[Orbital hemangiomas: capabilities of modern neuroradiological diagnostics]. / Gemangiomy orbity: vozmozhnosti sovremennoi neiroradiologicheskoi diagnostiki.

MATERIAL AND METHODS: In the period from 2010 to 2016. 14 patients with cavernous hemangioma (CH) and 2 patients with capillary hemangioma (CapH) of the orbit were examined. The age of CH patients varied from 17 to 67 years (median, 53 years); 8 females and 6 males. The age of CapH patients was 35 and 54 years. All patients underwent surgery with subsequent histological verification. CT-perfusion was performed in 10 CH patients and 2 CapH patients according to a developed low-dose protocol (80 kV, 200 mAs, tscan=40 s) with allowance for a target localizer (80 kV, 120 mAs) and at a maximum radiation dose of not more than 4.0 mZv. Neoplasm microcirculation was quantitatively assessed by calculating hemodynamic parameters: blood flow velocity (BFV), blood volume (BV), and mean transit time (MTT). MRI without and with contrast enhancement was performed in 11 CH patients and 2 CapH patients according to the ophthalmologic protocol (Signa GE, 3.0 T) accepted at the Institute: without contrast enhancement - T1, T2, and T2-FLAIR modes, T1 and T2 with a Fat Sat technique at a scan thickness of 3 mm, and DWI MRI; contrast enhancement - T1 (three projections) mode, including the Fat Sat technique. SWAN (n=2) and non-contrast MR perfusion ASL (n=3) were also used. Diffusion-weighted images (DWI) were processed with calculation of the apparent diffusion coefficient (ACD). RESULTS: In all CH patients, CT-perfusion revealed low perfusion parameters of blood flow: BVCH=0.86±0.37 mL/100 g, BFVCH= 4.89±2.01 mL/100 g/min with a high mean transit time MTTCH=10.13±3.05 s compared to the same parameters of blood flow in the normal white matter: CBVNormWM=1.63±2.22 mL/100 g, CBFVNormWM=9.72±3.13 mL/100 g/min, and MTTNormWM=6.76±2.78 s. In CapH cases, significantly increased blood flow velocity and volume values and a low MTT value in the tumor were observed: BVCapH=10.30±4.10 mL/100 g, BFVCapH=119.72±53.13 mL/100 g/min, and MTTCapH=4.35±1.79 s. In the case of orbital hemangiomas, optimal MRI modes were T1 and T2 with the Fat Sat technique, a scan thickness of 3 mm, and intravenous contrast enhancement. The revealed pattern of contrast agent accumulation by CH, initially in the central part and then in the periphery, may be a useful radiographic sign in the differential diagnosis with other orbital tumors. CONCLUSION: Modern CT- and MRI-based diagnostics of orbital hemangiomas provides not only the exact location, size, and spread of the lesion but also reveals the characteristic structural features of these tumors, and the use of perfusion techniques visualizes hemodynamics of the tumors. CT-perfusion-based hemodynamic parameters of cavernous hemangiomas typical of this type of hemangiomas may be used in the differential diagnosis with other tumors of this location. The use of contrast enhancement and the Fat Sat technique with a scan thickness of not more than 3 mm is optimal for MRI diagnostics of orbital hemangiomas.

Outcome using selective hemihepatic vascular occlusion and Pringle maneuver for hepatic resection of liver cavernous hemangioma.

