title: Aggressive spinal haemangiomas: imaging correlates to clinical presentation with analysis of treatment algorithm and clinical outcomes.
abstract: OBJECTIVE
  Aggressive spinal haemangiomas (those with significant osseous expansion/extraosseous extension) represent approximately 1% of spinal haemangiomas and are usually symptomatic. In this study, we correlate imaging findings with presenting symptomatology, review treatment strategies and their outcomes and propose a treatment algorithm.
  
  
  METHODS
  16 patients with aggressive haemangiomas were retrospectively identified from 1995 to 2013. Imaging was assessed for size, location, CT/MR characteristics, osseous expansion and extraosseous extension. Presenting symptoms, management and outcomes were reviewed.
  
  
  RESULTS
  Median patient age was 52 years. Median size was 4.5 cm. Lumbar spine was the commonest location (n = 8), followed by thoracic spine (n = 7) and sacrum (n = 2); one case involved the lumbosacral junction. 12 haemangiomas had osseous expansion; 13 had extraosseous extension [epidural (n = 11), pre-vertebral/paravertebral (n = 10) and foraminal (n = 6)]. On CT, 11 had accentuated trabeculae and 5 showed lysis. On MRI, eight were T1 hyperintense, six were T1 hypointense and all were T2 hyperintense. 11 symptomatic patients underwent treatment: chemical ablation (n = 6), angioembolization (n = 3, 2 had subsequent surgery), radiotherapy (n = 2, 1 primary and 1 adjuvant) and surgery (n = 4). Median follow-up was 20 months. Four of six patients managed only by percutaneous methods had symptom resolution. Three of four patients requiring surgery had symptom resolution.
  
  
  CONCLUSIONS
  Aggressive haemangiomas cause significant morbidity. Treatment is multidisciplinary, with surgery reserved for large lesions and those with focal neurological signs. Minimally invasive procedures may be successful in smaller lesions.
  
  
  CONCLUSIONS
  Aggressive haemangiomas are rare, but knowledge of their imaging features and treatment strategies enhances the radiologist's role in their management.
authors: 1 Division of Neuroradiology, Department of Radiology, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA.
authors: Francis J
authors: FJ
authors: Cloran
authors: 1 Division of Neuroradiology, Department of Radiology, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA.
authors: Bryan A
authors: BA
authors: Pukenas
authors: 1 Division of Neuroradiology, Department of Radiology, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA.
authors: Laurie A
authors: LA
authors: Loevner
authors: 2 Kaiser Permanente Diagnostic Imaging, San Diego, CA, USA.
authors: Christopher
authors: C
authors: Aquino
authors: 3 Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
authors: James
authors: J
authors: Schuster
authors: 1 Division of Neuroradiology, Department of Radiology, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA.
authors: Suyash
authors: S
authors: Mohan
mesh_terms: D000328:Adult; D000368:Aged; D000465:Algorithms; D005260:Female; D006391:Hemangioma / Q000473:pathology* / Q000628:therapy; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D013125:Spinal Neoplasms / Q000473:pathology* / Q000628:therapy; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome