Aggressive Vertebral Hemangiomas Research Articles

Aggressive vertebral hemangioma in early adolescent age group: Atypical presentation with computed tomography and magnetic resonance imaging appearance

Vertebral hemangiomas (VH) are vertebral vascular malformations, which may remain asymptomatic until adulthood. Sometimes, young individuals present with unexplained backache, which poses the diagnostic dilemma. We present a case of 15-year-old female who presented with prolonged unexplained intermittent upper back pain in the dorsal region. She was diagnosed as a case of aggressive VH after ruling out other infective and malignant pathologies and treated with decompressive therapy. The present case highlights the role of imaging studies such as computed tomography and magnetic resonance imaging in such conditions.

Blood Loss in Surgery for Aggressive Vertebral Haemangioma with and without Embolisation.

Despite their benign nature some symptomatic aggressive vertebral haemangiomas (AVH) require surgery to decompress spinal cord and/or stabilise pathological fractures. Preoperative embolisation may reduce the considerable blood loss during surgical decompression. This systematic review investigated whether preoperative embolisation reduced surgical blood loss during treatment of symptomatic AVH. PubMed Medline, Web of Science, and Ovid Medline were searched for case reports and clinical studies on surgical AVH treatment. Included were cases from all publications on surgical treatment of AVH where the amount of surgical blood loss and the use of preoperative embolisation were documented. 51 cases with surgically treated AVH were retrieved from the included studies. Blood loss in the embolised treatment group (980±683 mL) was lower than the non-embolised control group (1,629±946 mL). This systematic review found that embolisation prior to AVH resection reduced surgical blood loss (level of evidence, very low) and can be recommended (strong recommendation).

Total en bloc spondylectomy for locally aggressive vertebral hemangioma causing neurological deficits.

Vertebral hemangiomas are common; however, aggressive vertebral hemangiomas with extraosseous extensions causing neurological deficits are rare. The treatment for this subtype of hemangioma remains controversial, since there are few reports on long-term clinical outcomes or tumor recurrence rates. We describe a case of aggressive vertebral hemangioma treated by total en bloc spondylectomy, with a literature review focusing on long-term recurrence. A 52-year-old male with a two-month history of numbness in the bilateral lower extremities was referred to our hospital. Imaging studies showed a tumor originating in the T9 vertebra and extending to the T8 and T10 vertebrae, with extraosseous extension causing spinal-cord compression. Ten months after onset, the patient presented with progressive paraparesis and hypalgesia. Total en bloc spondylectomy was performed, and pathology was consistent with cavernous hemangioma. Motor and sensory deficits improved significantly, and no signs of recurrence are seen at 2.5 years after operation. A review of literature revealed a recurrence rate of 12.7% (10/79 cases). The available evidence indicates satisfactory long-term outcomes for total tumor resection without adjuvant radiotherapy.

Type IV Aggressive and Symptomatic Vertebral Hemangioma

Vertebral hemangiomas (VHs) are benign tumours with rich vasculature. They are the most common tumours of the spine with an estimated incidence of 10% - 12% of the population. Despite its high incidence, they are often asymptomatic and only 0.9% - 1.2% are symptomatic. They may also be aggressive and are characterised by bone expansion, extra osseous extension of the tumour, disturbance of local blood flow and, in rare cases, compression fractures. We report a 59-year-old woman, presented with back pain after falling from standing height. Magnetic resonance imaging revealed lumbar spine vertebral fractures and T12 osteolytic lesion with spinal canal extension, concurring to VH type IV, according to Tomita’s surgical classification of spinal. Embolization, posterior decompression and fixation were performed followed by postoperative radiotherapy. Her symptoms were resolved immediately without recurrence after 6 mouths.

A systematic approach to vertebral hemangioma.

