Vertebral hemangiomas (VH) are vertebral vascular malformations, which may remain asymptomatic until adulthood. Sometimes,young individuals present with unexplained backache, which poses the diagnostic dilemma. We present a case of 15-year-old femalewho presented with prolonged unexplained intermittent upper back pain in the dorsal region. She was diagnosed as a case of aggressiveVH after ruling out other infective and malignant pathologies and treated with decompressive therapy. The present case highlights therole of imaging studies such as computed tomography and magnetic resonance imaging in such conditions

Balesa, Jitendra

Jilowa, Sarita

Sharma, B B

Sharma, Sandeep

Sharma, Shashi

Singh, Yashvant

English

Atharva Scientific Publications (E-Jounals)

Vol 2 | Issue 1 | Jan - Mar 2015 Indian J Child Health 37
Sharma et al. Atypical aggressive vertebral hemangioma
Case Report
Aggressive vertebral hemangioma in early adolescent age group: Atypical 
presentation with computed tomography and magnetic resonance imaging 
appearance
B B Sharma1, Shashi Sharma2, Sandeep Sharma3, Jitendra Balesa1, Sarita Jilowa1, Yashvant Singh1
From 1Department of Radio-diagnosis, Post Graduate Institute of Medical Education and Research & Dr Ram Manohar Lohia 
Hospital, New Delhi, India, 2Department of Pediatrics, SGT Medical College, Gurgaon, Haryana, India, 3Department of Anaesthesia, 
SGT Medical College, Gurgaon, Haryana, India
Correspondence to: B B Sharma, B-32, Nivedita Kunj, Sector-10, R K Puram, New Delhi, India. Tel: 91-11- 26182700, Fax: 91-11- 
26182700, E-mail: bbhushan986@gmail.com
Received – 20 November 2014 Initial Review – 31 December 2014 Published Online – 24 February 2015
Abstract
Vertebral hemangiomas (VH) are vertebral vascular malformations, which may remain asymptomatic until adulthood. Sometimes, 
young individuals present with unexplained backache, which poses the diagnostic dilemma. We present a case of 15-year-old female 
who presented with prolonged unexplained intermittent upper back pain in the dorsal region. She was diagnosed as a case of aggressive 
VH after ruling out other infective and malignant pathologies and treated with decompressive therapy. The present case highlights the 
role of imaging studies such as computed tomography and magnetic resonance imaging in such conditions.
Key words: Aggressive, Backache, Computed tomography, Magnetic resonance imaging, Vertebral haemangiomas, Vascular 
malformations
Vertebral Hemangiomas (VH) are generally asymptomatic vascular malformations with a slight predilection for females. Only 3.7% of VH may 
become symptomatic and show invasion of the spinal canal 
and/or paravertebral spaces. These are mostly asymptomatic in 
pediatric age group and become symptomatic in 40-50 years of 
age. The main presenting feature is a pain due to axial loading 
either by exercise or housework. Complications are due to 
encroachment upon the spinal canal and vertebral collapse 
leading to aggravation of symptoms [1]. Sometimes, back 
pain is the only presenting feature in adolescents leading to 
the diagnosis of VH [2]. We present such a case of VH in the 
adolescent girl who presented with back pain.
CASE REPORT
A 15-year-old adolescent girl of army personnel family presented 
with dull back pain in the upper back of 2 year’s duration. 
There was a delay in diagnosis and treatment because of the 
father being away on armed forces duty. There was progressive 
weakness in both the lower limbs for the last 2 months without 
any neurological deficit. Plain radiograph of the spine done at 
other hospital did not reveal any significant abnormality, and 
she was managed at the pain and physiotherapy clinic on an 
irregular basis with little temporary relief in pain. Therefore, 
she was refereed to our hospital for diagnosis and management. 
On examination, she was conscious, well oriented, and well 
nourished. Her vitals and general examination were also 
normal except tenderness along the paravertebral regions over 
upper dorsal vertebrae (D2-D5). Her neurological examination 
was within normal limits, and there was no neurological deficit. 
Rest of the systemic examination was also within normal limits.
Laboratory investigations including complete blood count, 
renal function test, and liver function test were normal. Patient 
was subjected to cross sectional imaging of non-contrast 
computed tomography (NCCT) and magnetic resonance 
imaging (MRI) of the dorsal spine. NCCT of the dorsal spine 
in axial (Fig. 1a and b) and sagittal (Fig. 1c) images show 
expansible lesion of D3 vertebral body involving posterior 
elements giving characteristic “polka dot” appearance. MR 
T1W images of the spine showed hyperintensity in body 
and posterior element of D3 vertebrae which was suppressed 
on fat sat sequences (Fig. 2a-c). MR T2W images showed 
characteristic polka dots appearance (Fig. 3a-c). MR 
TIW contrast enhanced images have shown avid contrast 
enhancement in the vertebral body and posterior element 
of D3 vertebra (Fig. 4a-c). Diagnosis of aggressive VH was 
made on the basis of NCCT and MRI. The case was managed 
with decompressive laminectomy without pre-surgery 
embolization. Histopathological examination of the specimen 
showed displacement of bone by multiple vascular spaces. The 
Vol 2 | Issue 1 | Jan - Mar 2015 Indian J Child Health 38
Sharma et al. Atypical aggressive vertebral hemangioma
