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Vertebral Haemangioma

Summary

  • Benign vascular tumour of the spine, composed of thin-walled blood vessels and fatty tissue
  • Usually asymptomatic, incidentally found on imaging
  • Characteristic "polka-dot" appearance on CT and hyperintense signal on T1-weighted MRI1

Pathophysiology

  • Hamartomatous lesion of vascular origin
  • Composed of:
    • Thin-walled blood vessels
    • Fatty tissue
    • Fibrous stroma
  • Slow-growing, with potential for expansion and bone remodeling
  • Rarely causes vertebral body expansion or extraosseous extension

Demographics

  • Prevalence: 10-12% of the general population
  • Most common in adults aged 30-50 years
  • Slight female predominance
  • Can occur in any vertebra, but most common in:
    • Thoracic spine (60-70%)
    • Lumbar spine (20-30%)
    • Cervical spine (rarely affected)

Diagnosis

  • Often asymptomatic and incidentally discovered on imaging
  • Symptomatic cases may present with:
    • Local pain
    • Radiculopathy
    • Myelopathy (in cases of spinal cord compression)
  • Physical examination usually unremarkable
  • Differential diagnosis includes:
    • Metastatic disease
    • Multiple myeloma
    • Lymphoma
    • Eosinophilic granuloma

Imaging

X-ray

  • Coarse vertical trabeculation ("corduroy" appearance)
  • Thickened trabeculae may create a "honeycomb" pattern

CT

  • Characteristic "polka-dot" appearance on axial images
    • Represents thickened trabeculae surrounded by low-density fatty tissue
  • Coarse vertical trabeculation on sagittal and coronal reconstructions

MRI

  • T1-weighted: Hyperintense signal due to fat content
  • T2-weighted: Hyperintense signal
  • STIR: Variable signal suppression depending on fat content
  • Contrast enhancement: Usually present, may be intense and homogeneous

Nuclear Medicine

  • Bone scintigraphy: Usually photopenic ("cold") lesion
  • FDG-PET: Typically low uptake

panels-1

  • An incidental finding in the L2 vertebral body was T1- and T2-hyperintense, due to fat content, and hypointense on STIR. CT showed the classical trabecular thickening of a hemangioma.

Treatment

  • Almost always incidental and left alone. "Aggressive" hemangiomas (low fat, epidural extension, cord compression) may need embolisation, vertebroplasty, radiotherapy or surgery
  • The T1-bright "polka-dot"/"corduroy" trabecular pattern is diagnostic

Differential diagnosis

Differential Diagnosis Differentiating Feature
Metastatic disease Multiple lesions with destructive appearance; T1 hypointense and STIR hyperintense; no trabecular pattern
Multiple myeloma Diffuse osteopenia; punched-out lytic lesions without sclerotic rim; no characteristic trabecular pattern
Lymphoma Permeative pattern with soft tissue mass and epidural extension; no trabecular "polka-dot" appearance
Paget's disease Coarsened trabecular pattern with bone enlargement and cortical thickening; "picture frame" appearance on plain film
Enostosis (bone island) Smaller, dense sclerotic focus without trabecular pattern; no T2 signal change
Osteoblastoma Expansile lytic lesion typically in posterior elements; variable enhancement; no trabecular pattern
Aneurysmal bone cyst Multiple fluid-fluid levels on MRI; expansile thin-cortical shell; no trabecular pattern
Giant cell tumour Eccentric location with soap-bubble appearance; extends to articular surface; no trabecular "corduroy" pattern
Osteoid osteoma Small lesion with dense nidus and surrounding sclerosis; NaF PET avid; typically in posterior elements
Tuberculosis (Pott's disease) Disc space involvement with end-plate erosion; paraspinal and psoas abscess; no preserved disc height

  1. Subramaniam et al. Management of Aggressive Vertebral Haemangioma and Assessment of Differentiating Pointers Between Aggressive Vertebral Haemangioma and Metastases - A Systematic Review. 2023. Global spine journal - Open in new tab. ↩