Hepatic Hemangioma: Review of Imaging and Therapeutic Strategies.

Hepatic hemangiomas are the most common benign liver tumors. Typically, small- to medium-sized hemangiomas are asymptomatic and discovered incidentally through the widespread use of imaging techniques. Giant hemangiomas (>5 cm) have a higher risk of complications. A variety of imaging methods are used for diagnosis. Cavernous hemangioma is the most frequent type, but radiologists must be aware of other varieties. Conservative management is often adequate, but some cases necessitate targeted interventions. Although surgery was traditionally the main treatment, the evolution of minimally invasive procedures now often recommends transarterial chemoembolization as the treatment of choice.

A unique case of multiple calvarial hemangiomas with one large symplastic hemangioma.

BACKGROUND: Symplastic hemangioma is a benign superficial abnormal buildup of blood vessels, with morphological features which can mimic a pseudo malignancy. A few cases have been reported in the literature. We report here, a unique case of calvarial symplastic hemangioma, which is the first case in the calvarial region. CASE PRESENTATION: A 29-year-old male patient, with a left occipital calvarial mass since childhood, that gradually increased in size with age, was associated with recurrent epileptic fits controlled by Levetiracetam (Keppra), with no history of trauma. He presented to the emergency room with a recent headache, vomiting, frequent epileptic fits and a decrease in the level of consciousness 1 day prior to admission. A CT scan showed three diploic, expansile, variable sized lytic lesions with a sunburst appearance; two that were biparietal, and one that was left occipital, which were all suggestive of calvarial hemangiomas. However, the large intracranial soft tissue content, within the hemorrhage of the occipital lesion was concerning. The patient had refused surgery over the years; however, after the last severe presentation, he finally agreed to treatment. The two adjacent, left parietal and occipital lesions were treated satisfactorily using preoperative embolization, surgical resection, and cranioplasty. Histopathology revealed cavernous hemangiomas, in addition to symplastic hemangioma (pseudo malignancy features) on top at the occipital lesion. The right parietal lesion was not within the surgical field; therefore, it was left untouched for follow-up. CONCLUSIONS: Histopathology and radiology examinations confirmed the diagnosis as symplastic hemangioma, on top of a pre-existing cavernous hemangioma. To the best of our knowledge, this is the first case of a calvarial symplastic hemangioma, which we report here.

Urethral cavernous hemangioma: a highly misdiagnosed disease (a case report of two patients and literature review).

BACKGROUND: Diagnosis of urethral cavernous hemangioma (UCH) is very rare. It can be easy to misdiagnose and mistreat due to its atypical clinical manifestations and a lack of relevant knowledge. The study is to explore the diagnosis, differential diagnosis, and treatment of UCH. CASE PRESENTATION: The first patient was a 15-year-old male, who was admitted to the hospital for more than 1 year with repeated hematuria. UCH was diagnosed by cystoscope biopsy, and cured with local injection of pingyangmycin. The second patient was a 49-year-old male, who was admitted for repeated painless gross hematuria and intermittent urethral bleeding after penile erection for more than 20 years. The case had been misdiagnosed as seminal vesiculitis, urethritis, or prostatitis, for over 20 years, until it was diagnosed as UCH by MR examination of the penis. It was treated by injection of pingyangmycin into the hemangioma's lumen and base. A small incision in the ventral penile area was separated from the location of the hemangioma, which was injected with pingyangmycin again. A biopsy of resected tissue further confirmed the diagnosis of UCH. CONCLUSIONS: UCH is an easily misdiagnosed disease. Intermittent painless hematuria is important characteristic of UCH. Local injection of pingyangmycin is a good option for treatment of UCH.

Ultrasonography-guided percutaneous microwave ablation for large hepatic cavernous haemangiomas.

