CT Findings of a Thoracic Vertebral Hemangioma Presenting with Acute Neurological Symptoms

Article (PDF Available)inTurkish neurosurgery 21(1):113-5 · January 2011with142 Reads
DOI: 10.5137/1019-5149.JTN.3278-10.2 · Source: PubMed
  • 17.74 · Ankara Atatürk Training and Research Hospital
  • 22.58 · Dışkapı Yıldırım Beyazıt Training and Research Hospital
  • 20.46 · Necmettin Erbakan Üniversitesi
Abstract
Vertebral body hemangiomas are benign lesions and account for 4% of all spinal tumors. The most common histological type is cavernous hemangioma. These tumors generally locate in the vertebral body as a solitary lesion. Multiple lesions are seen in approximately 25-30% of vertebral hemangiomas. Mostly they are asymptomatic and incidentally found with radiological studies. Symptomatic vertebral hemangiomas are rare and represent < 1% of all hemangiomas; however, if untreated, they may cause local or radicular pain and neurological deficits ranging from myeloradiculopathy to paralysis. In this case we aim to present preoperative and postoperative Computed Tomography findings of a cavernous hemangioma that caused sudden motor deficit and was localised to the thoracic vertebra corpus and posterior elements.
Turkish Neurosurgery 2011, Vol: 21, No: 1, 113-115 113
Case Report
CT Findings of a oracic Vertebral Hemangioma
Presenting with Acute Neurological Symptoms
Akut Nörolojik Semptomlar Gösteren Torakal Vertebral Hemanjiyomunun
BT Bulguları
Sinan TAN
1
, Aydın KURT
1
, Ozerk OKUTAN
2
, Suat KESKIN
1
1
Ankara Ataturk Education and Research Hospital, Department of Radiology, Ankara, Turkey
2
Ankara Ataturk Education and Research Hospital, Department of Neurosurgery, Ankara, Turkey
Correspondence address: Sinan TAN / E-mail: drsinantan@gmail.com
ABSTRACT
Vertebral body hemangiomas are benign lesions and account for 4% of all spinal tumors. The most common histological type is cavernous
hemangioma. These tumors generally locate in the vertebral body as a solitary lesion. Multiple lesions are seen in approximately 25-30% of
vertebral hemangiomas. Mostly they are asymptomatic and incidentally found with radiological studies. Symptomatic vertebral hemangiomas
are rare and represent <1% of all hemangiomas; however, if untreated, they may cause local or radicular pain and neurological deficits ranging
from myeloradiculopathy to paralysis. In this case we aim to present preoperative and postoperative Computed Tomography findings of a
cavernous hemangioma that caused sudden motor deficit and was localised to the thoracic vertebra corpus and posterior elements.
KEYWORDS: Spine, Cord compression, Vertebral hemangioma, Computed tomography
ÖZ
Vertebral hemanjiyomlar benign lezyonlar olup tüm spinal tümörlerin %4’ üne neden olur. En yaygın histolojik tip kavernöz hemanjiyomdur.
Bu tümörler, genellikle vertebra cisminde yerleşen soliter lezyon şeklindedirler. Yaklaşık %25-30 olguda ise lezyonlar birden fazla sayıda
görülür. Çoğu asemptomatik olup görüntüleme yöntemleri ile rastlantısal olarak bulunur. Semptomatik vertebral hemanjiyomlar nadir olup
tüm hemanjiyomların %1 inden azını temsil ederler ancak tedavi edilmezse lokal yada radiküler ağrıya ve miyeloradikülopatiden paralize kadar
uzanan çok çeşitli nörolojik defisitlere neden olabilirler. Biz bu olguda torakal düzeyde vertebra korpusu ile posterior elemanları tutan, hızlı
motor defisite yol açan hemanjiyomun cerrahi öncesi ve sonrası BT bulgularını tartışmayı amaçladık.