BACKGROUND: Though accumulated evidence proved the advantages of laparoscopic hepatectomy, bleeding still remains the most important challenge in clinical practice. Our study aimed to compare the outcomes of Pringle maneuver (PM) and selective hemihepatic vascular occlusion (SHVO) surgeries for patients with liver cavernous hemangioma (LCH). METHODS: The SHVO (n = 26; mean age, 42) and PM (n = 78; mean age, 43) surgeries were performed in 104 LCH patients from January 2006 to January 2015. The intraoperative (bleeding, arterial pressure, oxyhemoglobin saturation, etc.) and postoperative parameters (anal exhaust time, complications, blood cell numbers, etc.) were measured and compared between the two groups. Liver function of all these patients was detected by blood test at 1-day preoperation, and at 1, 3, and 5 days postoperation. RESULTS: Both of the two surgeries were successfully performed without any mortality. The intraoperative systolic arterial pressure and pulse in PM group were much higher than that in SHVO group (P < 0.01). The postoperative liver function parameters such as alanine transaminase (ALT), aspartate transaminase (AST), and total bilirubin (TBIL) increased much more in the PM group than that in the SHVO group compared with preoperation results (P < 0.05). However, there were no statistical differences in intraoperative bleeding, blood transfusion, hepatic inflow occlusion time, oxygen saturation occlusion, anal exhaust time and incidence of complications between the two groups (P > 0.05). CONCLUSIONS: SHVO is safer with less ischemia reperfusion injury than PM surgery for hemangioma resection on patients with LCH.

[Cavernous haemangioma of the chest wall--case report]. / Naczyniak jamisty sciany klatki piersiowej--opis przypadku.

BACKGROUND: Cavernous hemangiomas are among the least common benign chest wall masses. The aim of this study is to present a case of a 40-year-old women, with a giant cavernous haemangioma arising in the left axillary area. CASE REPORT: A 40-year-old female, was referred to a pulmonologist, after her chest radiograph showed, in the upper field of the left lung, a peripherally located shading (13 cm long and 3.5 cm deep) connecting with the pleura. The skin above the change was not discoloured. Contrast-enhanced CT showed a cavernous haemangioma (17 cm long and 13 cm wide) located mostly in the left axillary area. The main vascular supply of the haemangioma came from a direct branch of the left axillary artery, the left intervertebral arteries (levels Ill-VII) and a branch of the left internal thoracic artery. CONCLUSIONS: This report illustrates a rare case of a giant cavernous haemangioma and the treatment challenges it poses.

An analysis of flow dynamics in cerebral cavernous malformation and orbital cavernous angioma using indocyanine green videoangiography.

BACKGROUND: Cerebral cavernous malformations (CCMs) are known to be vascular anomalies with low perfusion because of being angiographically occult. We attempted direct visualization of blood flow within CCMs and orbital cavernous angiomas (CAs), and analyzed flow dynamics using indocyanine green videoangiography (ICG-VAG). METHODS: This series included seven CCMs and two orbital CAs. ICG-VAG was performed to visualize blood flow of the lesions before resection. Time to peak of staining was evaluated by reviewing recorded ICG-VAG. RESULTS: In five of seven CCMs, stain was identified. CCMs were seen as avascular areas in both arterial and venous phases, and were stained gradually. Stain was maximized late after venous phase. The orbital CAs were also stained lately, but more intensely than CCMs. CONCLUSIONS: The present study directly demonstrated slow and low perfusion within CCM and orbital CA using ICG-VAG. On the basis of characteristic flow dynamics of CCMs, intraoperative ICG-VAG provides useful information in microsurgical resection.

Pre-operative arterial embolization of symptomatic giant hemangioma of the liver.

The cavernous hemangiomas of the liver are usually small sized and asymptomatic. Most of them are incidentally diagnosed and a very small portion requires therapy. Giant hemangioma can be symptomatic, and this condition is the indication for treatment. The striking complication of surgical treatment of cavernous hemangiomas is intra-operative bleeding. In this case, we aimed to demonstrate that the risk of intraoperative bleeding can be eliminated with the preoperative percutaneous trans-catheter arterial embolization technique.

Respiratory motion correction in free-breathing ultrasound image sequence for quantification of hepatic perfusion.