PURPOSE: To evaluate the efficacy and safety of ultrasound-guided percutaneous microwave ablation (MWA) for large hepatic cavernous haemangiomas (HCHs) with ablation of the feeding artery and aspiration of blood from haemangioma simultaneously. MATERIALS AND METHODS: From January 2011 to December 2016, 40 patients (29 females, 11male; average age 43.25 ± 7.65 years) with 42 giant hepatic haemangiomas (mean diameter 7.02 ± 1.55 cm, range 4.1-10.8 cm) were treated with image-guided percutaneous MWA with ablation of the feeding artery and aspiration of blood from haemangioma simultaneously. After MWA, therapeutic efficacy was assessed by contrast-enhanced imaging during follow-up. Median follow-up time was 24 months (range 6-60 months). RESULTS: Technical effectiveness rate was 100% with a mean ablation time of 1175 ± 516 (range 480-2340) seconds. The mean number of antenna insertions was 3.82 ± 1.23 for each lesion. Clinical effectiveness rate was 95% (38/40). There was a significant decrease of the tumour volume within three days after ablation compared with before ablation (p < 0.001). The mean tumour volume shrinkage rate was 59.67 ± 16.73% (range 28.20-89.72%) within three days after ablation. Minor complications mainly included fever, transient elevation of transaminase, pleura effusion, and haemoglobinuria. One patient developed a major complication with acute kidney injury (AKI) shortly after MWA, whose renal function gradually recovered after haemodialysis. No other severe complications occurred in perioperative and follow-up periods. CONCLUSIONS: Ultrasound-guided percutaneous MWA for large HCHs with ablation of the feeding artery and aspiration of blood from haemangioma simultaneously is safe and effective.

CAVERNOUS HEMANGIOMA OF THE RETINA: A Comprehensive Review of the Literature (1934-2015).

PURPOSE: Cavernous hemangioma of the retina (CHR) is a rare retinal vascular hamartoma. The objective of this study was to summarize the current knowledge of this rare condition based on a detailed review of 96 documented cases. METHODS: The incidence, clinical and histological appearance, differential diagnosis, treatment, and prognosis of CHR were analyzed by evaluating clinical data obtained from 96 cases in the literature since the first case report in 1934. RESULTS: More than 90% of cases of CHR have been reported in white individuals with even gender distribution. A majority of patients presented a unilateral unifocal lesion without positive family history. Our analysis showed bilateral cases were strongly correlated with family history, which suggests the importance of screenings for family members in bilateral CHR cases. Intracranial involvement was reported in 14% of CHR cases. Most patients were asymptomatic, but in patients with history of headaches, transient visual disturbance, or seizures 80% had intracranial involvement. CONCLUSION: It is important to screen family members in bilateral CHR cases, and it is critical to exclude cerebral vascular abnormalities in view of relative high incidence of intracranial involvement and high morbidity.

MR imaging features that distinguish spinal cavernous angioma from hemorrhagic ependymoma and serial MRI changes in cavernous angioma.

Cavernous angiomas of the spinal cord exhibit imaging characteristics that may overlap with those of hemorrhagic ependymoma. In the present study, we aimed to identify specific magnetic resonance imaging (MRI) findings that could be used to differentiate cavernous angioma from hemorrhagic ependymoma, and to evaluate serial MRI changes in cases of cavernous angioma. We retrospectively evaluated MR images of spinal cord tumors collected at our hospital from 2007 to 2015. From this cohort of images, 11 pathologically confirmed cavernous angiomas and 14 pathologically confirmed hemorrhagic ependymomas were compared with respect to the size of the tumor, longitudinal location, axial location, enhancement pattern, syrinx, edema, tumor margin, signal intensity of T2WI, signal intensity of T1WI, and longitudinal spreading of the hemorrhage. Serial MR images of seven spinal cavernous angiomas were reviewed. Small size, eccentric axial location, minimal enhancement, and absence of edema were more frequently observed on images of cavernous angioma compared to those of hemorrhagic ependymoma (p < 0.01). Serial MRI changes in cases of cavernous angioma included increased longitudinal spreading of the hemorrhage (6/7, 86 %) and emergence of high signal intensity on T1WI (1/7, 14 %). Small size, eccentric axial location, minimal enhancement, and absence of edema are significant MRI findings that may be used to distinguish Type I and Type II spinal cavernous angiomas from hemorrhagic ependymomas. Furthermore, longitudinal spreading of the hemorrhage may be observed on follow-up MRIs of cavernous angiomas.

Gastrointestinal Infantile Hemangioma: Presentation and Management.

