Musculoskeletal Imaging

Haemangioma

a benign vascular tumour that is especially common on the skin but may be present in any tissue, including bone, muscle, tendon, synovium and connective tissue. For a general description, see haemangioma.

Most lesions are asymptomatic. The tumours are found in numerous conditions, such as consumption coagulopathy, cardiac decompensation, gangrene, osteomalacia, varicose veins, massive osteolysis, Maffuccis syndrome, Klippel Trenaunay Weber syndrome and Kasabach Merritt syndrome.

Classically haemangiomas have been divided into capillary, cavernous, and mixed (capillary cavernous) types. Capillary haemangiomas are composed of capillaries with a sparse fibrous stroma, whereas cavernous haemangiomas are composed of large, dilated, blood-filled spaces lined by flat endothelium. On radiographs soft tissue tumours appear as nonhomogeneous masses of water density with poorly defined margins. Occasionally tortuous channels of water density are observed within the adjacent subcutaneous fat, which represent the arterial supply and venous drainage of the tumour, and calcification is common. A specific type of calcification is the phlebolith, a rounded calcific mass that frequently has a laminated structure (Fig.1).

Synovial haemangiomas are uncommon and occur most frequently in the knee (Fig.2). Frequently they are associated with adjacent cutaneous and deeper soft tissue haemangiomas, as in Klippel Trenaunay Weber syndrome and Parke Weber syndrome. Plain film radiographs usually show soft tissue swelling or a mass about the involved joint, osteoporosis and subchondral bone erosions and cysts; phleboliths may also be present. Leg length discrepancy, periosteal new bone and epiphyseal overgrowth may be seen. On arthrography the intra-articular mass appears as multiple filling defects with a villous configuration that are hypervascular on arteriography.

Haemangiomas of bone are fairly common; frequently they are discovered incidentally on radiographs (Fig.3). The tumours may occur in the spine, skull or facial bones (mandible and maxilla). Spinal haemangiomas present a corduroy appearance of the vertebral bodies (a coarse vertical trabecular pattern) and sometimes of the pedicles and laminae. A honeycomb or cartwheel configuration may also be observed. Extraspinal haemagiomas of bone appear as radiolucent, slightly expansile, well-defined lesions with cortical thinning and a distinctive trabecular pattern on radiographs. Intracortical and periosteal haemangiomas occur most commonly in the diaphysis of long tubular bones.

Histiocytoid haemangioma is an epithelioid variant of haemangioendothelioma.

Enchondromatosis with soft tissue haemangiomas that may undergo malignant transformation is known as Maffuccis syndrome.

Bone scans may be helpful in diagnosing haemangiomas, but CT scanning and MR imaging, particularly after administration of contrast agent, can provide additional information.

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Fig.1

Phleboliths PA radiograph of the hand demonstrates numerous phleboliths within the dilated vascular spaces of a soft tissue haemangioma.
Haemangioma, Fig.1
Haemangioma, Fig.2 (a)
Haemangioma, Fig.2 (b)
Haemangioma, Fig.3 (a)
Haemangioma, Fig.3 (b)
Haemangioma, Fig.3 (c)