Lumbar vertebral hemangioma presenting with the acute onset of neurological symptoms

Case report

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✓Vertebral hemangiomas are common entities that rarely present with neurological deficits. The authors report the unusual case of a large L-3 vertebral hemangioma with epidural extension in a 27-year-old woman who presented with hip flexor and quadriceps weakness, foot drop, and leg pain. The characteristics of the mass on magnetic resonance imaging suggested an aggressive, hypervascular lesion. The patient underwent embolization of the lesion followed by direct intralesional injection of ethanol. Significant resolution of clinical symptoms was observed immediately after the procedure and at her follow-up visits. Follow-up imaging studies obtained 9 months after the procedure also documented a considerable reduction in the size of the hemangioma with minimal loss of vertebral height and a mild kyphosis at the affected level. On repeated imaging studies obtained 21 months postoperatively, the size of the hemangioma and the degree of vertebral body compression were stable. As demonstrated in this case, patients with vertebral hemangiomas can present with acute nerve root compression and signs and symptoms similar to those of disc herniation. Vertebral hemangiomas can be treated effectively with interventional techniques such as embolization and ethanol injection.

Abbreviations used in this paper:MR = magnetic resonance; VB = vertebral body.

Article Information

Address reprint requests to: M. Sean Grady, M.D., Department of Neurosurgery, University of Pennsylvania, 3400 Spruce Street, Philadelphia, Pennsylvania 19104. email: gradys@uphs.upenn.edu.

© AANS, except where prohibited by US copyright law.

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Figures

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    Imaging studies obtained at presentation. Sagittal T1-weighted MR images obtained before (A) and after (B) the addition of contrast demonstrating a hypointense, enhancing lesion involving the entire L-3 VB with extension into the epidural space. On axial T2-weighted imaging (C), the lesion is seen to extend into the left pedicle, transverse process, and lamina, as well as the left paravertebral space. The epidural tissue is seen compressing the thecal sac. Sagittal (D), coronal (E), and axial (F) views of the bone architecture on computed tomography imaging show the classic vertical striations due to trabecular thickening attributed to vertebral hemangiomas.

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    Anteroposterior angiograms. Upper: Contrast can be seen puddling within the L-3 VB after injection at the left L-3 lumbar artery. Embolization was performed with polyvinyl alcohol particles. Arterial feeding vessels to the hemangioma were not observed after injection of the other lumbar arteries from T-10 to L-4. Lower: On postembolization angiography, no contrast is seen within the L-3 VB after left L-3 lumbar artery injection.

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    Follow-up T2-weighted MR images. Significant resolution of the epidural and paravertebral components of the hemangioma is demonstrated at 3 weeks (A) and 9 months (B) after ethanol treatment. A sagittal image (C) obtained 9 months after ethanol treatment shows minimal L-3 VB collapse and mild kyphosis at the L2–3 level. Bone edema, probably secondary to mechanical stress, is seen in the anterior–inferior aspect of the L-2 VB.

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