OBJECTIVES: The aim of the present study was to document the clinical presentation, diagnostic studies, and therapy of gastrointestinal infantile hemangiomas. METHODS: This is a retrospective analysis of children with gastrointestinal hemangiomas culled from our Vascular Anomalies Center database. We detailed the location of visceral and cutaneous tumors, as well as radiologic and procedural methods used for diagnosis and treatment. RESULTS: A total of 9 of the 16 children (14 girls and 2 boys) with hollow visceral hemangiomas also had cutaneous lesions. The most common extravisceral sites were regional facial lesions (n = 6), multifocal lesions (n = 2), and a solitary chest lesion (n = 1). Presenting symptoms were melena and hematochezia in the first 4 months of life (n = 14); several infants required multiple blood transfusions. The most frequent locations were small bowel and mesentery. One-half of the patients (n = 8) were diagnosed by laparotomy; the majority (n = 12) had suspicious radiologic findings. Corticosteroid and/or propranolol were the most common therapies. CONCLUSIONS: Melena and hematochezia, sometimes with profound anemia, in the first 4 months of life, suggest the possibility of intestinal infantile hemangioma even in the absence of cutaneous tumor. Intestinal bleeding, particularly in association with a regional facial lesion, should initiate workup: ultrasonography, computed tomography, and magnetic resonance imaging display diagnostic features. First-line treatment is medical management; bowel resection may be necessary, particularly for perforation.

Potential correlation between menopausal status and the clinical course of orbital cavernous hemangiomas.

PURPOSE: To evaluate the clinical course of radiologically diagnosed orbital cavernous hemangiomas in the setting of presumed changes in estrogen/progesterone levels. METHODS: An institutional review board-approved retrospective cohort chart review of patients from January 1, 1983, to January 1, 2013, was undertaken searching both outpatient ophthalmology diagnoses and radiologic diagnoses, identifying 32 orbital cavernous hemangiomas, which were subsequently divided into group 1, presumed to have stable levels of estrogen/progesterone, and group 2, presumed to have decreasing levels of estrogen/progesterone. Patients were then categorized as having short-term, mid-range, or long-term follow up. Serial imaging studies were evaluated and graded as having increased, decreased, or remained stable in size. RESULTS: In group 1, no lesions decreased in size, 69% remained stable, and 31% increased in size. In group 2, no lesions increased in size, 45% remained stable, and 55% decreased in size. When evaluating only those patients with long-term follow up, many masses in group 1 increased in size, while the majority in group 2 decreased in size. CONCLUSIONS: In this study evaluating orbital cavernous hemangiomas over a span of 30 years, the authors found that in postmenopausal women with assumed decreasing levels of circulating estrogen/progesterone, the vast majority of lesions either remained stable or decreased in size, suggesting the effect of hormone levels on such vascular lesions and supporting the role for observation in asymptomatic individuals in this patient population.

A creative therapy in treating cavernous hemangioma of penis with copper wire.

INTRODUCTION: Cavernous hemangiomas of penis are rare benign lesions infrequently described in the literature. No completely satisfactory treatment has been found to correct the cosmetic deformities especially the extensive hemangiomas of corpus penis. AIM: In light of the promising application of copper wire/needle in vascular malformations, we began a clinical study to investigate the safety, feasibility, and cosmetic effect of copper wire therapy in treating cavernous hemangioma of penis. METHODS: Seven patients ranging in age from 12 to 32 years with penile cavernous hemangiomas entered our study from 2005 to 2011. All patients received treatments with percutaneous copper wires. MAIN OUTCOME MEASURES: Perioperative data including mean operation time, estimated blood loss, length of copper wire retention, and length of hospital stay were analyzed. All possible complications were noted, and cosmetic result was evaluated. Patients were followed up after discharge from the hospital. RESULTS: All operations were successful, and no obvious complications were observed. The patients were satisfied with the aesthetic results. Follow-up time ranged from 1 to 5 years. Recurrence was discovered in a patient with the largest lesion of corpus penis 2 months after the treatment. Secondary procedure was carried out with the same technique, and no lesions were found later. CONCLUSIONS: The shortage of studies on this topic prevented us from defining a therapeutic reference standard. The results of our study confirmed that copper wire therapy was a simple, safe, and useful option for penile cavernous hemangioma.

What is changing in indications and treatment of hepatic hemangiomas. A review.

Hepatic cavernous hemangioma accounts for 73% of all benign liver tumors with a frequency of 0.4-7.3% at autopsy and is the second most common tumor seen in the liver after metastases. Patients affected by hemangioma usually have their tumor diagnosed by ultrasound abdominal examination for a not well defined pain, but pain persist after treatment of the hemangioma. The causes of pain can be various gastrointestinal pathologies including cholelithiasis and peptic ulcer disease.The malignant trasformation is practically inexistent. Different imaging modalities are used to diagnosis liver hemangioma including ultrasonography, computed tomography (CT), magnetic resonance (MR) imaging, and less frequently scintigraphy, positronemission tomography combined with CT (PET/CT) and angiography. Imaging-guided biopsy of hemangioma is usually not resorted to except in extremely atypical cases. The right indications for surgery remain rupture, intratumoral bleeding, Kasabach-Merritt syndrome and organ or vessels compression (gastric outlet obstruction, Budd-Chiari syndrome, etc.) represents the valid indication for surgery and at the same time they are all complications of the tumor itself. The size of the tumor do not represent a valid indication for treatment. Liver hemangiomas, when indication exist, have to be treated firstly by surgery (hepatic resection or enucleation, open, laproscopic or robotic), but in the recent years other therapies like liver transplantation, radiofrequency ablation, radiotherapy, trans-arterial embolization, and chemotherapy have been applied.

