Dx: Central Hemangioma

KEY FACTS

Terminology Definition: Benign blood vessel proliferation creating mass resembling neoplasm; may be hamartoma Imaging Uni- or multilocular; variable margins from ill defined to well defined with cortication Classic sunray linear spicules from surface of bone if cortical perforation present; often honeycomb (early) orsoap bubble (late) internal trabecular appearance; others may be unilocular If in mandibular canal, canal is widened and may have "serpentine" shape Possible phleboliths if lesion extends to soft tissue Adjacent teeth often resorbed or displaced Teeth developing adjacent to hemangioma may be macrodonts and erupt earlier than normal Mandible > maxilla; posterior body and within canal Imaging protocol CBCT/CT bone or CECT best overall Angiography to demonstrate vascularity and delineate lesion High-resolution Doppler US for vascular flow Top Differential Diagnoses
Osteosarcoma

Arteriovenous fistula
Ameloblastoma Odontogenic myxoma Central giant cell granuloma

Aneurysmal bone cyst Clinical Issues Slow expansion; may throb bleeding around teeth Treatment: Embolization, en bloc resection with ligation of external carotid, or sclerosing techniques
TERMINOLOGY

Definitions Benign blood vessel proliferation creating mass resembling neoplasm; may actually be hamartoma
IMAGING

General Features Best diagnostic clue Uni- or multilocular radiolucency with honeycomb or soap bubble trabecular appearance Classic sunray linear spicules from surface of bone if cortical perforation present If in mandibular canal, canal is widened and may have "serpentine" shape Location Mandible > maxilla (2:1) Most common site: Posterior mandibular body and within mandibular canal Morphology: Uni- or multilocular; variable margins from ill defined to well defined with cortication Radiographic Findings Extraoral plain film Often honeycomb (early) or soap bubble (late) trabecular appearance; others may be unilocular

Thinned, expanded cortices Possible sunray spicules projecting at right angles from cortical surface Phleboliths may be apparent if soft tissue extension Adjacent teeth often resorbed or displaced Teeth developing adjacent to hemangioma may be macrodonts and erupt earlier than normal CT Findings CECT Ill-defined lytic mass with moderate enhancement Sunray spicules and phleboliths common, especially with soft tissue extension Ultrasonographic Findings Color Doppler Ill-defined hypoechoic mass Pulsing demonstrated with real-time US Imaging Recommendations Best imaging tool: CBCT/CT bone or CECT Protocol advice Panoramic is most appropriate initially Angiography and high-resolution Doppler US
DIFFERENTIAL DIAGNOSIS

Osteosarcoma Sunray appearance is similar to hemangioma

Sclerotic/lytic destructive lesion; ill-defined borders Symmetrical widened periodontal ligament space around few teeth Arteriovenous Fistula Radiographic appearance not specific Does not involve mandibular canal Spontaneous hemorrhage around teeth
Ameloblastoma

Most common site is posterior mandible Uni- or multilocular, usually adjacent to impacted tooth Adjacent tooth root resorption common
Odontogenic Myxoma

3rd or 4th decade; mandible Lacy trabecular pattern resembles tennis racquet Dental root resorption rare
Central Giant Cell Granuloma

Swelling may be only clinical sign; anterior mandible May be peripheral or central; mean age: 30 years Malposition and resorption of teeth are not unusual Aneurysmal Bone Cyst 1st or 2nd decades; usually in posterior mandible Progressive jaw swelling with possible pain/tenderness Fluid-fluid levels on T2WI MR

PATHOLOGY

General Features Cavernous hemangioma: Deep soft tissue mass; thin-walled large vessel/sinusoid lined with single endothelial layer Capillary hemangioma: Superficial "strawberry" appearance; small capillaries supported by connective tissue stroma
CLINICAL ISSUES

Presentation Most common signs/symptoms Slowly expanding, bony hard swelling May or may not be painful; may throb Bleeding around loosened, migrating teeth Aspiration: Arterial blood under pressure Other signs/symptoms: Audible bruit in highly expansile lesions Natural History & Prognosis Female > male (2:1) Most common in 1st decade but may occur later Treatment Embolization, en bloc resection with ligation of external carotid, or sclerosing techniques
DIAGNOSTIC CHECKLIST

Image Interpretation Pearls Sunray appearance similar to osteogenic sarcoma Honeycomb or soap bubble trabecular appearance