Vertebral hemangiomas (VHs) are a frequent and often incidental finding on computed tomography (CT) and magnetic resonance (MR) imaging of the spine. When their imaging appearance is "typical" (coarsened vertical trabeculae on radiographic and CT images, hyperintensity on T1- and T2-weighted MR images), the radiological diagnosis is straightforward. Nonetheless, VHs might also display an "atypical" appearance on MR imaging because of their histological features (amount of fat, vessels, and interstitial edema). Although the majority of VHs are asymptomatic and quiescent lesions, they can exhibit active behaviors, including growing quickly, extending beyond the vertebral body, and invading the paravertebral and/or epidural space with possible compression of the spinal cord and/or nerve roots ("aggressive" VHs). These "atypical" and "aggressive" VHs are a radiological challenge since they can mimic primary bony malignancies or metastases. CT plays a central role in the workup of atypical VHs, being the most appropriate imaging modality to highlight the polka-dot appearance that is representative of them. When aggressive VHs are suspected, both CT and MR are needed. MR is the best imaging modality to characterize the epidural and/or soft-tissue component, helping in the differential diagnosis. Angiography is a useful imaging adjunct for evaluating and even treating aggressive VHs. The primary objectives of this review article are to summarize the clinical, pathological, and imaging features of VHs, as well as the treatment options, and to provide a practical guide for the differential diagnosis, focusing on the rationale assessment of the findings from radiography, CT, and MR imaging.

Aggressive vertebral hemangioma as a rare cause of myelopathy

Vertebral hemangiomas (VHs) are common lesions in the adult population. They are usually asymptomatic and found incidentally on radiological imaging. New-onset back pain followed by subacute progression of thoracal myelopathy is the most common presentation in patients with neurological deficit. Differential diagnoses would include metastasis, multiple myeloma, lymphoma, Paget disease, osseous tumors such as Ewing sarcoma or hemangioblastoma and blood dyscrasia. We present a 41 year-old-male patient with thoracal VH causing myelopathy that completely improved after rehabilitation program with embolization and vertebroplasty procedures.

A Rare Cause of Myelopathy; Aggressive Vertebral Hemangioma

A Rare Cause of Myelopathy; Aggressive Vertebral Hemangioma

Aggressive Vertebral Hemangioma Treated with Combination of Vertebroplasty and Sclerotherapy Through Transpedicular and Direct Approach

Aggressive Vertebral Hemangioma Treated with Combination of Vertebroplasty and Sclerotherapy Through Transpedicular and Direct Approach

Percutaneous ethanol embolization and cement augmentation of aggressive vertebral hemangiomas at two adjacent vertebral levels

This report describes a case of successful percutaneous direct-puncture ethanol embolization, followed by vertebroplasty, of an aggressive vertebral hemangioma (VH) involving two adjacent thoracic vertebral levels. In this case, the 78-year-old male patient presented with a 6-month history of progressive paraparesis due to spinal cord compression by a T8-T9 VH with an extensive epidural component. Follow-up demonstrated epidural component shrinkage with complete regression of symptoms at 3 months. This case suggests that exclusive percutaneous treatment may be considered for symptomatic VH even when two adjacent vertebral levels are affected.

Novel use of propranolol for management of pain in children with vertebral hemangioma: report of two cases

Vertebral hemangioma (VH) is an exceedingly rare neoplasm in pediatric population with less than 10 cases reported in the literature. It is usually asymptomatic in adults and diagnosed incidentally at radiographic investigations of other medical conditions. In this report, we describe two children who presented to our institution with severe back pain and were diagnosed with VH. Case 1 was an 8-year-old male with a pain score of 10 out of 10 at presentation. Clinical investigations eliminated the possibility of a neoplasm or infectious process and MRI findings were highly suggestive of an aggressive vertebral hemangioma. Case 2 was a 17-year-old female who presented with back pain radiating to shoulders. Her pain score was 4 out of 10 and she was diagnosed with vertebral hemangioma due to the specific findings on MRI studies. Both patients received propranolol with a dose of 20 and 40mg per day, respectively. They were free of pain at 2months follow-up. There are different invasive treatment modalities for the management of VH, including vertebroplasty, kyphoplasty, radiotherapy, alcohol injection, embolization, and surgery. These methods have been used in adult patients for several years, but each of them has potential risks which make these options unsuitable for children. Propranolol is a beta blocker which is safely used in the management of infantile hemangiomas. This is the first report demonstrating its efficacy in symptomatic treatment of childhood VH. The lesions did not show any regression, but the pain relief obtained was very significant under propranolol therapy.