A Case of a Refractory Bleeding Giant Vaginal Wall Cavernous Hemangioma Successfully Managed with Sclerotherapy.

BACKGROUND Vaginal wall hemangiomas are extremely rare, benign, vascular tumors of the female genitalia. Most cases occur in childhood, but a few cases can be acquired; however, the mechanism of hemangioma formation remains unknown. Most hemangiomas involving female genital organs are small and asymptomatic. However, huge hemangiomas can cause irregular genital bleeding, infertility, and miscarriage. Surgical excision and embolization are the most common treatment options. We reveal that sclerotherapy achieved good outcomes in a patient with an intractable huge vaginal wall hemangioma. CASE REPORT A 71-year-old woman visited a local doctor with concerns of frequent urination. A ring pessary was inserted after a diagnosis of pelvic organ prolapse. However, symptoms did not improve, and the patient consulted another hospital. The previous physician diagnosed vaginal wall tumors and prolapse and performed a colporrhaphy. However, she was referred to our hospital with heavy intraoperative bleeding. Imaging examination revealed a huge hemangioma on the vaginal wall, which was histologically diagnosed as a cavernous hemangioma. Angiography revealed hemorrhage in the right peripheral vaginal artery. Owing to concerns regarding extensive vaginal wall necrosis caused by arterial embolization, sclerotherapy using monoethanolamine oleate was selected. Hemostasis was achieved 1 month after sclerotherapy, and postoperative imaging showed the lesion had shrunk in size. No recurrence of hemangioma was observed 19 months after surgery. CONCLUSIONS We report a case of a large vaginal wall intractable bleeding hemangioma. Sclerotherapy can be a suitable treatment option for large vaginal hemangiomas that are too extensive to be treated using surgery or arterial embolization.

Vascular myelopathies.

Vascular abnormalities of the spinal cord are an important cause of myelopathy. Clinicians need to be aware of these disorders as they can present with a variety of neurologic symptoms ranging from acute spinal neurologic emergencies, relapsing/remitting spells to gradually progressive dysfunction. The unique topography and vascular anatomy of the spinal cord lends to the variety of clinical presentations. Both ischemic and hemorrhagic insults can occur. Increased clinical suspicion, better detection with newer imaging modalities and early treatment can often impact outcomes. The authors review clinical diagnoses, novel imaging, and advanced treatment modalities for the most common causes of vascular myelopathy.

Primitive retinal vascular abnormalities: tumors and telangiectasias.

Primitive retinal vascular abnormalities are benign conditions of the retinal circulation that comprise vascular tumors and telangiectasias. The principal vascular tumors of the retina include retinal capillary hemangioma, cavernous hemangioma of the retina, racemose hemangiomatosis of the retina and retinal vasoproliferative tumor, while primary retinal telangiectasias include Coats' disease, Leber's miliary aneurysms and idiopathic juxtafoveal telangiectasias. In most cases, these alterations result in significant visual impairment due to exudation determined by the structural abnormalities of the retinal vasculature. The aim of this review is to assess the different clinical and diagnostic features of the single pathological entities and to discuss the available treatment modalities including the onset of intravitreal antivascular endothelial growth factor therapy.

Cavernous hemagioma of the maxillary sinus: a rare cause of epistaxis.

BACKGROUND: A case of cavernous hemangioma of the maxillary. METHOD: A 25 year old lady presented with history of nasal obstruction, recurrent epistaxis and headache. On exam she had a mass in the left osteomeatal complex that was friable and bled easily on palpation. Computerized tomography of the paranasal sinuses 2mm coronal cuts showed complete opacification of the left maxillary sinus and magnetic resonance imaging revealed a 1.5 x 3 x 2.5 cm lobulated soft tissue mass lesion that enhanced with intravenous gadolinium administration, but no flow-void signals were present. Histologically, the mass was made up of dilated and anastomosing blood vessels. RESULT: The radiologic findings may be attributed to a malignant lesion especially when extensive bone erosion is present. CONCLUSION: Cavernous hemangioma of the maxillary sinus is a very rare benign entity that presents with recurrent epistaxis and nasal obstruction.

