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Intraosseous Haeangioma

Summary

  • Benign vascular tumour of bone, typically affecting vertebrae and skull
  • Characterised by proliferation of blood vessels within bone marrow spaces
  • Often asymptomatic, incidentally discovered on imaging studies

Pathophysiology

  • Hamartomatous proliferation of endothelial cells forming vascular channels
  • Slow-growing lesions with potential for local expansion
  • May cause bone remodeling and cortical thinning
  • Rarely associated with pathological fractures

Demographics

  • Accounts for approximately 1% of all primary bone tumours
  • Peak incidence in 4th to 5th decades of life
  • Slight female predominance (1.5:1 female-to-male ratio)
  • Most common in vertebral bodies (30-50% of cases)
  • Skull involvement in 20% of cases, particularly frontal and parietal bones

Diagnosis

  • Often asymptomatic and discovered incidentally
  • When symptomatic:
    • Local pain or tenderness
    • Palpable mass (in superficial locations)
    • Neurological symptoms (if spinal involvement)
  • Laboratory findings typically normal
  • Biopsy may be necessary for definitive diagnosis in atypical cases

Imaging

  • Plain radiographs:
    • "Honeycomb" or "soap bubble" appearance
    • Trabecular thickening with radiolucent areas
    • Sunburst pattern of trabeculae (in skull lesions)
  • CT:
    • Polka-dot appearance (axial images of vertebral lesions)
    • Thickened trabeculae with low-density areas between
    • Cortical thinning without destruction
  • MRI:
    • T1: heterogeneous, predominantly hypointense
    • T2: hyperintense with flow voids
    • Strong enhancement with gadolinium
  • Bone scintigraphy:
    • Increased uptake in lesion
  • Angiography:
    • Rarely performed, may show tumour blush

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  • A 40-year-old patient presented with an enlarged forehead lump.
  • Imaging showed a partially calcified avidly enhancing intraosseous lesion in the left frontal bone.

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  • An incidental lesion in the intradiploic space of the parietal bone contained fat and did not enhance (allowing for prominent nearby veins).
  • The bone appearance was not typical, but a radiological diagnosis of a fatty hemangioma was given. A lipomatous lesion is also possible.

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  • A 70-year-old patient presented with a lump near the left zygoma.
  • MRI showed an avidly enhancing lesion replacing part of the frontal bone without significiant avidity on FDG PET.
  • Histopathology following resection (due to slow enlargement) confirmed a hemangioma.

Treatment

  • Asymptomatic lesions: observation with periodic imaging follow-up
  • Symptomatic lesions or risk of pathological fracture:
    • Surgical excision (curettage or en bloc resection)
    • Radiation therapy for inoperable lesions
    • Vertebroplasty or kyphoplasty for vertebral lesions
    • Embolization as adjunct to surgery or for pain relief
  • Recurrence rate is low after complete excision

Differential diagnosis

Differential Diagnosis Differentiating Feature
Metastasis Multiple lesions; aggressive destructive pattern; no honeycomb or sunburst trabecular pattern; T1 hypointense
Multiple myeloma Punched-out lytic lesions; diffuse osteopenia; no T1 hyperintensity due to fat
Bone island (enostosis) Dense, sclerotic lesion; no trabecular pattern; no T1/T2 signal change on MRI
Fibrous dysplasia Ground-glass appearance on CT; expansile; no honeycomb trabecular pattern
Paget's disease Thickened trabeculae with bone enlargement; coarsened cortex; "picture frame" vertebra
Eosinophilic granuloma Bevelled edge appearance; permeative bone destruction; no honeycomb trabeculation
Aneurysmal bone cyst Fluid-fluid levels on MRI, expansile lytic lesion with thin sclerotic rim
Giant cell tumour Eccentric lytic lesion, typically in epiphysis, soap bubble appearance
Osteoblastoma More aggressive appearance, pain often relieved by NSAIDs
Enchondroma Cartilaginous matrix, ring-and-arc calcifications