Outcome of dorsolumbar vertebral hemangiomas presenting with neuraxial compression

Background:Hemangiomas are benign vascular tumors associated with proliferation of blood vessels in bone or soft tissue and they are usually incidental findings in vertebrae. When symptomatic, they present with features of radiculopathy, myelopathy, or vertebral fractures. Treatment options are varied, include sole embolization, embolization combined with surgical excision, surgical excision alone, percutaneous ablation, and radiotherapy. We hereby describe a series of seven cases of symptomatic vertebral hemangiomas operated from 2006 to 2009.Materials and Methods:Their clinical and radiological profile and outcome have been described. All patients were subjected to surgical excision followed by instrumentation. Outcome was assessed at a followup of 2 years following surgery with Frankel grading system.Results:Seven patients (five females and two males) were included in the study. The mean age was 33.85 years with the mean duration of symptoms of 12 months. All seven cases were symptomatic vertebral hemangiomas with cord compression and underwent surgical excision. Preoperatively, patients with poor Frankel grade such as A and B improved postoperatively to C, D, or E.Conclusion:Surgical excision of these lesions is difficult due to the tremendous amount of intraoperative bleeding. During surgery, brisk bleeding is usually encountered, but can be brought under control with adequate preoperative preparation and expertize. Preoperative embolization may help to reduce the bleeding, but at times it may be difficult to do if vertebrae are replaced by a solid hard mass. In spite of the risks associated with surgery, it still is the treatment of choice as a single intervention, especially in aggressive vertebral hemangiomas.

Expert’s Comment concerning Grand Rounds case entitled “Aggressive vertebral hemangioma of the thoracic spine without typical radiological appearance” (Lei Dang, Chen Liu, Shao Min Yang, Liang Jiang, Zhong Jun Liu, Xiao Guang Liu, Hui Shu Yuan, Feng Wei, Miao Yu)

Although symptomatic aggressive vertebral hemangiomas are relatively rare, it is not unusual to encounter a case every few years in a tertiary spine practice. There are very few spinal lesions that have such a broad array of treatment options (observation, radiation therapy, radiosurgery, embolization, alcohol injection, vertebroplasty, kyphoplasty, laminectomy, intralesional resection, total en bloc spondylectomy and combinations of these treatments) with essentially no consensus in the literature regarding which is most appropriate and in which clinical circumstances. Although these lesions appear extremely hostile on imaging, it is important to remember that the histology is benign. This patho-radiologic contradiction may explain much of the variation in treatment. The authors describe a case of a 41-year old physician who presented with back pain and left thoracic radiculopathy due to aggressive vertebral hemangioma at T5 [1]. Although there was spinal cord compression, the patient had no weakness or numbness in her lower extremities. I want to congratulate the authors for successfully alleviating the symptoms with surgery. There was no recurrence 12 months after radiation therapy.

Aggressive vertebral hemangioma of the thoracic spine without typical radiological appearance

Vertebral hemangioma (VH) is virtually vascular malformation, which is usually asymptomatic. Only 3.7% of VH may become active and symptomatic, and 1% may invade the spinal canal and/or paravertebral space. Treatment protocols for active or aggressive VHs are still in controversy. Reported treatments include radiotherapy, vertebroplasty, direct alcohol injection, embolization, surgery and a combination of these modalities. A 41-year-old lady was presented with 18month history of intermittent back pain. CT revealed T5 osteolytic lesion with epidural and paravertebral extension. The first CT guided biopsy yielded little information. Histopathological diagnosis of the second biopsy was VH. Vertebroplasty, posterior decompression and fixation were performed followed by postoperative radiotherapy. Her symptoms were resolved immediately after the operation. At 12months follow-up, no recurrence was detected by CT with contrast enhancement. Surgical decompression, vertebroplasty and fixation are safe and effective for aggressive VH. More attention is needed in determining the algorithm for the diagnosis and treatment of aggressive VH.

Cervical Spinal Brucellosis: A Diagnostic and Surgical Challenge

Vertebral Haemangiomas (VHs) are frequent and generally asymptomatic benign tumors, involving the spine, usually incidentally found on computed tomography and magnetic resonance. Despite being usually asymptomatic and quiescent lesions, VHs can occasionally manifest aggressive features, leading to clinical manifestations such as back pain and neurological deficits.Case report.We report a case of a 54-year-old man, presented with 5 months history of pain, associated with lower limbs paraesthesia and weakness, gait disturbance and episodes of accidental falls. Radiological evaluation by spine pre- and post-contrast MRI indicated multiple vertebral hypervascular lesions, compatible with haemangiomas, involving from T3 to T11 levels, showing several different features (typical and atypical); aggressive haemangioma radiological pattern may be valuable at T3 and T4 vertebras. A thoracic spine pre- and post-contrast computed tomography confirmed the radiological diagnosis of multiple aggressive haemangiomas.Aggressive VH consists in a very rare subset of vertebral haemangiomas characterized by a greater tendency in being symptomatic. They may show atypical radiological features, that make their diagnosis very complex. In the recent years, many strategies for treatment of symptomatic or aggressive VHs have been developed, but the optimal treatment strategy is still controversial.Although aggressive VHs being extremely rare, recognizing radiological features of these lesions is mandatory to achieve a correct diagnosis and appropriate therapeutic targets.