PURPOSE: Evaluation of regional hepatic perfusion by contrast-enhanced ultrasound (CEUS) is helpful to the differential diagnosis of focal liver lesions (FLLs). Because most patients cannot hold their breath for the duration of the entire hepatic perfusion scan, ultrasonographists tend to employ free-breathing acquisition method. A new strategy using a combination of template matching and frame selection is proposed to correct the respiratory motion and improve the accuracy of the quantification evaluation of the perfusion. METHODS: Considering that most commercial ultrasound machines can provide a dual display mode for simultaneously visualizing contrast and tissue images, the registration of the contrast images was achieved by the registration of the corresponding tissue images. After the template was located, the rough search space was estimated using a priori knowledge of the tumor location in the free-breathing image sequence. Then, a simple double-selection method was proposed to select the similar images from a large number of successive matched images via global and local threshold settings. In this method, alpha and m were the offset of the global threshold and the time interval for setting local sampling range, respectively. These two parameters were also investigated. The strategy was tested on ten liver CEUS acquisitions with a handle probe by using sum of absolute differences (SAD) metric. The visual evaluation for 2D image sequences and the extracted time-intensity curves from the regions of interest were performed. Simpler curve descriptors of the motion-uncorrected and motion-corrected image sequences were calculated on a pixel-by-pixel basis and evaluated as parametric perfusion maps. The quality of these parametric images was compared, in terms of both the accuracy and spatial resolution. For the corrected and uncorrected sequences, their mean deviation values (mDVs) and mean quality-of-fits (mQOFs) were measured. RESULTS: When alpha and m were both set to 0.5, 9.20 +/- 3.22% of the total number of frames were selected. After the motion correction, the mDVs of all the image sequences decreased from 21.69 +/- 2.80 to 13.78 +/- 2.68. The mQOFs of all the corrected sequences increased by an average of 15.32 +/- 5.13%. The quality of curve fitting and the corresponding parametric imaging computed on motion-corrected sequences were improved. On the average, the motion correction of a sequence containing about 100 frames was performed in approximately 3 min using MATLAB, whereas a completely manual approach requires approximately 10 min. CONCLUSIONS: The image-based strategy independent of the tumor size can quickly correct respiratory motion in CEUS image sequences. Simple manual operation is only needed, such as the selection of the template image and search space. It is user-friendly and suitable for most clinical cases affected by adverse factors of sampling. Due to the merit of the saving time, this strategy can be widely applied to clinical practice, and the diagnostic efficiency of FLLs will be improved. Moreover, the correction strategy is a key preprocessing step toward local quantification of hepatic perfusion studies.

Intra-tumoral ligation and the injection of sclerosant in the treatment of lingual cavernous haemangioma.

INTRODUCTION: Haemangiomas are developmental vascular abnormalities and more than 50% of these lesions occur in the head and neck region, with the tongue, buccal mucosa, lips and palate most commonly involve. They are considered as harmatomas rather than true neoplasms Factors such as patient's age, size and site of lesion and the proximity of lesion to vital structure are paramount in the determination of the therapeutic approach 7 surgical excision, cryotherapy, injection of feeder vessels with sclerosants and embolization of the blood vessels. CASE REPORT: We report the management of cavernous haemangioma of the tongue in a 38 year old man using intra-tumoral ligation (The Popescu Procedure) and injection of sclerosant under general anaesthesia. RESULT: The efficacy of this method lies in the fact that it obstructs the vascular channels to and from the entire tumour mass leading to progressive atrophy of the vascular endothelia, fibrous hyperplasia and the substitution of the angiomatous tissues by a fibroconnective tissue mass which initially appears excessive but remodels and produces an acceptable appearance which can be further improved by plastic surgery. CONCLUSION: The procedure was well tolerated and the patient made excellent recovery. It is recommended in our centre where facilities for technologically demanding methods are not available.

Cavernous hemangioma with arterioportal and portosystemic shunts: precise diagnosis with dynamic multidetector computed tomography imaging.

Cavernous hemangiomas with shunt formations have been a recently recognized entity. Arterioportal (AP) shunts with cavernous hemangiomas have been described. However, a combination of AP and portosystemic (PS) shunts causing portal hypertension has not been previously demonstrated by computed tomography (CT) imaging. In this study, we report an atypical cavernous hemangioma associated with portal hypertension. Cavernous hemangioma with AP and PS shunts formations was precisely demonstrated with dynamic multidetector CT imaging.

Cavernous hemangioma of the external ear: case report and literature review.