irradiation of the involved region was advised in follow up 
for further management. 20 fractions were advised in 4 weeks 
period in divided doses with a total dose of 40 Gy.
DISCUSSION
VH are called as aggressive hemangiomas because of their 
extra-osseous extension, bone expansion, disturbance of blood 
flow, and occasionally compression fracture of the involved 
vertebra. These behave like infiltrative mass and can cause 
mass effect on the spinal cord. Rarely, it can also present with 
back pain in younger age group. These may be associated with 
severe cord compression, which gradually leads to neurological 
deficits. VH presenting with back pain is very rare and Cross 
et al. reported four cases and one out of which has presented 
with cord compression [3]. The differential diagnosis of back 
Figure 1: Non-contrast dorsal spine computed tomography. Axial (a and b) and sagittal (c) images show expansile lesion of 
D3 vertebral body and posterior elements (broad arrow in c). Trabecular thickening and intervening decreased density gives 
the characteristic “polka dot” appearance on axial images (white arrow in a and black arrow in b). Right paravertebral and 
epidural soft tissue component is seen extending from D2 to D4 vertebrae
cba
Figure 2: Magnetic resonance T1W sagittal (a) and axial (b) images show hyperintensity in body and posterior element of D3 
vertebrae (arrow in a and star in b) which is suppressed on fat sat T1W sagittal image (arrow in c)
cba
Figure 3: Magnetic resonance T2W sagittal (a and b) and axial (c) images show hyperintensity in body and posterior element 
of D3 vertebrae with mild expansion and coarse vertical trabeculae (polka dots). Hyperintense soft tissue component is seen in 
epidural space and right paravertebral space with thinning and myelomalacic changes in the cord (black arrow in a)
cba
Vol 2 | Issue 1 | Jan - Mar 2015 Indian J Child Health 39
Sharma et al. Atypical aggressive vertebral hemangioma
pain in adolescents includes non-specific pain or muscle strain, 
herniated disc, spondylolysis, scoliosis and Scheuermann’s 
kyphosis. Less common causes include intramedullary tumors 
like hemangioblastoma, ependydoma and astrocytoma, 
infection and sickle cell crisis. Therefore, careful evaluation of 
these patients is of paramount importance, and VH has to be 
differentiated from these pathologies [4-7].
Management of these cases also varies depending upon 
the aggressiveness of the VH. There is an inverse relationship 
between the amount of intra-osseous fatty stroma and 
aggressiveness of the lesion [8]. Asymptomatic VH shows 
high signal intensity on both T1 and T2 sequences that helps 
to distinguish them from lymphoma and other highly cellular 
neoplasms as has been seen in our case [9]. Involvement of 
the posterior elements and the whole vertebral body with less 
marked pathological compression of the vertebral body points 
more towards symptomatic VHs when compared to metastatic 
diseases. Friedman [6] suggested following characteristics to 
consider aggressive VH: Female sex, mid-thoracic location, 
marked hyperintensity on T2, intraosseous signal voids and 
enlarged paraspinal vessel.
Surgical resection using the laminectomy with or without 
fusion is advocated. In cases with spinal cord compression, a 
decompressive laminectomy is usually preferred [10].
There is no standard treatment protocol for active or 
aggressive VH. Initial management includes supportive 
treatment with analgesics. Radiation therapy or embolization 
is an effective therapeutic alternative for patients with 
severe refractory pain with no neurological deficits or 
with slowly developing neurological symptoms [11]. The 
region of interest is irradiated with 40 Gy in divided doses 
over 4 weeks. However, in case of rapidly progressing 
neurological deficits, surgical decompression with spinal 
reconstruction is needed [12]. The management protocol of 
these patients includes preoperative embolization and surgical 
decompression which is followed by radiation [13]. Annual 
neurological and radiological examination is recommended 
for the patients where hemangiomas are associated with 
pain [2].
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Figure 4: Post-contrast magnetic resonance T1W Sagittal (a and b) and axial (c) images show avid enhancement in vertebral body 
and posterior element of D3 vertebra with visualization of prominent draining vessels (black arrow in b). Right paravertebral 
and epidural soft tissue component show similar enhancement. Epidural soft tissue is seen extending from D2 to D4 vertebral 
level
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Funding: None; Conflict of Interest: None Stated
How to cite this article: Sharma BB, Sharma S, Sharma S, 
Balesa J, Jilowa S, Singh Y. Aggressive vertebral hemangioma in 
early adolescent age group: Atypical presentation with computed 
tomography and magnetic resonance imaging appearance. Indian 
J Child Health. 2015;2(1):37-9.


Aggressive vertebral hemangioma in early adolescent age group: Atypical presentation with computed tomography and magnetic resonance imaging appearance

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Aggressive vertebral hemangioma in early adolescent age group: Atypical presentation with computed tomography and magnetic resonance imaging appearance

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