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Primary intraosseous hemangioma

Primary intraosseous hemangiomas are vascular hamartomas arising within bone, seen most frequently in the vertebrae or skull. Given their nonneoplastic nature, some authors prefer to refer to these lesions as vascular malformations rather than hemangiomas. These come in four histological varieties (see below) 1,2.

Intraosseous hemangiomas are common, with vertebral hemangiomas seen in 10-15% of the adult population. They are more commonly encountered in men (M:F ratio of 2:1) and typically seen in the 4th to 5th decade of life.

These tumors are slow growing and are generally asymptomatic unless they exert mass effect on sensitive structures. Occasionally they may present as a swelling or a palpable mass, especially in the skull. When large and strategically located, they may present with a pathological fracture.

If they are high-flow lesions, shunt-related symptoms may also be present.

Primary intraosseous hemangiomas are slow growing vascular malformations, usually located in the medullary cavity. They are classified as benign, but rarely may be locally aggressive.

Intraosseous hemangiomas come in four histologic types:

  1. intraosseous cavernous hemangioma
  2. intraosseous capillary hemangioma
  3. intraosseous arteriovenous hemangioma (may represent congenital arteriovenous malformations) 2
  4. intraosseous venous hemangioma

Histologically, intraosseous hemangiomas demonstrate hamartomatous vascular tissue within endothelium, but may also contain fat, smooth muscle, fibrous tissue, and thrombi.

It should be noted that it is difficult to distinguish between the various histological types on imaging, except for those with a large arterial component.

Plain radiographs are usually the first line of imaging and may be sufficient in vertebral or calvarial lesions. Findings include:

  • prominent trabecular pattern
  • sclerotic vertebra with vertical trabeculae: corduroy sign
  • lytic calvarial lesions with spoke-wheel appearance
  • irregular and lytic in long bones, with a honeycomb appearance

Usually as an incidental finding, especially in the vertebrae.

Better visualization of thickened vertical trabeculation: polka-dot appearance on axial images and corduroy sign on coronal and sagittal images.

Signal intensity is somewhat variable, depending largely on the amount of fat content.

  • T1
    • high is more common (fat rich)
    • intermediate to low signal intensity is seen in fat poor hemangiomas
  • T2: high
  • T1 C+ (Gd): enhancement is often present
  • STIR: intermediate or high

MRI is the ideal modality to demonstrate mass-effect complications, such as neural impingement and extraosseous extension.

Usually normal but may show increased or decreased uptake.

Treatment is reserved for symptomatic lesions, and a number of options exist:

  • radiation therapy
  • embolization to reduce intraoperative blood loss
  • surgical resection, especially if complicated by spinal cord compression
  • vertebroplasty
  • intralesional ethanol injection
Bone tumours

The differential diagnosis for bone tumors is dependent on the age of the patient, with a very different set of differentials for the pediatric patient.

Article information

rID: 6742
Synonyms or Alternate Spellings:
  • Primary osseous haemangioma
  • Primary osseous hemangioma
  • Osseous haemangioma
  • Osseous hemangioma
  • Primary intraosseous hemangioma
  • Intraosseous haemangioma
  • Intraosseous hemangioma
  • Osseous haemangiomas
  • Osseous hemangiomas
  • Primary osseous haemangiomas
  • Primary osseous hemangiomas

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Cases and figures

  • Case 1: sacral hemangioma : MR
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  • Case 2: vertebral hemangioma : CT
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  • Case 3: vertebral hemangioma : MR : T1
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  • T2 axial
    Case 4: cranial vault hemangioma
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  • Case 5
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  • Case 6: intraosseous hemangioma
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  • Case 7: vertebral hemangioma
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  • Case 8: tibial head
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  • Case 9
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  • Case 10: with complicating patholgical fracture
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  • Case 11: in spine
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  • Case 12: vertebral
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  • Case 13: vertebral
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  • Case 14: cranial vault
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  • Case 15: skull
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  • Case 16
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