OBJECTIVES: To describethe occurrence of a cavernous hemangioma of the external auditory meatus extending to the middle ear and the retroauricolar region in an adult patient, and to review the relevant literature. METHODS: Case report. We report the clinical presentation, imaging studies and surgical procedures used in the study. RESULTS: The angiographic study showed that the blood supply of the mass originated from the posterior auricular artery. Via a retroauricular approach, this artery was isolated and ligated in order to control the intra-operative bleeding. A canal wall up mastoidectomy with posterior tympanotomy and a tympano-canaloplasty were performed, permitting a complete excision. At 36 months of follow-up, no clinical and radiological signs of recurrence were detected. CONCLUSION: Surgical removal is the treatment of choice, with rare recurrence of the hemangiomas. Pre-operative evaluation is based on computed tomography (CT scan), but should be followed by magnetic resonance angiography (MR-angio) or intra-arterial digital subtraction angiography (IA-DSA), especially in case of wider lesions.

Abnormal blood vessels formed by human liver cavernous hemangioma endothelial cells in nude mice are suitable for drug evaluation.

Cavernous hemangioma is vascular malformation with developmental aberrations. It was assumed that the abnormality of endothelial cells contributed greatly to the occurrence of cavernous hemangioma. In our previous study, we have found distinct characteristics of endothelial cells derived from human liver cavernous hemangioma (HCHEC). Here, we reported the abnormal vascular vessels formed by primary HCHEC in nude mice and that the drug podophyllotoxin can destroy HCHEC in vitro and in vivo. HCHEC was isolated from a human liver cavernous hemangioma specimen, and the HCHEC generated a red hemangioma-like mass 7 days after subcutaneously co-inoculating HCHEC and human liver cancer cells (Bel-7402) in nude mice. Lentiviral expression of GFP and immunohistochemistry for human CD31 was used to confirm that the HCHEC formed the blood vessels in nude mice. And the pathological features of vascular vessels formed by HCHEC were very similar to clinical cavernous hemangioma. In addition, by MTT assay, the drug podophyllotoxin was found inhibiting HCHEC viability, and by TUNEL and DNA ladder assays, podophyllotoxin was found inducing apoptosis of HCHEC. Moreover, podophyllotoxin was also effective for destroying the abnormal vascular vessels in the hemangioma-like mass in nude mice. In summary, the HCHEC can form abnormal blood vessels in nude mice, and we can evaluate drugs for cavernous hemangioma by using HCHEC in vitro and in vivo.

Differential expression of decorin by human malignant and benign vascular tumors.

An increasing amount of evidence indicates that a small extracellular chondroitin/dermatan sulfate proteoglycan, decorin, is indirectly involved in angiogenesis. Given that angiogenesis is a sine qua non for tumor growth and progression, we attempted to examine whether human malignant vascular tumors differ from human benign vascular tumors in terms of their decorin expression and synthesis. CD31 immunostaining demonstrated that the human malignant vascular tumors Kaposi's sarcoma and angiosarcoma were filled with capillary-like structures, whereas in benign cavernous and capillary hemangiomas, blood vessels were not as abundantly present. By utilizing in situ hybridization and immunocytochemical assays for decorin, we showed that there was no detectable decorin mRNA expression or immunoreactivity within the tumor mass in the Kaposi's sarcoma or angiosarcoma group. Instead, decorin was expressed in the connective tissue stroma lining the sarcoma tissue. In contrast to sarcomas, in hemangiomas, decorin mRNA expression and immunoreactivity were observed also within the tumor mass, particularly in the connective tissue stroma surrounding the clusters of intratumoral blood vessels. Finally, distribution of type I collagen was found to be similar to that of decorin in these tumor tissues. Our findings can be explained with different states of angiogenesis in dissimilar growths. In sarcomas, angiogenesis is extremely powerful, whereas in hemangiomas, angiogenesis has ceased. Thus, decorin is likely to possess a suppressive effect on human tumor angiogenesis in vivo, as previously described by studies using different experimental models. Decorin certainly provides a usable biomarker for distinguishing between benign and malignant vascular tumors in patients.

Contrast-enhanced US with Levovist for the diagnosis of hepatic hemangioma: time-related changes of enhancement appearance and the hemodynamic background.

