Magnetic Resonance Imaging

MRI features largely depend on the proportion of fat and vascularity of the lesions. With T1-weighted MRI, particularly in vertebral hemangiomas, areas of high fat content appear as areas of high signal intensity. On T2-weighted images, high signal intensity typically corresponds to the vascularity of hemangiomas (see the images below). Imagistica prin rezonanta magnetica Caracteristici RMN depind n mare msur proporia de grsime i vascularizaie a leziunilor. Cu T1ponderate RMN, n special n hemangioamele vertebrale, zone de coninut ridicat de grsimi apar ca zone de intensitatea semnalului mare. Pe T2-ponderate imagini, intensitatea semnalului mare de obicei, corespunde vascularizrii hemangioamelor (a se vedea imaginile de mai jos).

Bone hemangioma. Axial T2-weighted MRI shows the MRI equivalent of the CT

polka-dot appearance. The hypointense foci correspond to coarsened, thickened trabeculae. Bone hemangioma. Sagittal T1-weighted MRI of a spinal hemangioma affecting most of the body of L2. There is hyperintense

change; hypointense thickened vertical trabeculae are also visible. Bone hemangioma. T2-weighted image in the same patient as in the previous image demonstrates the typically high signal intensity of marrow and the low signal intensity of the vertical trabeculae.

Low signal intensity on T1-weighted images indicates decreased marrow fat or a greater vascular component; such a finding may be correlated with more aggressive behavior and is also more characteristic in cases involving vertebral collapse. Thickened trabeculae demonstrate low signal intensity on MRI obtained with all sequences (see the image below). Extraosseous components tend not to show high signal intensity on T1-weighted images owing to the paucity or absence of adipose tissue, but avid enhancement occurs with gadolinium enhancement owing to the vascularity of the lesions.

Epidural extension and neural involvement are well depicted with MRI (see the images below). Intensitatea semnalului sczut n T1-ponderate imagini indic grsime mduva sczut sau o component mai mare vasculare, o astfel de constatare poate fi corelat cu un comportament mai agresiv i este, de asemenea, mult mai caracteristic, n cazurile care implic colaps vertebrale. ngroat trabecule demonstra intensitatea semnalului redus pe RMN obtinut cu toate secvenele (a se vedea imaginea de mai jos). Componentele extraosoas tind s nu arate intensitatea semnalului mare pe T1-ponderate imagini datorate insuficiena sau absena esutului adipos, dar accesoriu pasionat apare din cauza accesoriu cu gadoliniu la vascularizrii leziunilor. Extinderea epidurala si implicarea neuronale sunt bine reprezentate cu RMN (a se vedea imaginile de mai jos).

Bone hemangioma. Sagittal T1-weighted MRI of a typical example of a thoracic hemangioma

involving only part of the vertebral body. same patient as in the previous image.

Bone hemangioma. Sagittal T2-weighted MRI in the

Gadolinium-based contrast agents (gadopentetate dimeglumine [Magnevist], gadobenate dimeglumine [MultiHance], gadodiamide [Omniscan], gadoversetamide [OptiMARK], gadoteridol [ProHance]) have been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). For more information, see the eMedicine topic Nephrogenic Systemic Fibrosis. The disease has occurred in patients with moderate to end-stage renal disease after being given a gadolinium-based contrast agent to enhance MRI or MRA scans. NSF/NFD is a debilitating and sometimes fatal disease. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the whites of the eyes; joint stiffness with trouble moving or straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness. For more information, see Medscape. Lesions in flat and long bones may show serpentine vascular channels. These demonstrate low signal intensity on T1-weighted images and high signal intensity on T2-weighted images with slow blood flow; they show low signal intensity on MRI obtained with all sequences in conditions of high blood flow.[4]

Degree of confidence
Complicated symptomatic spinal hemangiomas may be difficult to differentiate from malignant lesions.

Computed Tomography

CT scanning is more sensitive than plain radiography. Vertebral hemangiomas are typified by punctate sclerotic foci representing thickened vertical trabeculae seen in cross-section and giving a polka-dot appearance (see the image below). Tomografia computerizata CT scanare este mai sensibil dect radiografia simpl. Hemangioamele vertebrale sunt caracterizate de focare punctiforme sclerotice, reprezentnd trabecule ngroat vertical vzut n seciune transversal i oferind un aspect polka dot-(a se vedea imaginea de mai jos).