ANAHTAR SÖZCÜKLER: Vertebra, Kord kompresyonu, Vertebral hemanjiyom, Bilgisayarlı tomografi
INTRODUCTION
Vertebral hemangiomas are present without symptoms in
approximately 10% of the population usually located in the
lower thoracic and lumbar vertebra, and are often multifocal
(8). These tumors generally involve a solitary lesion localized
in the vertebral body. Symptomatic vertebral hemangiomas
are rare and represent <1% of all hemangiomas; however,
if untreated, they may cause local or radicular pain and
neurological de cits ranging from myeloradiculopathy to
paralysis (1,8). Vertebral hemangiomas can cause neurological
symptoms by means of multiple mechanisms. The most
common is enlargement of the vertebral body, which leads
to narrowing and distortion of the spinal canal. The other
mechanisms are extraosseous extension of the tumor into
the epidural space, compression fracture, and bleeding
from the tumor into the epidural space (2,3). In this case we
aim to present preoperative and postoperative Computed
Tomography (CT)  ndings of a cavernous hemangioma that
caused sudden motor de cit and was localised to the thoracic
vertebra corpus and posterior elements.
CASE REPORT
This 30-year-old man without medical or surgical history
presented to the emergency department with a 3-week
history of severe back pain and left lower extremity pain that
began in the thigh and ascended into his left buttocks and
down his left leg. He also complained of urinary incontinence.
On neurological examination, the patient demonstrated
decreased motor strength in hip  exion (1/5), leg extension
(1/5), and dorsi exion (1/5) bilaterally. Strength in his upper
extremities was 5/5 in all muscle groups. Laboratory studies
yielded normal values. Radiographs found no evidence of
a vertebral pathology. CT imaging demonstrated di usely
thickened, vertically oriented trabeculae in the T4 vertebra
body and posterior elements as well as expansile appearance
of the left lamina and transverse process. Additionally, CT
images at the T4 level demonstrated the presence of severe
spinal canal compression (Figure 1). Two days after admission,
surgery was performed to relieve the cord compression. A
prominent vascular tumor was found invading the bilateral
lamina of T4 vertebra. A bilateral laminectomy was performed.
Received: 21.05.2010 / Accepted: 19.10.2010
114
Tan S, et al: oracic Vertebral Hemangioma
Turkish Neurosurgery 2011, Vol: 21, No: 1, 113-115
Figure 2: A postoperative axial CT image in soft-tissue window
settings A) and axial SSD (surface shaded display) 3D image
B) shows the adequately widened and decompressed spinal
canal (arrows).
Pathology examination of the surgical material conrmed
the diagnosis of cavernous hemangioma. Two days after
the operation, this patient’s clinical symptoms improved
signicantly. The postoperative CT showed complete
decompression of the spinal canal (Figure 2A, B). Two weeks
later, the muscle strength was 4/5 in all extremities.
DISCUSSION
Vertebral body hemangiomas are benign lesions and account
for 4% of all spinal tumors. Hemangiomas are frequently
asymptomatic and are discovered incidentally on imaging
studies. An active lesion with spinal cord compression or
nerve root compression is seen rarely (1). The clinical onset
of spinal cord compression is usually progressive over many
months but may be acute.
Hemangiomas are benign neoplasms of cavernous,
capillary, or venous origin. The most common histological
type is cavernous hemangioma (5). Hemangiomas are
often found in the lower thoracic or supper lumbar spine,
usually involving only a single vertebra. Multiple lesions are
seen in approximately 25-30% of vertebral hemangiomas.
Characteristics seen more often in symptomatic lesions
include location between the T3 and T9 vertebral bodies,
involvement of the entire vertebral body, involvement of the
posterior elements, irregular trabeculation, expanded and
indistinct cortex, and presence of a soft-tissue mass (5,6).
There may also be varying degrees of collapse and loss of
Figure 1: Axial CT scan in bone window settings shows the
characteristic ‘polka dot’ appearance (trabecular thickening
involving most of the vertebral body) (white arrow). The
hemangioma seems to extend into bilateral lamina (black
arrowhead) and transverse process (black arrow) of the vertebra.
The lesion is also compressing the spinal canal (prominent on the
left) (white arrowheads).
vertebral height with extensive involvement. This may result
in paraplegia (compression of the spinal cord), radiculopathy
(nerve-root impingement), or loss of function in the bladder
or bowel.