BACKGROUNDS/AIMS: To elucidate the diagnostic confidence of contrast-enhanced ultrasound (CEUS) with Levovist for hepatic hemangioma. METHODOLOGY: The subjects were 34 patients with 38 hemangiomas and 12 patients with 15 hypervascular hepatocellular carcinomas. The early-phase (15-60 second) and liver-specific phase (after 5 min) were observed by the first injection. The 2nd injection was done for solo-phase method to observe liver-specific phase images without taking early-phase sonograms. The 3rd injection was done for changing posture method to observe liver-specific sonograms under left lateral ducubitus position. RESULTS: In the early-phase of hemangioma, nodular enhancement (NE) was found transiently in 13 lesions (34%) and continuously in 25 lesions (66%), while hepatocellular carcinoma (HCC, n = 15) did not show this pattern. Intratumoral arterioportal shunt was closely related to the short duration of NE. Two enhancement patterns were observed in the liver-specific phase of hemangioma, diffuse in 12 lesions (31%) and partial in 26 lesions (69%), which were dependent on the early-phase enhancement. Liver-specific findings were also affected by taking early-phase sonograms or changing the posture of the patient. This method provided sensitivity of 79% and specificity of 100% for the diagnosis of hemangioma. CONCLUSIONS: CEUS with Levovist may be promising method for the diagnosis of hepatic hemangioma.

Technetium tc 99m-labeled red blood cells in the preoperative diagnosis of cavernous hemangioma and other vascular orbital tumors.

OBJECTIVES: To evaluate technetium Tc 99m (99mTc) red blood cell scintigraphy as a diagnostic tool for orbital cavernous hemangioma and to differentiate between orbital masses on the basis of their vascularization. METHODS: We performed 99mTc red blood cell scintigraphy on 23 patients (8 female and 15 male; mean age, 47 years) affected by an orbital mass previously revealed with computed tomography (CT) and magnetic resonance imaging (MRI) and suggesting cavernous hemangioma. In our diagnosis, we considered the orbital increase delayed uptake with the typical scintigraphic pattern known as perfusion blood pool mismatch. The patients underwent biopsy or surgical treatment with transconjunctival cryosurgical extraction when possible. RESULTS: Single-photon emission tomography (SPET) showed intense focal uptake in the orbit corresponding to radiologic findings in 11 patients who underwent surgical treatment and pathologic evaluation (9 cavernous hemangiomas, 1 hemangiopericytoma, and 1 lymphangioma). Clinical or histologic examination of the remaining 22 patients revealed the presence of 5 lymphoid pseudotumors, 2 lymphomas, 2 pleomorphic adenomas of the lacrimal gland, 1 astrocytoma, 1 ophthalmic vein thrombosis, and 1 orbital varix. CONCLUSIONS: The confirmation of the preoperative diagnosis by 99mTc red blood cell scintigraphy shows that this technique is a reliable tool for differentiating cavernous hemangiomas from other orbital masses (sensitivity, 100%; specificity, 86%) when ultrasound, CT, and MRI are not diagnostic. Unfortunately, 99mTc red blood cell scintigraphy results were positive in 1 patient with hemangiopericytoma and 1 patient with lymphangioma, which showed increased uptake in the lesion on SPET images because of the vascular nature of these tumors. Therefore, in these cases, the SPET images have to be integrated with data regarding clinical preoperative evaluation and CT scans or MRI studies. On the basis of our study, a complete diagnostic picture, CT scans or MRI studies, and scintigraphic patterns can establish the preoperative diagnosis of vascular orbital tumors such as cavernous hemangioma, adult-type lymphangioma, and hemangiopericytoma.

CT arteriography for orbital tumors: diagnostic and surgical value.