Bone hemangioma. Incidental finding of a small thoracic vertebral body hemangioma in a patient who had another lesion in the lumbar spine. Note the punctate sclerotic foci, or polka-dot appearance, which is a characteristic finding.

This finding may be absent in patients with symptomatic lesions. Bulging of the posterior cortex and paravertebral soft-tissue extension are readily assessed on CT scans, as is bone destruction with aggressive hemangiomas. CT findings in nonvertebral hemangiomas confirm plain radiographic results but give more detailed assessment of medullary, cortical bone, and extraosseous involvement.

Radiography
Most vertebral hemangiomas are small and cannot be seen on plain radiographs. The characteristic radiographic appearance is of a sclerotic or ivory vertebra with coarse, thickened vertical trabeculae giving a corduroy, accordion, or honeycomb appearance. (See the images below). Aceasta constatare poate fi absent la pacienii cu leziuni simptomatice. Bombat de cortexul posterior i ale esuturilor moi paravertebrale extensie sunt uor de evaluat pe scanari CT, astfel cum este distrugerea oaselor cu hemangioame agresive. Constatrile CT n hemangioamele nonvertebral confirma rezultatele radiografice neteda, dar da o evaluare mai detaliat a medular, osului cortical, i implicarea extraosoas. radiografie Cele mai multe hemangioame vertebrale sunt mici i nu pot fi vzute pe radiografii simple.Aspectul caracteristic radiografic este o sclerotic sau vertebre de filde cu trabecule groase, verticale ngroat oferind o catifea, acordeon, sau aspectul fagure de miere. (A se vedea imaginile de mai jos).

Bone hemangioma. Localized view of a frontal skull radiograph shows a well-demarcated lesion in the frontal bone with a characteristic sunburst appearance or a radiating, weblike trabecular pattern.

Bone hemangioma. Lateral projection in the same patient as in the previous image depicts the

diagnostic appearance of a calvarial hemangioma well. Bone hemangioma. View depicting the typical corduroy or accordion appearance of coarse, thickened vertical trabeculae in a hemangioma affecting the right side of the vertebral body

at L2. Bone hemangioma. Lateral view in the same patient as in the previous image shows no obvious involvement of the posterior elements, though this is better assessed with CT and MRI. The trabecular pattern on plain images is usually better seen on this view.

This appearance is due to resorption of horizontal trabeculae, caused by vascular channels and consequent reinforcement of vertical trabeculae. This finding can be differentiated from Paget disease, in which picture framing of the vertebral body is seen owing to prominent horizontal trabeculae. Similar findings may occur with lymphoma and metastases. Bulging of the posterior cortex or expansion of the vertebral body is sometimes present. Calvarial hemangiomas are usually round, osteolytic lesions that may demonstrate the characteristic sunburst, radiating spoke-wheel, or weblike pattern of trabecular thickening. Radiographic appearances in craniofacial hemangiomas are often nonspecific. Mixed radiopacity, radiolucency, and honeycomb patterns are observed. Long-bone hemangiomas are usually lytic, with a spiculated pattern creating a latticelike or Irish-lace appearance. A honeycomb structure can also result from bubbly bone osteolysis. Irregular bone destruction can occur, simulating malignant lesions. Reactive sclerosis may be seen at the margins of the lesions; with surface-based hemangiomas, they may mimic osteoid osteoma. Epithelioid hemangiomas characteristically demonstrate well-defined lysis, and they may also exhibit surrounding sclerosis, cortical expansion, or destruction.

Acest aspect se datoreaz resorbtia orizontale trabecule, cauzat de canale vasculare i consolidarea ulterioar a trabecule vertical. Aceast constatare poate fi difereniate de boala Paget, n care ncadrarea imagine a corpului vertebral este vzut ca urmare a trabecule orizontal proeminent. Constatri similare pot s apar cu limfom i metastaze. Bombat de cortexul posterior sau extinderea corpului vertebral este uneori prezent. Hemangioamele sunt de obicei rotunde Calvarial, leziuni osteolitice, care pot demonstra Sunburst caracteristic, radiaz spie roi, sau model weblike de ngroare trabecular. Apariii radiografice n hemangioamele craniofaciale sunt adesea nespecifice. Radioopacitate mixt, osteoliz, i modele de fagure sunt respectate. Lung-osoase hemangioamele sunt de obicei litice, cu un model de spiculated crearea unui aspect latticelike sau irlandez-dantela. O structur de fagure, de asemenea, poate duce la osteolizei osoase ampanie. Distrugerea osoasa neregulate pot aprea, simulnd leziuni maligne. Scleroza reactiv pot fi observate la marginea leziunilor, cu suprafata de joc pe baz de hemangioame, ei pot mima osteoma osteoid. Hemangioamele epitelioide demonstra caracteristic liz bine definite, i ei pot prezenta, de asemenea, scleroz incadrand, expansiunea cortical, sau distrugerea

