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Radiology
Management
of Vertebral body hemangioma by transarterial embolisation and percutaneous
alcohol ablation.
A 14-year-old girl presented with progressive weakness and numbness in both lower extremities. The weakness progressed from distal to proximal and over a period of two months, the patient became bed-ridden.
Plain films and MRI (Fig 1, 2) of the dorsal spine showed a hemangioma involving the D10 vertebral body and posterior elements causing partial collapse. The lesion had paravertebral and intraspinal extension causing cord compression.
The patient was operated for vertebral body stabilization with Harrington rods. However, there was no improvement. Gradually she developed difficulty in passing urine and stools at which time she was referred to our institution. She now had spastic paraplegia with flexor spasms. Pain & touch sensation were impaired below D11 level on both sides.
In view of the previous surgery and cord compression, it was decided to treat the hemangioma by intra-arterial alcohol instillation and particle embolisation.
The spinal angiogram at D10, D9 & D11 levels revealed a prominent blush involving the D10 vertebral body and posterior elements (Fig 3).
Selective left D10 intercostal angiogram revealed a prominent vertebral body blush, which was embolised with 5cc of absolute alcohol followed by occlusion of the feeding artery with PVA particles. Bilateral D11& D9, right D10 intercostals were selectively cannulated and embolization done with 150-250 micron PVA particles (Fig. 4).
Post embolisation, the patient reported significant improvement in lower-extremity strength from Grade 0/5 to 3/5 power in left lower limb and 1/5 in right lower limb as also improvement in sensations. The spasticity in the lower limbs significantly decreased and the bladder symptoms disappeared. She was treated with Methylpredinosole 1gm followed by Inj. Dexamethasone 4mg TDS for two days. Physiotherapy was also instituted.
After a month, CT guided direct puncture of the D10 vertebral body was performed by a left transpedicular route and 4mlof absolute alcohol injected. The needle tract was sealed with 25% cyanoacrylate glue (Fig. 5)
The patient reported for follow-up after 6 weeks with dramatic improvement in power in both lower limbs. She was able to walk without support. There was no spasticity. The flexor spasms had disappeared. Touch and pain sensation improved. No bladder or bowel complaints were present (Fig. 6)
DISCUSSION:
Skeletal hemangiomas are caused by hamartomatous proliferation of vascular tissue - more precisely of endothelial tissue. A hemangioma is a benign tumor that is most frequently localized in the spine - involving about 10% of the population. It is often a solitary lesion, usually localized in the vertebral body, although it may extend to the posterior arch. There is predilection for the thoracic region of the spine, while it less frequently occurs in the cervical and lumbar spines. Generally, it remains asymptomatic throughout life.
Though vertebral hemangiomas are relatively common those causing spinal cord compression are rare. Symptomatic hemangioma (less than 1% of all hemangioma) are most often observed during adult age.
Early diagnosis and treatment of the intraspinal extension of the hemangioma is critical to prevent permanent and irreversible neurologic deficit.
Imaging features include plain radiographs showing a striated appearance of the involved vertebra. Sometimes, a compression fracture may be seen. On CT, vertebral hemangiomas are seen as lucent areas separated by bony trabecule. MRI features depend upon the fat content of the lesion. The lesions are typically hyper intense on both T1 and T2 weighted sequences.
Therapeutic options available for vertebral hemangioma are:
Direct injection of ethanol into symptomatic vertebral hemangioma is an effective and safe treatment - provided the dose is less than 15mL. This treatment is targeted at both extra osseous and intraosseous components of the hemangioma. Absolute alcohol is a sclerosant and causes tissue necrosis. Hence, alcohol ablation will reduce the exatraosseous component responsible for cord compression. Within the vertebral body, it causes reduction in the hemangiomatous tissues, but resultant tissue necrosis may lead to weakening of bony trabecule. In such cases, percutaneous vertebroplasty using bone cement may be needed as it consolidates the vertebral body and provides biomechanical strength. This is usually undertaken about three months after alcohol ablation.
In cases where there is a large paravertebral extension, additional alcohol injection is made in the paravertebral soft tissue component to induce shrinkage of the whole tumor mass and release the compression on the spinal cord.
We, propose a protocol for the comprehensive treatment of vertebral hemangioma by interventional neuroradiology.
I. If patient presents with backache and no neurological deficit and imaging rules out epidural and or extra osseous extension, transarterial particle embolization followed by strengthening of the vertebra by percutaneous vertebroplasty will suffice.
II. But if imaging shows epidural and extra osseous soft tissue and patient presents with some form of neurological deficit, then
- transarterial particle embolization followed by
- CT guided percutaneous alcohol ablation followed by strengthening of the vertebra by percutaneous vertebroplasty should be the ideal and adequate treatment.
III. However if the collapse of the vertebra is more than 2/3 of its height, then kyphoplasty should be tried to restore the height and strengthen the vertebra.
With this strategy, we feels that surgery and its associated potential morbidity can be avoided in properly selected patients.
Case 19 : Contributed
by Dr. Suyash Kulkarni
Other Cases
A 14-year-old girl presented with progressive weakness and numbness in both lower extremities. The weakness progressed from distal to proximal and over a period of two months, the patient became bed-ridden.
