Vertebral hemangiomas are the most common benign vertebral neoplasms. They are usually asymptomatic and incidentally detected on imaging due to their characteristic hyperintense appearance on both T1- and T2-weighted MRI sequences. While typically asymptomatic, they can sometimes cause pain if large enough to compromise the structural integrity of the vertebral body. Distinguishing hemangiomas from metastatic lesions is important, as hemangiomas will appear hyperintense on both T1- and T2-weighted images unlike metastases.

1. Vertebral
hemangioma
Prof. Ahmed El-Gebaly
Presented by

2.  http://www.wallskid.com/c/atypical-hemangioma-
cervical-
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3. Vertebral Hemangioma
 Vertebral hemangioma is the most common spinal axis tumor.21
This benign vascular tumor of the vertebral body, often discovered
incidentally on imaging, can be associated with vertebral body
collapse and epidural extension with spinal cord compression; on
rare occasions, it may exhibit aggressive growth. MRI sequences
of the typical (fatty) hemangioma show lesions that are
hyperintense on T1-weighted and T2-weighted images, with robust
contrast enhancement). Vertebral hemangiomas are one of the very
few spinal tumors that show increased signal intensity on T1-
weighted images and T2-weighted images. Occasionally, such
lesions are more vascular and may appear isointense or
hypointense on T1-weighted images, making them difficult to
distinguish from metastases. Although CT images show the typical
“polka dot” appearance on axial images and the typical “corduroy”
or “jailhouse striation” pattern on sagittal images, secondary to the
thickened trabeculae, MRI is the best modality for characterizing
the epidural extent and cord compromise of aggressive lesions.
Although such lesions primarily involve the vertebral body, 10% to
15% have concomitant involvement of the posterior elements.
Multiple lesions are seen in 25% to 30% of patients.

4.  There are two very important things to know
about benign hemangiomas in the spine
 1. Distinguishing from cancer metastasis to the
spine
 2. Knowing the sequelae of a benign hemangioma
in the spine

5.  Distinguishing from Spinal Metastasis
 When you look at a patient’s MRI and spot lesions that have an increased signal
intensity on T2-weighted images (the most commonly viewed sequences by
interventional pain physicians), you may get worried that these could be
cancerous, especially if your patient also has a history of prostate / breast / lung /
renal / GI cancer.
 Before you get too worried, look at the same slices on the T1-weighted
images. Both osteoblastic and osteolytic metastatic lesions are typically hypo-
intense on both T1 and T2. For more detail, check out this
site: http://radiopaedia.org/articles/vertebral-metastases
 On the other hand, spinal hemangioma “light up” (hyper-intense) on both T1 and
T2.
 Hemangioma in the spine are WHITE on both T1 & T2
 Sequelae of Benign Hemangioma
 Pathologic Fracture: If these vertebral hemangioma get large enough and
weaken the vertebral body integrity enough, a pathologic compression fracture
can occur. So if a patient has a known large vertebral hemangioma at L1 and
develops pain in that area months or years later, suspect a compression fracture
and re-image them with an MRI with STIR sequences.
 Patient and Location Characteristics
 Benign (and usually asymptomatic) lesions located mostly in the lower thoracic or

6. Vertebral hemangioma
 Vertebral hemangiomas are the most common benign
vertebral neoplasms. They are usually asymptomatic
and incidentally detected due to their characteristic
features on imaging for other reasons.
 The incidence of vertebral haemangiomas is about
10% at autopsy 1. The majority of haemangiomas are
incidentally noted on routine radiographs of the spine.
Often, small haemangiomas cannot be visualized on
radiographs and are found with more advanced
imaging such as CT or MRI, or upon gross dissection.
The occurrence of vertebral haemangiomas are seen
slightly more in females for unknown reasons and are
more symptomatic in the 4th decade of life.

7.  Most haemangiomas are asymptomatic. Collapse of the
vertebral body or encroachment into the neural canal
are some of the classic causes of pain. An increase in
activity can cause the vertebral haemangioma to
become painful, such as starting to exercise,
housework and such. This is most likely due to axial
loading through the body of the vertebra.
 Pathology
 They are composed of vascular spaces which causes a
displacement of bone. In some cases, specifically
capillary types, lytic erosion into the epidural space can
occur, however rare 2. They are slow growing and most
are not symptomatic.
 Distribution
 The majority of all vertebral haemangiomas occur in the

8.  The classic “corduroy cloth” appearance is strongly
associated with vertebral haemangiomas.
 CT
 Axial CT will show a “polka dotted” appearance due to the
thickened vertebral trabeculae 3-4.
 MRI
 MRI shows extraosseous components better and depicts
the haemangioma components as fat and water. Thickened
trabeculae appear as low signal areas in both T1 and T2
images.
 T1: high intensity signal due to its fat component
 T2: bright/high intensity signal, usually greater than on T1,
due to its high water content
 T1 C+: with contrast, significant enhancement seen due to
high vascularity

9.  Differential diagnosis
 metastases : usually have decreased signal
intensity on T1 and increased signal intensity on T2

10.  From a strict radiological point of view, VHs can be
classified as typical, atypical, and aggressive (also
called compressive). This terminology should not be
confused with a histological classification, even
though the tissue structure of VHs is the basis of
these radiological types. The terms “typical” and
“atypical” refer primarily to the MR imaging
appearance, which is directly correlated with the
histopathological features (ratio of fatty to vascular
components and interstitial edema). The term
aggressive refers to the presence of radiological
features such as extension beyond the vertebral
body, destruction of the cortex, and invasion of the
epidural and paravertebral spaces.