Degree of confidence
Radiographic appearances of hemangiomas can be pathognomonic, especially with vertebral and calvarial hemangiomas. CT scanning and MRI increase diagnostic confidence in equivocal cases.
Previous

Overview
Bone hemangiomas are benign, malformed vascular lesions, overall constituting less than 1% of all primary bone neoplasms. They occur most frequently in the vertebral column (30-50%) and skull (20%), whereas involvement of other sites (including the long bones, short tubular bones, and ribs) is extremely rare. (See the images below.) Prezentare general Hemangioamele sunt leziuni benigne osoase, malformate vasculare, reprezentnd total mai mic de 1% din toate neoplasmele osoase primare. Ele apar cel mai frecvent n coloana vertebral (30-50%) i a craniului (20%), n timp ce implicarea alte site-uri (inclusiv oasele lungi, oase scurte tubulare, si coaste) este extrem de rar. (A se vedea imaginile de mai jos.)

Bone hemangioma. Localized view of a frontal skull radiograph shows a welldemarcated lesion in the frontal bone with a characteristic sunburst appearance or a radiating, weblike trabecular pattern.

Bone hemangioma. View depicting the typical corduroy or accordion appearance of coarse, thickened vertical trabeculae in a hemangioma affecting the right side of the vertebral body at L2.

Bone hemangioma. Incidental finding of a small thoracic vertebral body hemangioma in a patient who had another lesion in the lumbar spine. Note the punctate sclerotic foci, or polka-dot appearance, which is a

characteristic finding. Bone hemangioma. Sagittal T1-weighted MRI of a spinal hemangioma affecting most of the body of L2. There is hyperintense change; hypointense thickened vertical trabeculae are also visible.

Bone hemangiomas are usually asymptomatic lesions discovered incidentally on imaging or postmortem examination and mostly encountered in the middle-aged. The symptoms are largely nonspecific and depend on the site, size, and aggressiveness of the tumors.[1, 2]

Preferred examination
Plain radiography is useful for evaluation as the first-line imaging modality in most cases. Radiographic appearances differ depending on the anatomic site and histologic variant of the lesion. However, the radiographic hallmark of bone hemangiomas is a prominent trabecular pattern. Radiographic patterns may be nonspecific, necessitating further imaging or histology to achieve diagnosis. This is especially true in extraspinal hemangiomas occurring in an age group and location in which other more ominous diagnostic entities, such as myeloma or metastases, are more common. When plain radiographs do not suffice and appearances remain equivocal, cross-sectional imaging is crucial for further characterization of these lesions. Computed tomography (CT) scanning is especially useful for assessing changes in bone trabeculae; the results support the plain radiographic findings and provide greater detail. The superior soft-tissue and bone marrow contrast resolution of magnetic resonance imaging (MRI) allows for better evaluation of extraosseous extension and depiction of the characteristic fatty content in

vertebral hemangiomas and also flow patterns in general. The multiplanar capabilities of MRI are also crucial in defining the extent of neural involvement in the spine and planning therapeutic interventions.[3]

