states that her symptoms are 90% right upper extremity, 10% neck. She denies associated loss of bowel or bladder control. Currently, she is taking naproxen and cyclobenzaprine with little relief.
Imaging Findings: Plain radiographs show vertebra with vertical coarse thickened trabecular striations. CT scan imaging showed an intraosseous “polka-dot appearance” on cross-sectional imaging. Sagittal images show “vertical striations” or “corduroy cloth” appearance vertebra. MRI scan is done to evaluate dural sac compression caused from tumor entering the canal. The vertebral hemangioma is usually hyperintense on both T1 and T2-weighted images with variable enhancement after intravenous contrast. Aggressive hemangiomas are hypointense on T1 weighted images.
| Figure 1: Axial CT scan showing the “polka-dot” pattern of the hemangioma in the vertebral body that is produced by the vertical coarse bony trabeculae. Break (arrow) is present in the posterior vertebral body wall through which soft tissue tumor has entered the vertebral canal compressing the thecal sac. |
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| Figure 2A: Sagittal T2WI MR image. |
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Figure 2B: Axial T2WI MR image. |
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| Figure 2C: Sagittal T1WI MR image. |
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| Figure 2D: Axial post-contrast MR image |
Figures 2A-D. Focal right-sided vertebral body lesion, appearing hyperintense on T2WI (A & B) and hypointense on T1WI (C) and showing uniform enhancement post-contrast (D). There is breach (arrows) in the posterior vertebral body wall (corresponding to break seen on the CT) with extension of the soft tissue in the right anterolateral epidural space causing thecal indentation. |
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| Figure 3: CT-guided biopsy with biopsy needle tip is in the core of the lesion. |
Diagnosis: Vertebral body hemangioma with epidural component
Discussion: Vertebral hemangiomas are relatively common benign lesions consisting of vascular channels (capillary, cavernous, arteriovenous, or venous) lined with endothelial cells [1,2]. Based on postmortem studies, hemangiomas are present in about 11% of spines [3] and represent 28% of all skeletal hemangiomas [4]. The majority of vertebral hemangiomas occur in the thoracic spine [2] and are asymptomatic [5]. Occasionally, they cause pain, and more infrequently, cause nerve root or spinal cord compression [1,2].
The mechanism by which hemangiomas cause neurologic symptoms can occur by four mechanisms. This includes enlargement of the vertebral body with ballooning of the posterior cortex and narrowing of the spinal canal, extension of the tumor into the canal through the cortex, fracture of the body with retropulsion of bone or tumor, and bleeding of the tumor into the epidural space [6]. Predominantly fatty stroma at CT and increased signal intensity at MR imaging were associated with normal or only slightly increased vascularization at selective spinal arteriography or contrast-enhanced CT, while soft-tissue stroma at CT and low signal intensity at MR imaging were associated with distinct hypervascularization and more aggressive nature [7].
Treatment for symptomatic lesions includes preoperative embolization of feeding vessels before decompression to minimize blood loss and improve the safety of decompression [2]. Other methods of preoperative treatment reported in the literature include ligation of the feeding vessels or perfusion of the hemangiomas itself with absolute ethanol to devascularize the tumor [2]. Vertebroplasty as a method of hemostasis has not been discussed previously in the literature. It has been more commonly used in the treatment of back pain for osteoporotic fractures, hemangiomas, and metastases [6].
References:
- Yung BC, Loke TK, Yuen NW, Chan CC. Spinal cord compression caused by thoracic vertebral hemangioma involving only the posterior elements of two contiguous vertebrae. Skeletal Radiol. 1998 Mar;27(3):169-72. [Medline]
- Rudnick J, Stern M. Symptomatic thoracic vertebral hemangioma: a case report and literature review. Arch Phys Med Rehabil. 2004 Sep;85(9):1544-7. [Medline]
- McAllister VL, Kendall BE, Bull JW. Symptomatic vertebral haemangiomas. Brain. 1975 Mar;98(1):71-80. [Medline]
- Mirra JM. Bone Tumors: Clinical, Radiologic, and Pathologic Considerations. Philadelphia: Lea & Febiger, 1989:1340–478.
- Cross JJ, Antoun NM, Laing RJ, Xuereb J. Imaging of compressive vertebral haemangiomas. Eur Radiol. 2000;10(6):997-1002. [Medline]
- Ahn H, Jhaveri S, Yee A, Finkelstein J. Lumbar vertebral hemangioma causing cauda equina syndrome: a case report. Spine. 2005 Nov 1;30(21):E662-4. [Medline]
- Laredo JD, Assouline E, Gelbert F, Wybier M, Merland JJ, Tubiana JM. Vertebral hemangiomas: fat content as a sign of aggressiveness. Radiology. 1990 Nov;177(2):467-72. [Medline]
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