Treatment of Enneking Stage 3 Aggressive Vertebral Hemangiomas With Intralesional Spondylectomy

A retrospective review of consecutive series of Enneking stage 3 vertebral hemangiomas surgically treated at a major tertiary spine tumor center. To determine the short-term recurrence rates, pain improvement, and operative morbidity of intralesional spondylectomy combined with preoperative embolization for Enneking stage 3 vertebral hemangiomas. Aggressive vertebral hemangiomas (Enneking stage 3) often involve both the anterior and posterior columns with spinal canal and local soft tissue extension and may present with dramatic bony destruction, spinal instability, and pain accompanied with neurologic compromise. Although the current treatment paradigm for most vertebral hemangiomas is conservative management directed toward symptomatic relief, the subset of patients presenting with this rare variant requires more extensive surgical treatment. A retrospective clinical review of patients diagnosed with Enneking stage 3 vertebral hemangiomas was conducted at the University of California at San Francisco. We identified 10 consecutive cases of Enneking stage 3 hemangiomas. Average follow-up was 2.42 years. The most common presentation was pain with or without myelopathy. Three of the 10 cases were recurrences after prior partial resection and reconstruction or cement augmentation. All patients underwent preoperative embolization. Average blood loss despite embolization was 2.1 L (range: 0.8 to 5 L). Average preoperative back pain visual analog scale was 7.2 and postoperative visual analog scale was 3.1 at 6 months. On postoperative imaging, all patients had gross total resection. Six patients had staged posterior/anterior transcavitary approach and 4 patients underwent single stage posterior transpedicular spondylectomy. To date, no patient has required adjuvant radiation therapy for tumor recurrence. Our results suggest that complete wide resection of aggressive Enneking stage 3 lesions can be safely accomplished with acceptable morbidity and blood loss and significant improvement in pain and neurological status. Partial resection of stage 3 lesions, even with stabilization or vertebroplasty, may lead to early recurrence.

Management of Cement Vertebroplasty in the Treatment of Vertebral Hemangioma

The vertebral hemangiomas are benign vascular lesions occurring in spine. Although uncommon, symptomatic vertebral hemangiomas can be painful and can limit daily activities. A number of methods have been used in the treatment of symptomatic and aggressive vertebral hemangioma, but none of them is optimal. Treatment with cement vertebroplasty showed very good results. This study aims to illustrate the validity of the treatment with cement vertebroplasty in patients with painful vertebral hemangiomas. From January 2000 to January 2007, 24 patients were treated by percutaneous vertebroplasty because of hemangioma: 16 thoracic, 8 lumbar. There were 11 males and 13 females. The average age at the time of surgery was 48 years. All the patients complained of a pain syndrome resistant to continuing medication. All patients underwent X-ray examination, CT-scan and MR of the involved level preoperatively. A unipedicular approach under fluoroscopic guidance has been performed in all patients. All procedures have been carried out under the local anesthesia. The mean follow-up was 5.8 years. In all the patients a successful outcome has been observed with a complete resolution of pain symptom. Extravertebral vascular cement leakage has been observed in 3 patients, without any clinical radicular syndrome onset due to the epidural diffusion. Clinical and radiological follow-up showed stability of the treatment and absence of pain in all patients. Percutaneous treatment with vertebroplasty for symptomatic vertebral hemangiomas is a valuable, less-invasive, and a quick method that allows a complete and enduring resolution of the painful vertebral symptoms without findings of the vertebral body's fracture.

Clinical and imaging findings in patients with aggressive spinal hemangioma requiring surgical treatment

Vertebral hemangiomas (VHs) are frequently asymptomatic lesions found incidentally during investigations for other spinal problems. Symptomatic VHs are less common, and there are few reports of compressive VHs in the literature. VHs with aggressive behavior present with low signal intensity on T1-weighted and high signal intensity on T2-weighted MRI. We present a case series of four patients with compressive VH, all of whom were neurologically compromised. Each of the four patients underwent preoperative arterial embolization followed by surgical treatment of their VHs. All patients recovered normal motor function after surgery. At follow-up (average 53 months), one patient had a recurrent tumor requiring reoperation and radiotherapy. Although it is rare, aggressive VH can be a devastating condition. Total surgical resection or subtotal resection with radiotherapy may be warranted.