Limitations of techniques
Despite the added diagnostic information available with CT scanning and MRI, the angiomatous nature of many extraspinal lesions can be confirmed only with histologic analysis. preferat de examinare Radiografia simplu este util pentru evaluarea ca modalitate de imagistica de prima linie, n cele mai multe cazuri. Apariii radiografice difer n funcie de site-ul anatomice i varianta histologica a leziunii. Cu toate acestea, marca radiografic al hemangioamelor osoase este un model proeminent trabecular. Modele radiografice pot fi nespecifice, necesitnd n continuare imagini sau histologie pentru a realiza diagnosticul. Acest lucru este valabil mai ales n hemangioamele extraspinal apar ntr-un grup de vrst i locul n care alte entiti mult mai ru augur de diagnostic, cum ar fi mielomul sau metastaze, sunt mai frecvente. Cnd radiografiile simple nu sunt suficiente i apariii s rmn nesigure, transversal imagistica este esenial pentru caracterizarea suplimentar a acestor leziuni. Tomografia computerizata (CT) de scanare este util n special pentru evaluarea modificrilor osoase trabecule; rezultatele sprijina aceste constatari simple radiografice i s ofere mai multe detalii. Superioara esuturilor moi i osoase rezolutie de contrast maduva de imagistica prin rezonanta magnetica (IRM) permite o mai bun evaluare a extinderii extraosoas i prezentare a coninutului de grsime caracteristic n hemangioame vertebrale i, de asemenea, modele de curgere n general. Capacitile de multiplanar ale RMN sunt, de asemenea, crucial n definirea gradului de implicare neuronale la nivelul coloanei vertebrale i planificarea interveniilor terapeutice. [3] Limitri ale tehnicilor n ciuda informaiilor adugat de diagnosticare disponibile cu CT si RMN scanare, natura angiomatous de multe leziuni extraspinal pot fi confirmate numai cu analiza histologica.

Nuclear Imaging
Osseous hemangiomas usually show normal uptake on isotope bone scans, but they may also demonstrate photopenia and mildly to moderately increased activity. Scintigraphy with labeled red blood cells usually demonstrates focally increased activity. Single-photon emission CT (SPECT) scans are more sensitive than planar images in depicting abnormal activity.[5] Hemangioamele osoase arat, de obicei, de absorbie normal pe scaneaza osoase izotopi, dar ele pot, de asemenea, demonstra photopenia i uor de activitatea a crescut moderat. Scintigrafia cu celule rosii din sange etichetate demonstreaz, de obicei, activitatea punctuala a crescut.

Single-Photon Emission CT (SPECT) scaneaza sunt mai sensibile dect imaginile plane n a descrie activitatea anormale. [5]

Magnetic Resonance Imaging

MRI features largely depend on the proportion of fat and vascularity of the lesions. With T1-weighted MRI, particularly in vertebral hemangiomas, areas of high fat content appear as areas of high signal intensity. On T2-weighted images, high signal intensity typically corresponds to the vascularity of hemangiomas (see the images below).

Bone hemangioma. Axial T2-weighted MRI shows the MRI equivalent of the CT

polka-dot appearance. The hypointense foci correspond to coarsened, thickened trabeculae. Bone hemangioma. Sagittal T1-weighted MRI of a spinal hemangioma affecting most of the body of L2. There is hyperintense

change; hypointense thickened vertical trabeculae are also visible. Bone hemangioma. T2-weighted image in the same patient as in the previous image demonstrates the typically high signal intensity of marrow and the low signal intensity of the vertical trabeculae.

Caracteristici RMN depind n mare msur proporia de grsime i vascularizaie a leziunilor. Cu T1ponderate RMN, n special n hemangioamele vertebrale, zone de coninut ridicat de grsimi apar ca zone de intensitatea semnalului mare. Pe T2-ponderate imagini, intensitatea semnalului mare de obicei, corespunde vascularizrii hemangioamelor (a se vedea imaginile de mai jos). Low signal intensity on T1-weighted images indicates decreased marrow fat or a greater vascular component; such a finding may be correlated with more aggressive behavior and is also more characteristic in cases involving vertebral collapse. Thickened trabeculae demonstrate low signal intensity on MRI obtained with all sequences (see the image below). Extraosseous components tend not to show high signal intensity on T1-weighted images owing to the paucity or absence of adipose tissue, but avid enhancement occurs with gadolinium enhancement owing to the vascularity of the lesions. Epidural extension and neural involvement are well depicted with MRI (see the images below). Intensitatea semnalului sczut n T1-ponderate imagini indic grsime mduva sczut sau o component mai mare vasculare, o astfel de constatare poate fi corelat cu un comportament mai agresiv i este, de asemenea, mult mai caracteristic, n cazurile care implic colaps vertebrale. ngroat trabecule demonstra intensitatea semnalului redus pe RMN obtinut cu toate secvenele (a se vedea imaginea de mai jos). Componentele extraosoas tind s nu arate intensitatea semnalului mare pe

T1-ponderate imagini datorate insuficiena sau absena esutului adipos, dar accesoriu pasionat apare din cauza accesoriu cu gadoliniu la vascularizrii leziunilor. Extinderea epidurala si implicarea neuronale sunt bine reprezentate cu RMN (a se vedea imaginile de mai jos).