Treatment of venous malformations with ethanolamine oleate: a descriptive study of 83 cases.

PURPOSE: To evaluate the outcome and complications of sclerotherapy with injection ethanolamine oleate for the treatment of venous malformations (VMs). METHODS: Eighty-three patients' (39 males and 44 females) age ranging from 3 months to 21 years with 85 lesions were followed clinically for about 1 year following treatment with injection of ethanolamine oleate. The cases were enrolled between January 2006 and December 2009. The amount of ethanolamine oleate per treatment session ranged from 0.50 to 10 ml, and maximum dose was 0.40 ml per kg body weight. All patients were evaluated after 8 weeks of last injection session. All of the treatment sessions were performed on a day-case basis. RESULTS: Eighty-five lesions have under gone 201 sclerotherapy sessions with 39 requiring one, 27 requiring two and 19 lesions requiring more than two sessions. Sclerotherapy with ethanolamine oleate provided complete resolution of symptoms in 79 lesions and significant improvement of 6 lesions. There is no recurrence of studied patients. All patients experienced pain and swelling to a variable degree for short duration. Skin sloughed out in four patients which were healed spontaneously. No other complications were observed in our study. CONCLUSION: The treatment of VMs with injection ethanolamine oleate is safe and effective.

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.

Resection of a Large Cavernous Hemangioma Following Preoperative Embolization in a Child's Temporal Bone.

Primary intraosseous cavernous hemangiomas (PICHs) in the temporal bone are very rare. Most treated cases are in adult patients, and there are very few reports involving children. To our knowledge, no cases reported have ever actually adopted embolization in children, although several reports recommend preoperative embolization of the feeding arteries. Here, we present a case of a child with a large cavernous hemangioma developing in the temporal bone. The patient was an 11-year-old girl whose chief complaints were hearing loss, aural fullness, and otalgia. Based on imaging, a lymphoma was initially suspected, but extensive arterial bleeding occurred during biopsy under local anesthesia. Angiography was performed to evaluate the blood flow in the tumor, and revealed the middle meningeal artery as a main feeding artery to the tumor. A huge PICH at the temporal bone was successfully resected following preoperative embolization of the feeding artery.

Endoscopic Ultrasound-Guided Ethanol Injection Associated with Trans-arterial Embolization of a Giant Intra-abdominal Cavernous Hemangioma: Case Report and New Therapeutic Option.

BACKGROUND: Cavernous hemangiomas are congenital hamartomatous lesions that originate from mesodermal tissue composed of dilated blood vessels. Abdominal pain and palpable mass are the most common presenting symptoms. The different types of treatment for symptomatic patients remain controversial. However, surgical resection is always the most preferred method when possible. To date, there are no reports of endoscopic ultrasound-guided (EUS-guided) absolute ethanol injection as a treatment for such disease when surgery is not an option. CASE PRESENTATION: A 19-year-old girl with giant cavernous intra-abdominal hemangioma extending to the hepatic hilum, also affecting the gastric wall and occupying the entire supra-mesocolic cavity, initially presents with upper gastrointestinal bleeding and loss of 20 kg in 1 year (BMI = 18 kg/m2). Percutaneous angiography identified a mass with arterial blood supply by the left gastric artery that was embolized. After re-bleeding, an alternative treatment with EUS-guided injection of alcohol was proposed once resection was not feasible without major risks to a young patient. This procedure was repeated 15 and 45 days after the initial treatment, with the ethanol injection of 25 cc and 15 cc, respectively. On the second and third procedure dates, there was evident regression of the hemangioma. On the third procedure, it was possible to identify all anatomic structures that were not clear on the first EUS. After 45 days of last injection, abdominal CT and EUS showed notorious regression of the lesion. Eight months later, abdominal CT showed only a remnant lesion in the hepatogastric ligament with 129 cm3 on volumetry (87% lower in comparison to the initial image), and the patient remains asymptomatic with BMI of 26. In the most recent follow-up CT, 4 years and 2 months after first treatment, the patient presents with a slight increase in the hemangioma-now with 183 cm3 on volumetry. CONCLUSION: Transgastric EUS-guided ethanol injection in the treatment of giant intra-abdominal cavernous hemangioma can provide good outcomes without major complications and can be repeated if necessary.