Vertebral hemangioma (vertebral angioma)

 

Vertebral hemangioma (vertebral angioma)

Vertebral hemangioma (vertebral angioma) is the most common benign tumor of the spine. Vertebral angiomas are usually asymptomatic and found incidentally (by their characteristic external features) during the diagnosis (MRI, CT, x-ray) for other diseases and pathological conditions (back pain, infection or spinal injury, etc.). Vertebral hemangioma is a benign tumor, which most often meet in the middle (thoracic) and lower (lumbar) spine.

 

Vertebral hemangiomas epidemiology

Vertebral hemangioma are very common and occur in about 10% of the population (on the basis of autopsies). Most hemangiomas detected with standard spine radiographs. Often, the small size of the hemangioma cannot be detected on radiographs and are revealed with more modern methods of diagnostics imaging, such as vertebral CT or vertebral MRI, or at autopsy. Hemangiomas formed most often in adults aged 30 to 50 years. The incidence of hemangiomas, for unknown reasons, most prevalent among women and the most symptomatic in the 4th decade of life.

Magnetic resonance imaging of the spine (MRI) shows hemangiomas soft tissue components.

 

Vertebral hemangiomas clinical presentation

Most hemangiomas during the life are asymptomatic. The vertebral body destruction or impact on near located intervertebral foramen (nerve root exit from the spinal canal) is the most common cause of the pain symptom in patients. Increased physical activity (exercises, home appliances, etc.) can cause the pain. It is most often associated with increased axial load on the vertebral body affected by a tumor. In most cases of vertebral hemangioma, do not induce any symptoms. Symptomatic vertebral hemangiomas occurrence for less than one percent of all hemangiomas cases and are more common in women than in men. In the absence of timely treatment of patient with symptomatic vertebral hemangioma in the future may cause a serious neurological disorder.

 

Vertebral hemangiomas symptoms

Most of hemangiomas are asymptomatic, but in symptomatic case they may manifest as:

• back pain
• pain spreading along the nerve due to inflammation or irritation of the spinal nerve
• symptoms of spinal cord compression

 

Vertebral hemangiomas pathophysiology

Vertebral hemangiomas composed from vascular cavities, which due to its volume can cause displacement of the surrounding bone tissue. In rare cases, especially in capillary type hemangioma, can be observed lytic erosion of the vertebra in to the epidural space direction. Most of vertebral hemangiomas grow slowly and asymptomatically.

Most hemangiomas occur in the thoracic spine, but also can be found in other sections of the vertebral spine.

 

Vertebral hemangiomas diagnosis

Vertebral hemangiomas radiographic features

If hemangioma suspected, the doctor orders spine x-rays, to check for typical vertebral body’s bones changes (spongy tissues trabecular pattern). Trabeculae represent the framework structure in a vertebral body’s bone. Spine radiography revealed a classical picture of “corduroy cloth”, which is characteristic for hemangioma.

Computed tomography of the spine (CT) reveals changes in vertebrae hemangioma case.

 

Vertebral hemangiomas computed tomography (CT)

Computed tomography of the spine (CT) on axial slice reveals petechial spots, similar in appearance to a “polka dot”, that occur because of the vertebral bodies trabeculae thickening. If this changes reveals, the next diagnostic test is magnetic resonance imaging of the spine (MRI) to show is it tumor spread on the vertebral spine, into the spinal canal or causes spinal cord compression.

Computed tomography of the spine (CT) on axial slice reveals petechial spots, similar in appearance to a "polka dot"

 

Vertebral hemangiomas magnetic resonance imaging (MRI)

Magnetic resonance imaging of the spine (MRI) shows hemangiomas soft tissue components (like fat and water) better, than computer tomography (CT). Vertebral body’s thickened trabeculae visualized on the MRI images in the form of a low signal in T1 and T2 sequences:

• T1 sequence — a high intensity signal from hemangiomas due to the presence of fat component
• T2 sequence — bright/high intensity signal from hemangiomas (usually more than in T1 sequence), in connection with high water content
• T1 C+ sequence (with contrast) — shows a significant improvement due to the high vascularization of hemangiomas

Differential diagnosis of vertebral hemangioma must be distinguished from malignant tumors metastases from other organs and tissues.

Tumors metastasis on the images obtained by magnetic resonance imaging of the spine (MRI) usually have low intensity signal in T1 and high intensity signal in T2 sequence.

Spine MRI can also show the of spinal nerves damage degree and may help in planning of patients following surgical treatment.

Vertebral body’s thickened trabeculae visualized on the spine MRI images (arrows).

 

Aggressive vertebral hemangioma

Unlike common vertebral hemangiomas, aggressive hemangioma can expand inside the vertebral body, penetrate into paravertebral soft tissue and reach the spinal canal, causing the spinal cord compression or vertebrae’s pathological fractures.

On spine MRI tumor may resemble metastases, but the presence of thickened trabeculae in the affected vertebral bodies allows differentiate aggressive hemangioma from other malignancies.

Computed tomography of the spine (CT) is more sensitive method than MRI to describe the typical changes in the bones with aggressive hemangioma, such as pinpoint foci of sclerosis, or inclusions of the “polka dot” on the transverse (axial) images, and vertical lines like a "corduroy cloth", "jail bars" or "honeycomb" on sagittal images.

Computed tomography of the spine (CT) reveals vertical lines like a "corduroy cloth", "jail bars" or "honeycomb" on sagittal images (arrows).

 

Vertebral hemangiomas treatment and the subsequent prognosis

For most identified hemangiomas treatment is not required. Treatment is necessary when the patient has symptoms of neurological deficit or severe pain symptom. In the case of these symptoms, there are several treatment options that selected individually: radiotherapy, balloon kyphoplasty or endovascular embolization of hemangioma with subsequent laminectomy, etc. For the open surgery serious complication can be bleeding, so care must be taken during the operation.

In the case of symptomatic hemangioma surgically removing operation (tumor’s resection from the affected vertebra) is indicated, and radiation therapy for the severe pain symptom treatment. In the tumor depth can also be performed ethanol injection (causes hemangioma tissue necrosis with subsequent scarring), or laminectomy surgery (for the spinal canal decompression).

Treatment of hemangioma depends on the size and location of the tumor. With timely use of procedures combination (hemangioma’s blood flow blocking (embolization), surgical removal and radiotherapy), can be achieved significant improvement in the patient's condition.

Radiation therapy is effective in the treatment of pain symptoms caused by vertebral hemangioma. In the treatment of pain symptom ethanol injection into the tumor is also effective (under fluoroscopic guidance). Another treatment option is tumor’s embolization by bone cement with the subsequent removal of the bones of the vertebral arches (laminectomy), or the complete removal of a vertebra (vertebrectomy) in the case of aggressive hemangioma.

 

If you have any questions on the diagnosis or treatment of vertebral hemangioma and aggressive vertebral hemangioma, you can ask them to our neurosurgeon or neurologist: (499) 130–08–09