Bone hemangioma. Sagittal T1-weighted MRI of a typical example of a thoracic hemangioma

involving only part of the vertebral body. same patient as in the previous image.

Bone hemangioma. Sagittal T2-weighted MRI in the

Gadolinium-based contrast agents (gadopentetate dimeglumine [Magnevist], gadobenate dimeglumine [MultiHance], gadodiamide [Omniscan], gadoversetamide [OptiMARK], gadoteridol [ProHance]) have been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). For more information, see the eMedicine topic Nephrogenic Systemic Fibrosis. The disease has occurred in patients with moderate to end-stage renal disease after being given a gadolinium-based contrast agent to enhance MRI or MRA scans. NSF/NFD is a debilitating and sometimes fatal disease. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the whites of the eyes; joint stiffness with trouble moving or straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness. For more information, see Medscape. Lesions in flat and long bones may show serpentine vascular channels. These demonstrate low signal intensity on T1-weighted images and high signal intensity on T2-weighted images with slow blood flow; they show low signal intensity on MRI obtained with all sequences in conditions of high blood flow.[4] Gadoliniu pe baza de substante de contrast care (gadopentetatului de dimeglumin [Magnevist], gadobenate dimeglumin [MultiHance], gadodiamid [Omniscan], gadoversetamid [OptiMARK], gadoteridol [ProHance]) au fost legate de dezvoltarea de fibroza sistemic nefrogen (FSN) sau dermopathy nefrogen fibrozante (NFD). Pentru mai multe informaii, consultai subiectul fibroza sistemic nefrogen eMedicine.Boala a aprut la pacienii cu moderat pn la stadiul final al bolii renale dupa ce a fost dat un agent de contrast pe baz de gadoliniu pentru a spori scanari RMN sau MRA. FSN / NFD este o boala debilitante si uneori fatale. Caracteristici includ patch-uri de culoare roie sau ntunecate pe piele, arsur, mncrime, umflare, ntrire, precum i nsprirea pielii; pete galbene pe albul ochilor, rigiditate n comun cu probleme mutarea sau ndreptare brae, mini, picioare, sau picioarelor; i slbiciune muscular, adnc n oasele soldului sau coaste durere. Pentru mai multe informaii, a se vedea Medscape.

Leziunile n oase plate i lungi pot arta canale serpentine vasculare. Acestea demonstreaz intensitatea semnalului redus pe T1-ponderate imagini i intensitatea semnalului mare pe T2-ponderate imagini cu fluxul sanguin lent,. Acestea arat intensitatea semnalului redus pe RMN obinute cu toate secvenele n condiii de debit arteriale [4]

Degree of confidence
Complicated symptomatic spinal hemangiomas may be difficult to differentiate from malignant lesions. Gradul de ncredere Hemangioamele simptomatice complicate spinali poate fi dificil s se diferenieze de la leziuni maligne.

References
1. Dahnert W. Haemangioma, bone. In: Radiology Review Manual. 4th ed. 1999: 76-7. 2. Resnik D, Kyriakos M, Greenway GD. Tumors and tumor-like lesions of bone. 4th ed. Diagnosis
of Bone and Joint Disorders;. 2002:3979-85.

3. Choi JJ, Murphey MD. Angiomatous skeletal lesions. Semin Musculoskeletal Radiology.
2000;4(1):103-12.[Medline].

4. Ross JS, Masaryk TJ, Modic MT, et al. Vertebral haemangiomas: MR imaging. Radiology.
1987;165(1):165-9.

5. Han BK, Ryu JS, Moon DH, et al. Bone SPECT imaging of vertebral haemangioma correlation
with MR imaging and symptoms. Clin Nucl Med. 1995;20(10):916-21.

6. Kahana A, Lucarelli MJ, Grayev AM, Van Buren JJ, Burkat CN, Gentry LR. Noninvasive dynamic
magnetic resonance angiography with Time-Resolved Imaging of Contrast KineticS (TRICKS) in the evaluation of orbital vascular lesions. Arch Ophthalmol. Dec 2007;125(12):1635-42. [Medline].