Open Journal of Medical Imaging, 2012, 2, 29-31
http://dx.doi.org/10.4236/ojmi.2012.21005 Published Online March 2012 (http://www.SciRP.org/journal/ojmi)
Spinal Cord Compression by Thoracic Vertebral
Hemangioma—A Case Report
Department of Radiology, Mayo Clinic, Rochester, USA
Received December 16, 2011; revised January 19, 2012; accepted January 30, 2012
A 68 year old with lower extremity numbness, vibratory sensation loss, coldness and burning of his feet, unsteady gait,
frequent falls and a sensory level had an MRI demonstrating a T7 and T8 vertebral body/p osterior element lesion with
epidural extension, cord compression and foraminal extension (Figures 1-5). Decompressive laminectomy/resection
confirmed vertebral hemangioma, a common benign neoplasm that typically remains asymptomatic, found incidentally
in 10% of the population. Progressive vertebral body hemangiomas may cause cord or nerve root compression due to
epidural tumor extension, expanded bone, hematoma or fracture. Radiographs demonstrate course vertical striations
caused by thick trabeculae. CT in indolent lesions demonstrates fat density while compressive lesions demonstrate soft
tissue density. Indolent lesions follow fat signal on MRI; symptomatic lesions are T1 isointense/T2 hyperintense.
Work-up for aggressive hemangiomas includes angiography to determine vascularity, identify feeding/draining vessels
and identify blood supply to the cord. Biopsy helps differentiate hemangioma, lymphoma, myeloma or metastasis.
Management of symptomatic hemangiomas includes vertebroplasty for pain, radiation for pain, compression or pre-op
and decompressive laminectomy for epidural disease. Embolization of feeding vessels may be performed pre-op or may
be curative. Hemangioma causing cord compression and neurologic symptoms by extraosseous extension is much less
common than benign hemangioma. Imaging features may suggest potential for progression.
Keywords: Spinal Cord Compression; Vertebral Hemangioma
1. Case Report
A 68 year old male with a history of prostate cancer de-
veloped progressive lower extremity numbness and tin-
gling, loss of lower extremity vibratory sensation, cold-
ness and burning of his feet, unsteady gait and frequent
falls. He had a sensory level just above the umbilicus.
MRI was obtained (Figures 1-5). Sagittal T1 weighted
images (Figure 1) demonstrated a heterogeneous signal
lesion with hyperintensity of the osseous component and
isointensity of the soft tissue component involving the T7
and T8 vertebral bodies and posterior elements with T6-9
epidural exten sion, significant T7 an d T8 spinal cord dis-
placement and compression as well as right T6-7, T7-8
and T8-9 neural foraminal extension. T2 weighted im-
ages demonstrate both the osseous and soft tissue com-
ponents to be hyperintense (Figure 2). Axial T2 weighted
images demonstrated significant spinal cord displace-
ment and compression (Figure 3). Post contrast sagittal
T1 demonstrated intense homogeneous enhancement (Fig-
ure 4). Post contrast axial T1 demonstrated intense Homo-
geneous enhancement (Figure 5). As a result of these
MRI findings, considered together with his rapidly pro-
gressive neurologic deterioration and question of metas
Figure 1. Sagittal T1 weighted MRI demonstrates a lesion
of heterogeneous signal with hyperintensity of the osseous
component and isointensity of the soft tissue component
involving the T7 and T8 vertebral bodies and posterior
elements with T6-9 epidural extension, significant T7 and
T8 spinal cord displacement and compression as well as
right T6-7, T7-8 and T8-9 neural foraminal extension.
opyright © 2012 SciRes. OJMI
Figure 2. T2 weighted images demonstrate both the osseous
and soft tissue components to be hyperintense.
Figure 3. Axial T2 weighted images demonstrate the signi-
ficant spinal cord displacement and compression.
tasis, decompressive laminectomy with partial resection
was performed. Capillary hemangioma was confirmed at
pathology. With the benefit of postoperative radiation, a
significant recovery was possi bl e .
Vertebral hemangioma is a common benign neoplasm
that typically remains asymptomatic throughout life, in-
frequently causing local or radicular pain or neurologic
deficits. It is a common incidental finding seen in ap-
Figure 4. Post contrast sagittal T1 with fat saturation dem-
onstrates intense homogeneous enhance m e nt.
Figure 5. Post contrast axial T1 with fat saturation demon-
strates intense homogeneous enhance ment.
proximately 10% of the population . It is more com-
mon in the thoracic region than in the lumbar or cervical
regions. Multi-level involvement may occur. It affects
the vertebral body more often than the posterior elements.
Progressive vertebral body hemangiomas are those that
are initially confined to the vertebral body, progress to
involve the posterio r arch and then expand further. Entire
vertebra are involved by these progressive lesions more
commonly than the vertebral body or posterior arch alone.
Single level involvement is much more common than
involvement of two or more contiguous levels. Preg-
nancy is a risk factor for the development of neurological
symptoms in quiescent hemangiomas, possibly due to
increased estrogen or increased flow in the vertebral ve-
nous system . Cord or nerve root compression may be
due to epidural tumor extension, expanded bone, hema-
toma, compression fracture or anomalous vessels. Cord
compression is often progressive but may be sudden.
Copyright © 2012 SciRes. OJMI
Copyright © 2012 SciRes. OJMI
Pain often precedes neurological symptoms, most com-
monly thoracic myelopathy. Imaging findings have been
well characterized [2,3] Radiographs demonstrate course
vertical striations caused by thick trabeculae. CT in in-
dolent or inactive lesions demonstrates fat density while
in symptomatic compressive lesions CT will demonstrate
soft tissue density. Indolent lesions tend to follow fat
signal on MRI while symptomatic lesions are T1 isoin-
tense and T2 hyperintense.
Extraosseous tumor contains very little fat although
may demonstrate flow voids. Both types typically enhance.
Pathology reveals hamartomatous proliferation of endo-
thelial vascular tissue with secondary resorption of un-
derlying bone. Most trabeculae are atrophic due to the
abnormal blood vessels although some become thickened
and sclerotic. Cavernous hemangiomas have multiple
large thin walled vascular spaces while capillary heman-
giomas have multiple capillary channels se parated by reac-
tive fibrous tissue . Work-up for aggressive heman-
giomas may include angiography to determine vascular-
ity, identify feeding an d draining vessels and identify the
blood supply to the cord. CT guided biopsy may be war-
ranted to differentiate hemangioma, lymphoma, myeloma
or metastasis. Management of symptomatic vertebral
hemangiomas can be very variable . Vertebroplasty is
contemplated for patients with localized pain. Radiation
has been utilized for those with pain, pain and compres-
sion or pre-operatively. Post-op radiation may reduce the
recurrence risk in subtotal tumor removal. Decompres-
sive laminectomy is considered for resection of epidural
disease. Embolization of feeding vessels may be a pre-
operative measure or may be curative. However it is not
always necessary or possible if the feeding vessel also
supplies the anterior spinal artery. Ethanol embolization
has also been utilized. Compressive vertebral hemangioma
causing cord compression and neurologic symptoms by
extraosseous extension is much less common than benign
hemangioma. The CT and MR features may suggest the
potential for progresssion. An asymptomatic incidental
hemangioma does not need further evaluation unless pain
or neurological deficit develops at the appropriate level.
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