The aim of this study is to investigate the efficacy of dynamic computed tomography (CT) during selective angiography (CT-arteriography) of orbital tumors in the evaluation of intratumoral vascular anatomy, feeding artery territory, and histological diagnosis. Among 35 consecutive cases with various orbital lesions, those cases showing tumor staining or pooling of the contrast medium on digital subtraction angiography (DSA) were evaluated by CT-arteriography (n = 14). The information obtained by CT-arteriography was compared with that provided by enhanced MRI (n = 31) and dynamic MRI (n = 21), in which the contrast medium was injected intravenously. In addition to the visualization of fine vascular anatomy, CT-arteriography emphasized areas of nodular enhancement and non-enhancing cystic/necrotic components as well as the intratumoral feeding arteries. Patterns of CT-arteriography were categorized into three subgroups: homogeneous enhancement (benign lymphoid lesion), partial enhancement (schwannomas and carcinomas), and patchy multinodular enhancement (specific for cavernous angiomas). In addition, CT-arteriography with selective arterial catheterization clearly delineated the feeding artery territories. CT-arteriography, with a minimal dose of contrast medium, can offer significant advantages over intravenously injected dynamic neuroimaging, and provides additional valuable preoperative information about the orbital tumor under investigation.

Endothelium in hepatic cavernous hemangiomas does not express the hyaluronan receptor for endocytosis.

The liver contains two distinct endothelial cell types: vascular and sinusoidal. Although cavernous hemangioma is the most common benign tumor of the liver, vascular or sinusoidal endothelial cell differentiation has not been described. An endocytic receptor responsible for the uptake and degradation of hyaluronan is present in the sinusoidal endothelium of the liver. The hyaluronan receptor for endocytosis (HARE) may therefore be a useful marker for sinusoidal endothelial cell differentiation. Using monoclonal antibodies specific for HARE, CD31, and factor VIII, we completed an immunohistochemical study of the endothelial cells of both hepatic cavernous hemangiomas and of nonneoplastic human liver. The anti-HARE monoclonal antibodies showed diffuse strong staining of nonneoplastic liver sinusoidal endothelium. No staining of nonsinusoidal endothelium or the endothelial lining of the hemangiomas was seen with anti-HARE. In contrast, diffuse strong staining for factor VIII and CD31 was present in nonsinusoidal endothelium and cavernous hemangioma endothelium. Neither factor VIII nor CD31 staining was present in the sinusoidal endothelium. In conclusion, the endothelium of hepatic cavernous hemangiomas demonstrates vascular but not sinusoidal differentiation based on the absence of HARE and presence of CD31 and factor VIII.

Assessment of the vascularity of a left ventricular mass using myocardial contrast echocardiography.

In addition to a thrombus, an intracardiac mass lesion can represent a primary cardiac tumor, or a metastatic lesion to the heart. The echocardiographic appearance and location of the mass, as well as the associated clinical scenario provide useful clues regarding cause, but these echocardiographic features alone may not always be diagnostic. Because most benign cardiac tumors are relatively avascular, the vascularity of a mass may be a feature that can help differentiate benign from malignant tumors. We present a case of a patient with a history of malignant melanoma who was found incidentally to have a cardiac mass on echocardiography. Contrast echocardiography (CE) was used to evaluate the vascularity of the mass. This case is compared with another patient with an apical thrombus, which represents an "avascular" intracardiac structure.

Intratumoral embolization of intracranial and extracranial tumors: technical note.

A new technique of intratumoral embolization is described. An intratumoral injection of N-butylcyanoacrylate is performed either perioperatively by direct puncture of the tumor or preoperatively through the nose or through the skin. The indications for this technique are hypervascularized tumors, such as juvenile angiofibroma, hemangiopericytoma, or paraganglioma. This technique has been applied in 21 patients with excellent results in terms of devascularization.

[MR tomography, CT and angiography of vascular malformations of the central nervous system]. / MR-Tomographie, CT und Angiographie vaskulärer Malformationen des zentralen Nervensystems.

The findings on MR tomography in 31 vascular malformations of the central nervous system are described; 26 of these had angiography and 24 were examined by CT. There were 19 A-V angiomas, 7 cavernomas and 5 large aneurysms. MRT provided a correct diagnosis in 29 out of 31 cases, angiography succeeded in 19 out of 26 cases and CT in 20 of 24. MRT was superior to CT and angiography. Nevertheless, it cannot replace arteriography, since this is the only method for demonstrating the vascular supply of angiomas and small aneurysms can be demonstrated only by arteriography.