Plain films and MRI (Fig 1, 2) of the dorsal spine showed a hemangioma involving the D10 vertebral body and posterior elements causing partial collapse. The lesion had paravertebral and intraspinal extension causing cord compression.
 |
 |
|
Fig
1
|
Fig
2
|
The patient was operated for vertebral body stabilization with Harrington rods. However, there was no improvement. Gradually she developed difficulty in passing urine and stools at which time she was referred to our institution. She now had spastic paraplegia with flexor spasms. Pain & touch sensation were impaired below D11 level on both sides.
In view of the previous surgery and cord compression, it was decided to treat the hemangioma by intra-arterial alcohol instillation and particle embolisation.
The spinal angiogram at D10, D9 & D11 levels revealed a prominent blush involving the D10 vertebral body and posterior elements (Fig 3).
 |
|
Fig
3
|
Selective left D10 intercostal angiogram revealed a prominent vertebral body blush, which was embolised with 5cc of absolute alcohol followed by occlusion of the feeding artery with PVA particles. Bilateral D11& D9, right D10 intercostals were selectively cannulated and embolization done with 150-250 micron PVA particles (Fig. 4).
 |
|
Fig
4
|
Post embolisation, the patient reported significant improvement in lower-extremity strength from Grade 0/5 to 3/5 power in left lower limb and 1/5 in right lower limb as also improvement in sensations. The spasticity in the lower limbs significantly decreased and the bladder symptoms disappeared. She was treated with Methylpredinosole 1gm followed by Inj. Dexamethasone 4mg TDS for two days. Physiotherapy was also instituted.
After a month, CT guided direct puncture of the D10 vertebral body was performed by a left transpedicular route and 4mlof absolute alcohol injected. The needle tract was sealed with 25% cyanoacrylate glue (Fig. 5)
 |
|
Fig
5
|
The patient reported for follow-up after 6 weeks with dramatic improvement in power in both lower limbs. She was able to walk without support. There was no spasticity. The flexor spasms had disappeared. Touch and pain sensation improved. No bladder or bowel complaints were present (Fig. 6)
 |
|
Fig
6
|
DISCUSSION:
Skeletal hemangiomas are caused by hamartomatous proliferation of vascular tissue - more precisely of endothelial tissue. A hemangioma is a benign tumor that is most frequently localized in the spine - involving about 10% of the population. It is often a solitary lesion, usually localized in the vertebral body, although it may extend to the posterior arch. There is predilection for the thoracic region of the spine, while it less frequently occurs in the cervical and lumbar spines. Generally, it remains asymptomatic throughout life.
Though vertebral hemangiomas are relatively common those causing spinal cord compression are rare. Symptomatic hemangioma (less than 1% of all hemangioma) are most often observed during adult age.
Early diagnosis and treatment of the intraspinal extension of the hemangioma is critical to prevent permanent and irreversible neurologic deficit.
Imaging features include plain radiographs showing a striated appearance of the involved vertebra. Sometimes, a compression fracture may be seen. On CT, vertebral hemangiomas are seen as lucent areas separated by bony trabecule. MRI features depend upon the fat content of the lesion. The lesions are typically hyper intense on both T1 and T2 weighted sequences.
Therapeutic options available for vertebral hemangioma are:
- Transarterial particle embolization,
- CT guided percutaneous alcohol ablation and
- Surgical decompression or total removal of tumor mass with bone grafting
- Percutaneous vertebroplasty
- Radiotherapy
Direct injection of ethanol into symptomatic vertebral hemangioma is an effective and safe treatment - provided the dose is less than 15mL. This treatment is targeted at both extra osseous and intraosseous components of the hemangioma. Absolute alcohol is a sclerosant and causes tissue necrosis. Hence, alcohol ablation will reduce the exatraosseous component responsible for cord compression. Within the vertebral body, it causes reduction in the hemangiomatous tissues, but resultant tissue necrosis may lead to weakening of bony trabecule. In such cases, percutaneous vertebroplasty using bone cement may be needed as it consolidates the vertebral body and provides biomechanical strength. This is usually undertaken about three months after alcohol ablation.
In cases where there is a large paravertebral extension, additional alcohol injection is made in the paravertebral soft tissue component to induce shrinkage of the whole tumor mass and release the compression on the spinal cord.
We, propose a protocol for the comprehensive treatment of vertebral hemangioma by interventional neuroradiology.
I. If patient presents with backache and no neurological deficit and imaging rules out epidural and or extra osseous extension, transarterial particle embolization followed by strengthening of the vertebra by percutaneous vertebroplasty will suffice.
II. But if imaging shows epidural and extra osseous soft tissue and patient presents with some form of neurological deficit, then
- transarterial particle embolization followed by
- CT guided percutaneous alcohol ablation followed by strengthening of the vertebra by percutaneous vertebroplasty should be the ideal and adequate treatment.
III. However if the collapse of the vertebra is more than 2/3 of its height, then kyphoplasty should be tried to restore the height and strengthen the vertebra.
With this strategy, we feels that surgery and its associated potential morbidity can be avoided in properly selected patients.