Sudden perceived absence of foetal movement – a unique presentation of a vertebral haemangioma in pregnancy

Objective: Symptomatic vertebral haemangiomas that present during pregnancy are extremely uncommon with few cases reported in literature. Epidural haemangiomas are rarer still with few documented. Methods: In this report, we describe the case of a 22-year-old pregnant patient who presented with apparent loss of foetal movement at 38 weeks’ gestation. Clinical review demonstrated the foetus was well but neurological examination revealed lower limb paresthesia, paresis, and evident uterine hypoesthesia. An MRI scan illustrated a haemangioma in the T1 vertebral body with an epidural component causing cord compression. Results: The management of spinal haemangiomas that present during pregnancy is a complex clinical scenario which requires careful multidisciplinary consideration to determine if surgical intervention is appropriate. In this case, the patient had an emergency caesarean section followed by posterior decompression and laminectomy of the T1 vertebra with excellent post-operative recovery. Conclusion: Gestational increase in the size of vertebral haemangiomas is well documented. We discuss a rare case in which a young pregnant patient presents with an atypical symptom of a vertebral haemangioma (uterine hypoesthesia). This case highlights the importance of prompt imaging in these scenarios and a cohesive multidisciplinary approach in order to provide optimal treatment for the patient.

Imaging features and atypical signs of symptomatic vertebral haemangioma: a retrospective single-centre analysis of 118 patients

Objectives: Symptomatic vertebral haemangioma (SVH) can present with atypical imaging features. Thus, this study analysed the imaging features of SVH using CT and MRI to improve SVH awareness. Methods: We retrospectively analysed CT and MRI characteristics of 118 patients with clinically and pathologically confirmed SVH. Results: Overall, 118 patients were diagnosed with SVH, including 79 females and 39 males (mean age, 45.76 ± 16.36 years). The thoracic spine (n = 86) was the most common location of SVH, followed by the lumbar spine (n = 17). Involvement of multiple spinal segments was observed in 15 patients (12.71%). A total of 101 lesions (85.59%) were centred in the vertebral body, 15 lesions (12.71%) were centred in the posterior attachment, and two lesions (2%) were centred in the paraspinal region. CT showed 39 lesions (33.05%) without a typical honeycomb or polka-dot pattern. Compression fracture was observed in 23 patients (19.49%). Extraosseous extension was present in 111 patients (94.1%), and 17 lesions (14.41%) presented with foraminal extension. Epidural bony compression was observed in 46 patients (38.98%). 20 lesions (16.95%) had atypical T2 weighted MRI signals, and 8 lesions (10.26%) showed atypical enhancement. Conclusion: SVH was predominantly located in the thoracic spine. Involvement of multiple segments, posterior attachment localisation, absence of honeycomb or polka-dot signs, compression fracture, and atypical T2 weighted imaging signals and enhancement were uncommon. Epidural bony compression was not uncommon and has important clinical significance. Advances in knowledge: The imaging features of SVHs are not fully understood. We examined the largest series of SVH cases reported to date.

Per-operative glue embolization with surgical decompression: A multimodality treatment for aggressive vertebral haemangioma

Objective The aim of this study is to share our experience in per-operative embolization of aggressive vertebral haemangioma and to compare the surgical outcome with existing modalities of management. Background Vertebral haemangioma accounts for 12% of benign lesions of the vertebral column detected incidentally. Rarely they may enlarge, cause pain and neurological deficit because of spinal cord compression, vertebral body or arch expansion, or pathological fracture. Treatment options for symptomatic vertebral haemangioma include pre-operative transarterial embolization, surgical excision, radiotherapy, and percutaneous injection of alcohol or methyl methacrylate. We present our experience of per-operative glue embolization for aggressive (Enneking stage 3) vertebral haemangiomas. Materials and methods We describe five patients with symptomatic vertebral haemangioma at the dorsal level who underwent per-operative glue embolization. After initial laminectomy, a tumorogram was obtained under fluoroscopic guidance through direct contrast injection via spinal needle inserted through the pedicles of vertebra at the involved level. Varied concentration of glue was injected via the same spinal needle. All patients underwent surgical decompression of the intraspinal epidural component in the same sitting along with posterior spinal stabilization of the adjacent levels in two patients. Results In all five patients, complete embolization of the tumour was possible per-operatively through the transpedicular approach along with adjunctive surgical decompression, and the blood loss was significantly less. Clinical follow-up of these patients at 12–48 months showed reduction in size of the epidural component, relief of cord compression, and significant improvement in their neurological deficits with no recurrence. Conclusion We conclude that per-operative embolization is a safe and efficacious adjunctive procedure with surgical decompression with or without spinal stabilization for the treatment of symptomatic vertebral haemangiomas.