On plain lms, the thickened vertical trabeculae of
hemangiomas cause parallel linear densities described
as having ‘’corduroy cloth appearance or may show lytic
foci with ‘’honeycomb trabeculations (7). A CT scan is the
diagnostic procedure of choice. It shows a lucent lesion with
the characteristic “polka dot” appearance, which represents
the transverse cuts through the thickened vertical trabeculae.
CT can be utilized to determine the extent of vertebral
involvement and any site of spinal cord compression (5,4).
Magnetic resonance imaging plays the signicant role in the
diagnosis of the vertebral hemangiomas. T1-weighted and
Turkish Neurosurgery 2011, Vol: 21, No: 1, 113-115 115
Tan S, et al: oracic Vertebral Hemangioma
T2-weighted MR images of hemangiomas reveal increased
signal intensity because the lesions contain fat and water (5).
There are a number of treatment options for vertebral
hemangioma, ranging from observation to surgical resection
to radiation. Radiation therapy and embolization therapy can
be performed for medically refractory pain. Surgery is indicated
when the hemangioma has caused neurological decits (5).
Acute spinal cord compression requires decompression by
laminectomy (1,2).
In conclusion, hemangiomas are frequently localised to the
columna vertebralis but they rarely cause acute neurological
symptoms. CT scans can demonstrate the extent of vertebral
involvement as well as the site of spinal canal compression.
Acute neurological decits which are rapidly progressive due
to compression should be considered for immediate surgical
decompression.
REFERENCES
1. Aksu G., Saynak M, Karadeniz A: Spinal Cord compression due to
vertebral hemangioma. Orthopedics 31:169, 2008
2. Castel E, Lazennec YC, Chiras J, Enkaoua E, Saillant G: Acute spinal
cord compression due to intraspinal bleeding from a vertebral
hemangioma: Two case-reports. Eur Spine J 8:244–248, 1999
3. Chen HI, Heuer GG, Zaghloul K, Simon SL, Weigele JB, Grady MS:
Lumbar vertebral hemangioma presenting with the acute onset
of neurological symptoms. J Neurosurg Spine 7:80-85, 2007
4. Fox MW, Onofrio BM: The natural history and management of
symptomatic and asymptomatic vertebral hemangiomas. J
Neurosurgery 78:36-45, 1993
5. Hwang PM: Vertebral abnormality in a patient with suspected
malignancy. Bayl Univ Med Cent 15:325-326, 2002
6. Laredo JD, Reizine D, Bard M, Merland JJ: Vertebral hemangiomas:
Radiologic evaluation. Radiology 161:183-189, 1986
7. Sainani NI, Pungavkar SA, Patkar DA, Lawande MA, Naik M:
Multiple hemangiomas involving the vertebral Column. Acta
Radiologica 146:510-513, 2005
8. Vijay K, Shetty AP, Rajasekaran S: Symptomatic vertebral
hemangioma in pregnancy treated antepartum. A case report
with review of literature. Eur Spine J 17:299-303, 2008
  • [Show abstract] [Hide abstract] ABSTRACT: This study aims to evaluate the hemilaminectomy approach and in situ restoration of vertebral laminae in microsurgery for thoracic intraspinal tumors. MATERIAL and METHODS: Sixteen patients with thoracic intraspinal tumors, consisting of 6 males and 10 females with a mean age of 47.5±16.4 years ranging from 21 to 71 years, underwent surgical treatment with hemilaminectomy approach and in situ restoration of vertebral laminae. All patients were followed up after surgery for 12 to 30 months, involving Frankel grade, spinal instability, and deformity. Mean operation time was 119.5±23.0 minutes. Laminotomy was performed with one vertebral plate in 2 cases, two vertebral plates in 12 cases, and three vertebral plates in 2 cases. Postoperative three-dimensional CT scanning revealed a stable bony reconstruction, and no cerebrospinal fluid leakage or subcutaneous hydrops. Surgical pathology was consistent with preoperative MRI diagnosis. With respect to neurological status, the percentage of good Frankel scale was markedly improved from 37.5% on admission to 81.3% at follow-up (p < 0.05). None of the subjects showed spinal deformity or instability. In situ restoration of vertebral laminae maximally preserves the spinal integrity and stability, and reduces postoperative complications including cerebrospinal fluid leakage, pseudomeningocele, spinal deformity, and instability.
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