1. Control #: 1939 Title: Vertebral Hemangiomas: Not So Benign After All eEdE#: eEdE-231 (Shared Display)

2. No Disclosures

3. Vertebral Hemangiomas: Not So Benign After All
Rajput, Anuj MD, Ahluwalia, T., Rajput, Aikta, Edelstein, Y.
Stony Brook University Hospital, NY

4. Purpose
The goal of this educational exhibit is to review incidence, prevalence, and clinical presentation of common and uncommon pathology in patients presenting to the emergency department with back pain and/or myelopathy with focus on aggressive vertebral hemangioma.
Knowing the appearance of this entity and other various pathologies will help the radiologist to correctly distinguish them and recommend appropriate treatment.

5. Background
Back pain is a very common presentation in the emergency department of all ages and a frequent reason for diagnostic imaging. It is important for the radiologist to be aware of the vast abnormalities involving the spine and associated elements, as time is of the essence.
Our aim is to discuss the imaging findings and consider a differential diagnosis of a rare phenomenon, an aggressive vertebral hemangioma. Awareness of this rare lesion is vital as diagnosing it can be difficult due to the absence of typical imaging characteristics.

6. PATIENT PRESENTS WITH SUDDEN ONSET OF BACK PAIN

7. NON-CONTRAST CT L-SPINE

8. MRI L-SPINE

9. Differential Diagnosis
Neoplastic – Paget’s disease, multiple myeloma, lymphoma, metastasis
Granulomatous – TB
Congenital – notochord remnant, segmentation anomalies
Vascular – aggressive vertebral hemangioma
Infectious – osteomyelitis

10. CT FINDINGS

11. CT FINDINGS
Coronal and Sagittal CT images demonstrated a vertrically oriented fracture through the anterior L3 vertebral body with slight retropulsion. There is prominent trabeculae seen within the vertebral body.

12. MRI FINDINGS A B C D E Out of phase
Areas of signal loss compatible with fatty marrow.
Epidural mass T1
Areas of very low signal – prominent trabecula
STIR
Prominent intraosseous flow voids.
Prominent soft tissue flow voids T2
Retropulsion
Linear hperintense signal paralleling endplate – high specificity for benign fracture.
T2/ stir / out of phase A B C D E

13. MRI FINDINGS A B C D E
Out of phase imaging (A): demonstrates areas of signal loss compatible with fatty marrow. An epidural mass is also noted.
STIR (B,C): demonstrates interosseous and soft tissue flow voids
T1WI (D): demonstrates areas of very low signal with prominent trabaculae
T2WI (E): demonstrates retropulsion with a linear hyperintense line paralleling endplate, high specificity for benign fracture.

14. AGGRESSIVE VERTEBRAL HEMANGIOMAS

15. Vertebral Hemangiomas
Vertebral hemangiomas are common lesions of the spinal column with incidence of 10-12%, and can be symptomatic in % of adults.6
Generally a benign lesion, of dysembryogenetic or hamartomatous origin. 5
May be progressive, or dormant, with differing asymptomatic periods. 5

16. Aggressive Vertebral Hemangiomas
“Aggressive” hemangiomas characterized by bony expansion with cord compression, extraosseous extension of tumor, diversion of local blood flow, and compression fractures. 6
Presentation
Of the small percentage that are symptomatic, 54% characterized by pain, 45% associated with variable neurologic symptomology, including cord compression. Compared to older patients, young patients under 30 years of age, had higher incidence of cord compression. 5
Pregnancy is an exacerbating condition, due to increased abdominal pressure and axial load. 5

17. Aggressive Vertebral Hemangiomas
Appearance/Characteristics
Decrease in density of vertebral body due to presence of fatty marrow. Characterized by sparing and thickening of vertically striated trabeculae which preserve vertebral body’s functional capability to withstand an axial load. 6
Generally occupy entire vertebral body, extend into neural arch, extend across osseous margins, and have soft tissue component. 6

18. Aggressive Vertebral Hemangiomas
Treatment
For symptomatic or aggressive hemangiomas without cord compression, treatment options include vertebroplasty, embolization, sclerotherapy. Surgical resection in cases with compression. 6

19. Differential Diagnosis
Neoplastic – Paget’s disease, multiple myeloma, lymphoma, metastasis
Granulomatous – TB
Congenital – notochord remant, segmentation anomalies
Vascular – aggressive vertebral hemangioma
Infectious – osteomyelitis

