Hepatic hemangioma is the most common benign liver tumor. It is composed of vascular channels of various sizes lined with endothelium and fibrous tissue. Imaging plays an important role in diagnosis. On ultrasound, hemangiomas appear hyper echoic but can also appear hypoechoic, especially in fatty livers. On CT and MRI, hemangiomas enhance gradually from the periphery inward over time following contrast administration. While typically benign, giant hemangiomas over 4cm can potentially cause complications and may require treatment with transarterial embolization. Differential diagnoses include other liver lesions that appear similar on imaging.

1. Hepatic hemangioma
Dr.Tanzilur Rahman
Resident,Phase-B
BSMMU

3.  Commonest benign hepatic tumour.
 Multiple Haemangioma-10% cases.
 Composed of vascular channels of various sizes
(cavernous to capillary) lined with endothelium
often with intervening fibrous tissue of variable
amount.
 80% in female

7. Imaging
 R/F: USG :Homogeneous hyper echoic lesion (80 % )
 Hypo echoic lesion 10% especially in fatty liver.
 Some adult and most neonatal and infantile H. are cavernous
type, which are hypoechoic. (As larger vascular channels).
 Giant H. are heterogenous.
 Post .acoustic enhancement –common.
 No detectable signal in Doppler USG.

9. Hyperechoic area at the bifurcation of portal vain

10. Hypoechoic nodule in right lobe with echogenic border.Background fatty liver is noted.

11. CT scan
 Well defined, lobulated lesion (hypo dense) in
pre-contrast scan .
 After contrast nodular heterogeneous peripheral
enhancement with progressive centripetal fill-in &
eventually merging with back ground parenchyma is
seen.

20. MRI
 Most specific and sensitive method for DX.
 T1W-hypointense
 T2W-hyperintense(light bulb sign
 After I/V Gd –DTPA-rapidly enhanced their periphery. Then
centripetally to become isointense with the adjacent
parenchyma.

23. Figure 35.26
Haemangioma. Typical
appearance of
enhancement following
IV gadolinium with initial
peripheral nodular high
signal vessel signal
followed by progressive
infilling of the lesion.
Images obtained at 40 s,
120 s, 5 min and 15 min
following injection.

24. Types
Capillary
Cavernous
Sclerosed

25. Capillary haemangioma
Known as fast flow haemangioma.
Accounts for 16% of all haemangiomas.42% are under 1cm in diameter.
USG:
Most often hypoechoic and homogenous(due to predominant fibrous stroma and fast
flow).
CT:Slightly hpodense in NECT. Enhancement kinetics is rapid.An early ,intense,homogenous
contrast is observed by flash similar to the aortic enhancement in arterial phase.Late,this
enhancement follows that of the aorta,without washing.
MRI:Homogenous and high intensity signals on T2WI images as well as a contrast kinetics
similar to that seen in CT.

27. Cavernous haemangioma
Most common sub-type and corresponds to classic description of
haemangioma in imaging.
Consists of large vascular spaces with a central cavernous zone.
In general ,This typical appearance is observed in lesions less than 3cm in
diameter.

29. Sclerosed haemangioma
 Degeneration with an extensive fibrosis, beginning at the centre of the lesion, at the origin of the
obliteration of vascular spaces.Also called thrombosed or hyalinsed haemangioma.
 USG:Heterogenous lesion with hypoechoic zones that may correspond to sclerotic zone in
histology.
 CT:Focal patches are observed that are more spontaneously hypodense than rest of the
lesion,also corresponding to sclerotic zones.
 MRI:T2W heterogenous signal with central hypointense zone is seen.
 Enhancement pattern is slow with a peripheral nodular enhancement,similar to cavernous
haemangioma.

32. Giant haemangioma
Controversial term since some authors consider as giant lesions measuring
4cm,6cm and even>12cm in diameter.
On non contrast images they are usually heterogenous hypoattenuated mass
with central areas of low attenuation.
Contrst filling may be slow and central portion may never demonstrate
complete contrast fill in.
Potential complication includes
Mass effect on adjacent structure
Kasabach Merritt Syndrome(A form of consumptive cagulopathy)
Rupture with haemoperitoneum

39. Flash haemangioma

41. Treatment

43. Transcatheter arterial embolisation
Done by trained and experienced radiologists.
Microcatheter is placed into feeding artery.
Mixure of pingyangmycin,bleomycin,iohexol,lipiodol is
injected until periphery of haemangioma is surrounded.

44. Fluoroscopic image:Deposited lipiodol completely surrounding the haemangioma

45. A.Before TAE B.After 3 months of TAE C.After 6 months of TAE.

46. Differentials

48. Looks like haemangioma but not HAEMANGIOMA

50. Not all lesions with blood pool are haemangioma .we should consider peliosis
hepatis,haemangioendothelioma and liver sarcoma

51. Haemangioma diagnosis :How to do it right