13.  Typical vertebral haemangioma, hyperintense on both T1 and T2 weighted
images

14.  Primary intraosseous haemangiomas, also
referred to as vascular hamartomas, are
haemangiomas seen most frequently in the
vertebrae or skull, that come in four histological
varieties
 Intraosseous haemangiomas are common, with
vertebral haemangiomas seen in 10-15% of the
adult population. They are more commonly
encountered in men (M:F ratio of 2:1) and typically
seen in the 4th to 5th decade of life.
 Primary intraosseous haemangiomas are slow
growing vascular neoplasms, usually located in the
medullary cavity. They are classified as benign, but

15.  Intraosseous haemangiomas come in four histologic
types:
 intraosseous cavernous haemangioma
 intraosseous capillary haemangioma
 intraosseous arteriovenous haemangioma (may
represent congenital arteriovenous malformations) 2
 intraosseous venous haemangioma
 Histologically, intraosseous haemangiomas
demonstrate hamartomatous vascular tissue within
endothelium, but may also contain fat, smooth muscle,
fibrous tissue, and thrombi.
 It should be noted that it is difficult to distinguish
between the various histological types on imaging,

16.  Location specific sub types
 vertebral haemangioma
 sacral haemangioma
 skull vault haemangioma
 intracortical hemangioma

17.  Plain radiograph
 Plain radiographs are usually the first line of
imaging and may be sufficient in vertebral or
calvarial lesions. Findings include:
 prominent trabecular pattern
 sclerotic vertebra with vertical trabeculae: corduroy
sign
 lytic calvarial lesions with spoke-wheel appearance
 irregular and lytic in long bones, with a honeycomb
appearance

18.  CT
 Usually as an incidental finding, especially in the vertebrae.
 Better visualisation of thickened vertical trabeculation: polka-dot
appearance on axial images and corduroy sign on coronal and
sagittal images.
 MRI
 Signal intensity is somewhat variable, depending largely on the
amount of fat content.
 T1
 high is more common (fat rich)
 intermediate to low signal intensity is seen in fat poor haemangiomas
 T2: high
 T1 C+ (Gd): enhancement is often present
 STIR: intermediate or high
 MRI is the ideal modality to demonstrate mass-effect
complications, such as neural impingement and extraosseous
extension.

19.  Somewhat heterogeneous, spherical high T1 / high
T2 signal lesion in the C2 vertebral body

20.  T2- T2Fat sat

21.  Vertebral
Hemangi
omas
 T1 and T2
hyperinten
se lesions
in D6, D7
and L1
vertebrae.

22.  Sagittal T1 T2 and STIR images of lumbar region spine shows:
Degenerative changes marked at L4-5 with reduced height of disc
and degenerative intra discal vacume phenomenon. An abnormal linear
hyper intensity of an inter spinous odema noted at the same level.

23.  Baastrup’s Disease
Syn: Kissing Spines Disease, intraspinous odema, intraspinous neo-arthrosis.
Baastrup’s Disease is a type of pseudo / neo-arthrosis between adjacent spinous processes.
Common in lumbar region at L4-5.
Extreme forward flexion may result in supraspinous and intraspinous ligaments sprain with
development of a spur. Repeated extension interferes with the healing. An interspinous bursae
may develop due to an associated supraspinous ligament laxity and intraspinous ligament
breakdown. The interspinous ligament degenerates with aging resulting in the formation of a
cavity, the adjacent spinous processes keep coming in contact with each other during
extension and result in formation of a joint which precede pain.
Risk Factors are degenerative disc disease, Athletics, Hyper lordosis, Paraspinal muscle
atrophy, Pars interarticularis defect.
Clinically characterized by localized interspinous or spinous process pain without a referral
pattern, pain present for many years with progressive worsening over time.
Imaging:
Lateral view LS spine radiograph may demonstrate sclerotic changes or flattening of adjacent
spinous processes.
MRI sagittal T2 and STIR images are needed assess interspinous edema.
Bone scan with SPECT can detect increased osteoblastic activity that is associated with
reactive sclerosis.
Treatment: Bed rest in semi upright sitting position, Surgical cavity resection, Surgical fusion.

26. ‫ال‬‫ا‬‫له‬‫ا‬‫ال‬ ‫ن‬‫ا‬‫شهد‬‫ا‬ ‫وبحمدك‬ ‫اللهم‬‫سبحانك‬
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