20. Paget’s Disease Chronic metabolic bone remodeling disorder.
Expanded vertebra with “picture frame” appearance with coarse and sclerotic peripheral trabecular pattern, with central osteopenia.
Bone marrow in Pagets contains fatty areas with heterogeneous distribution
Distinguished from vertebral hemangioma by expansion of vertebral body with peripheral cortical thickening7

21. 85 year old with Paget’s Disease

22. 85 year old with Paget’s Disease
Sagittal CT of the lumbosarcal spine demonstrates trabecular coarsening, involvement of posterior elements, and spondylolisthesis

23. 78 year old with Paget’s Disease

24. 78 year old with Paget’s Disease
Axial and sagittal CT of the thoracic spine demonstrates involvement of the posterior elements with a mild compression deformity. There is no epidural mass or no retropulsion.

25. 81 year old with Paget’s Disease

26. 81 year old with Paget’s DiseaseB C
Sagittal CT (A): demonstrates coarsened trabecula and thickened endplates.
Sagittal T1WI and Sagittal STIR (B,C): demonstrates preserved marrow signal

27. 16 Months Following Paget’s Disease

28. 16 Months Following Paget’s DiseaseB
Sagittal CT (A): demonstrates thickened endplates as well as thickened anterior and posterior cortex - “picture frame ” appearance
Sagittal T1WI (B): demonstrates no change without treatment

29. Chemotherapy associated Bone Marrow Necrosis
Chemotherapy results in changes that reflect cellular composition and vascularity of the bone. Initially bone marrow becomes dilated and hyperpermeable leading to edema, leading to low signal on T1 and high signal on T2/STIR. This is followed by decrease in marrow cellularity and fatty conversion of bone marrow during remission, leading to increased signal on T1 and decreased signal on fat saturated T2 and STIR.9
Necrosis of myeloid tissues and stroma without involvement of cortical bone. 9
Different from avascular necrosis (AVN), where cortical elements involved with sparing of myeloid elements. 9
Similar MR findings to AVN, although BMN is more diffuse, involving axial skeleton without vertebral collapse.10

30. 62 year old with B-cell lymphoma with Chemotherapy associated Bone Marrow Necrosis

31. 62 year old with B-cell lymphoma with Chemotherapy associated Bone Marrow Necrosis
Sagittal T1WI (A): demonstrates geographic areas of signal extending from endplate to enplate with sparing the anterior and posterior body. No compression or epidural mass.
Sagittal T2WI and STIR (B,C): demonstrates patchy low signal and a double line rim

32. Metastatic Hepatocellular (HCC) Carcinoma
In United States, 90% of primary liver cancers are HCC, and liver malignancy is fifth most common cancer in the world. Increasing incidence over past few decades, with greatest risk factors being cirrhosis, chronic hepatitis.
Metastases occur in 5-13% of patients with HCC and commonly involves ribs, spine, femur, and commonly presents with bone pain.
Vertebral metastases have been reported, but nerve root and spinal cord compression are rare.
Rim of high signal surrounding lesion or diffuse signal hyperintensity of a lesion on T2 weighted images have been reported as useful indicators in the diagnosis of metastasis10
Poor prognosis associated with metastatic HCC.

33. 66 year old with Metastatic Hepatocellular (HCC) Carcinoma

34. 66 year old with Metastatic Hepatocellular (HCC) CarcinomaB C
Sagittal CT (A): demonstrates destruction of posterior cortex, with an epidural mass
Sagittal T1WI (B): demonstrates confluent low signal with no internal fat.
Sagittal T2WI (C): demonstrates confluent high T2 weighted signal with no fat

35. Metastatic Prostate Cancer
Second most common cancer in men, accounting for 1 in 9 of all new cancers.
Skeletal metastases occur in approximately 90% of patients with advanced prostate disease.
Osteoblastic metastases may slow low signal intensity on both T1 and T2 images because relatively less tumor is present between the sclerotic trabeculae10
MRI is technique of choice in evaluating prostate bone metastases as it is sensitive to early changes in marrow preceding osteoblastic response from matrix. Metastases to marrow leads to long T1 relaxation time and signal loss, contrasting with high T1 signal from surrounding marrow fat. High conspicuity of bone metastases can be increased by T2 fat suppression.
MRI shown to detect prostate bone metastases in 37.5% of patients with negative or inconclusive bone scan and plain films. This is thought to be because even with extensive marrow involvement, the amount of bony matrix destroyed is small.
In vertebral bodies, there is large medullary cavity, and cortical involvement occurs late.

