Vascular Case Report 10














New York University School of Medicine Department of Radiology
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Vascular Case Report 10
Contributor: Allison Levy, M.D. and Manmeen Kaur, M.D.
Date: June 30, 2004


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Patient History

10 year-old girl with an enlarging mass on her left flank.

Images

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	Figure 1: Coronal T2-weighted turbo spin echo (TSE) with fat saturation.
	Figure 2: Axial T2-weighted turbo spin echo (TSE).

Movies

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Movie 1: Coronal time-resolved contrast-enhanced MRA.

Findings

Figure 1: Coronal T2 weighted image shows a hyperintense mass within the musculature of the left flank.

Figure 2: Axial T2 weighted image demonstrates a hyperintense lesion within the musculature of the left flank with flow voids within the lesion.

Movie 1: Coronal time resolved contrast enhanced MRA demonstrates a 4.5 x 3.9 x 2.5 cm enhancing intramuscular mass within the lower aspect of the abdominal wall/left flank. There is early enhancement with arterial supply via a large central branch from a left lower lumbar artery.

Diagnosis

Capillary hemangioma.

Discussion

Hemangioma, a tumor of vascular origin, is the most common tumor of childhood, occurring in 12% of infants. There is often a two-stage process of growth and regression. At birth, 60% of hemangiomas are not present. If the hemangioma is present it is usually small or inconspicuous. Shortly after birth, there is a phase of rapid proliferation that can last several months. Following this phase, hemangiomas typically begin to involute at approximately 10 months of age with 50% being completely resolved by 5 years of age. Most hemangiomas require no therapy. However, potential complications include Kassabach-Merritt syndrome (consumptive coagulopathy), compression of vital structures, and ulceration or bleeding. If treatment is necessary, options may include sclerosing agents, radiation, cryotherapy, lasers, embolization, and ligation of the feeding vessel with varying results. Often a combination of treatments are used. However, surgical removal offers the best outcome.

The diagnosis of hemangioma is often made based on growth history and physical inspection. Imaging is only required in atypical cases to characterize the lesion and evaluate the anatomic extent of disease. MR imaging demonstrates a discrete lobulated mass that is hyperintense on T2-weighted images and isointense to muscle on T1-weighted images. Typically, prominent draining veins will be identified as both central and peripheral high-flow vessels. There is diffuse enhancement with gadolinium. There may be fibrofatty tissue seen with involuting hemangiomas. In some cases it may be difficult to differentiate a hemangioma from the appearance of a soft tissue malignancy of infancy so it may be necessary to biopsy the lesion in order to exclude malignancy.

References:

Donnelly, Lane F. Fundamentals of Pediatric Radiology . Philadelphia : WB Saunders Co. 2001.
Mandel,L. DDS, Surattanont F. DDS. Clinical And Imaging Diagnoses Of Intramuscular Hemangiomas: The Wattle Sign And Case Reports . Journal of Oral and Maxillofacial Surgery . 2004; 62(6): 754-758.


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