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e-CASES: Aggressive vertebral angioma of T6

Channel Musculoskeletal

History

Back pain in a 80 year-old female

Findings

Figure 1. Pre-contrast magnetic resonance imaging (MRI) of the dorsal spine

a)     Axial T1, showing the oedematous signal of T6 vertebral body with  low-signal intensity T1

b) Axial STIR and @9.6 Sagittal STIR, confirming the oedematous signal of T6 with high signal intensity STIR involving the vertebral body and the right pedicle, with extension into  right paravertebral space. The expansile osseous lesion extends into right paravertebral space and anterior epidural space

@21.6 post-contrast magnetic resonance Imaging : Axial contrast-enhanced fat-saturated T1 weighted MR showing intense enhancement of the body of T6, anterior epidural space and right paravertebral space.


Diagnosis

Aggressive vertebral angioma of T6


Discussion

DEFINITION

Vertebral hemangiomas are common lesions which are usually considered to be bone lesion and benign. The prevalence increases with age, with a slight female predilection. They are commonly asymptomatic and limited to the vertebral body. Nevertheless a rare subset of them are characterized by extra-osseous extension, bone expansion and referred to as aggressive hemangiomas. They can cause spinal cord or nerve roots compression. They generally occupy the entire vertebral body, extend into the neural arch, expand the osseous margins, and contain a soft tissue component.

 

CHARACTERISTIC CLINICAL FEATURES AND RADIOLOGIC FINDINGS

Usually, vertebral angioma shows an increased signal on T1- and T2-weighted magnetic resonance (MR) images, relative to the fatty component, with classic vertebral trabecular pattern. Low signal intensity is seen in active lesions, which is the case here. The agressive hemangioma is suspected when the lesion is located in the dorsal spine (from D3 to D10), expands the osseous margins, extends into  the root of arch, epidural and paravertebral space, with intense enhancement.

Radiographic and CT can easily diagnose the angioma, showing  a polka-dot appearance, with reinforced trabeculae.


DDx

Differential diagnoses below can be considered:

  • metastatic lesion, which usually have low signal on T1 weighted images and high signal on T2 weighted images.
  • Paget’s disease of the spine can also  have a similar appearance.
  • Lymphoma may also have a similar appearance but is usually distinguished by homogeneous enhancement on contrasted MRI

CT aids in diagnosis solving, since the modality is more sensitive to the characteristic osseous remodeling, showing thickening of vertically striated trabeculae


References

  1. Schrock W B,Wetzel R J, Tanner S C, Khan M A. Case report : Aggressive hemangioma of the thoracic spine. J Radiol Case Rep. 2011; 5(10): 7–13.
  2. Ross JS, Masaryk TJ, Modic MT, Carter JR, Mapstone T, Dengel FH. Vertebral hemangiomas: MR imaging. Radiology. 1987 Oct;165(1):165-9
  3. Rodallec MH, Feydy A, Larousserie F, Anract P, Campagna R, Babinet A, Zins M, Drapé JL. Diagnostic imaging of solitary tumors of the spine: what to do and say. Radiographics. 2008 Jul-Aug;28(4):1019-41


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