36. 66 year old with Metastatic Prostate Cancer

37. 66 year old with Metastatic Prostate CancerB C
Sagittal T1WI (A): demonstrates a low signal lesion in the L3 vertebral body with no internal fat.
Sagittal T2WI (B): demonstrates a low signal lesion in the L3 vertebral body with no internal fat.
Sagittal STIR (C): demonstrates a low signal lesion in the L3 vertebral body with no internal fat.

38. Metastatic Prostate Cancer

39. Metastatic Prostate CancerB
Sagittal STIR (A,B): demonstrate a hypointense lesion with surrounding with halo in a thoracic vertebrae suggestive of prostate bone metastases

40. Multiple Myeloma
Malignant clonal neoplasm of plasma cells of B-lymphocyte origin resulting in overproduction of monoclonal immunoglobulins.13
Common presentation with fatigue and bone pain without associated fractures or infection.13
Infiltrative pattern on MRI is variable, ranging from normal to focal or diffuse.10
T1SE generally depict a hypointense area within a generally hyperintense marrow background. T2SE depict focal lesions that are hyperintense relative to hypointense marrow background. Diffuse disease identified as generalized hyperintensity of marrow background relative to intensity of skeletal muscles.13
Although diffuse disease may mimic MRI appearance of extensive red marrow reconversion, signal intensity on fat-suppressed T2 SE images is considerably higher than that of muscle.10
Due to lack of osteoblastic activity, bone scans and radiographs can be normal in multiple myeloma.10

41. 76 year old with Multiple Myeloma

42. 76 year old with Multiple MyelomaB C D
Sagittal CT(A), STIR (B), T1WI (C), T2WI (D): demonstrate diffuse infiltration of the bone and a focal plasmacytoma.

43. 75 year old with Multiple Myeloma after RadiationB C

44. 75 year old with Multiple Myeloma after RadiationB B C C
Sagittal STIR (A), T1WI (B), T2WI (C): demonstrate diffuse fatty marrow and focal areas of necrosis in the sacrum

45. Non-Hodgkin's Lymphoma
About 30 subtypes of NHL, ranging in severity from aggressive to mild.
Symptoms are nonspecific and can range from swollen lymph nodes, fever, fatigue, weightloss, etc.
NHL metastasis to the spine is rare as initial manifestation, but should be considered in cases of spinal cord compression thought to be due to malignant disease.
Cord compression from NHL usually due to primary deposit within spinal canal, extension from nodal mass, or collapsed vertebra.
STIR sequences, as they allow strikingly increased signal from fluid and edema, are valuable as they can allow detection of additional deposits of disease, and are sensitive for detecting soft tissue and marrow pathology. 14

46. 63 year old with Non-Hodgkin's Lymphoma

47. 63 year old with Non-Hodgkin's LymphomaB C D
Sagittal CT(A): demonstrates mixed isodense and sclerotic vertebral bodies.
STIR (B), T1WI (C), T2WI (D): demonstrates mixed hyperintense and heterogenous vertebral bodies. No bony expansion/ retropulsion. The cortex intact but an epidural mass present. Findings characteristic for lymphoma.

48. Osteomyelitis
Most commonly involving the lumbar spine, it would demonstrate bone marrow edema, end-plate destruction, and usually paraspinal edema on MR imaging.
The affected, now poorly defined vertebral body and involved disc segments display low T1WI signal intensity and high T2WI signal intensity.
Gadolinium-contrast administration would show enhancement of the bone marrow diffusely. The intervertebral disc varies in patterns of enhancement, which include homogenous, diffuse, patchy or thin peripheral enhancement.1 
These findings are useful in differentiating features of infection. 

49. Conclusion
Hemangiomas are typically benign lesions incidentally discovered on imaging. A small  subset demonstrate aggressive features with extraosseous involvement producing severe neurological symptoms. Review of this educational exhibit will enable a radiologist to be familiar with this entity, be able to confidently diagnose it, consider and narrow relevant differential considerations, and also offer appropriate recommendations.

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