Vertebral Hemangioma

A case report and a discussion of recent published data. To highlight the importance of vertebral hemangioma (VH) as a differential diagnosis in the evaluation of locally aggressive spinal lesions. VH commonly occur as incidental findings, however, locally aggressive VH have been described. Difficulties in diagnosing these lesions are well reported and relate to changes in fat content causing uncharacteristic appearances on imaging. The management options for these lesions include a combination of observation, embolization, sclerotherapy, surgical decompression, or stabilization and radiotherapy. A 45-year-old patient who was previously well presented with back pain and rapidly progressive paraparesis. Imaging confirmed the presence of an extensive lesion centered within the right T3 vertebral pedicle with intrusion into the spinal canal. Urgent surgical decompression was undertaken and was complicated by extensive intraoperative hemorrhage requiring massive transfusion. Histologically, the lesion was shown to be a cavernous VH with no evidence of malignancy. Following radiation oncology review, he was offered adjuvant radiotherapy to minimize the risks of recurrence. He achieved a near full neurologic recovery within 2 weeks and had a full recovery by 12 months. VH should be considered in the evaluation of locally aggressive spinal lesions. Angiography is a useful adjunct in the evaluation of these lesions, both as a diagnostic and therapeutic tool. After diagnosed correctly a wide range of treatment options exist that may prevent the patient from undergoing major surgical resection and reconstruction procedures, which may be associated with high rates of morbidity.

Surgical management of aggressive vertebral hemangiomas causing spinal cord compression: long-term clinical follow-up of five cases

BackgroundAggressive vertebral hemangiomas causing spinal compression are rare, and there is controversy with regard to treatment. The purpose of this study was to evaluate the clinical results of patients with aggressive vertebral hemangiomas at a mean follow-up of more than 10 years after total excision and discuss the treatment options for the tumors. MethodsWe performed a retrospective review of patients with aggressive vertebral hemangiomas who were treated with total excision. The surgeries were carried out on five patients (average age 47 years). In all five patients, the tumor was in the thoracic spine and was causing myelopathy with extraosseous extension. There were three tumors of type 5 and two of type 6 according to Tomita’s surgical classification of spinal tumors. The tumors were assessed using magnetic resonance imaging (MRI), and the clinical results were evaluated. ResultsAll of the tumors showed low-intensity or low-isointensity signal on T1-weighted MRI. All five patients had a combination of preoperative transarterial embolization and total excision including tumor margin. Total en bloc excisions were performed in two patients. En bloc and piecemeal combined total excisions were performed in two patients. Piecemeal total excision was performed in one patient. Intraoperative blood loss ranged from 1580 to 3400ml (mean 2424ml). There were no perioperative complications. According to the Japanese Orthopaedic Association score, the myelopathy improved after the surgery from 5.3 ± 2.9 to 9.8 ± 1.7 (total of 11 points). None of the patients have had a recurrence at a mean followup of 135.2 months (range 92–163 months). ConclusionsWe performed a combination of preoperative transarterial embolization and total excision for aggressive vertebral hemangiomas with extraosseous extension that were causing spinal cord compression in all five cases. The results in the long-term follow-up have proved satisfactory.

Unusual Cause of Back Pain in an Adolescent Patient: A Case Report and Natural History of Aggressive Vertebral Hemangioma in Children

Back pain is an unusual complaint in children as compared to the adult population but is more likely to be pathological. We present a longitudinal study of an 11-year-old patient who presented with a vertebral hemangioma which remained stable for a period of about 20 months followed by aggressive growth resulting in spinal cord compression. This is only the fourth reported case of aggressive vertebral hemangioma in children; however, we document for the first time the evolution of this lesion demonstrating a period of stability followed by aggressive growth of the lesion. We discuss the imaging differential diagnosis which includes asymptomatic vertebral hemangioma and malignant lesions. We also discuss different treatment options available and their complications. In our patient, among the risk factors for an aggressive hemangioma, female gender and involvement of posterior elements were positive. However, the natural history of this lesion is not well known in children. We need to study vertebral hemangioma further especially in children to understand the natural course and help identify lesions which have aggressive potential and prevent spinal cord compression. This will also help to manage the lesion earlier with less aggressive therapies such as embolization and ethanol injection rather than surgery.