Vertebral hemangioma is the most common benign vascular tumor of the vertebral body. It is usually discovered incidentally and is asymptomatic. It has a prevalence of 10-12% in autopsy series. There is a slight female predominance. It most commonly involves the thoracic vertebrae (T3-T9). Aggressive hemangiomas are rare and may cause epidural extension and spinal cord compression. Histologically, it contains thin-walled vascular channels and fatty tissue with vascular and adipose stroma between thickened vertical trabeculae.
Age Range
30-70
Peak Age
50
Gender
Female predominant
Prevalence
Very Common
Vertebral hemangioma consists of an abnormal proliferation of thin-walled vascular channels (cavernous or capillary type) within the vertebral body. The vascular proliferation resorbs normal bone marrow and trabecular bone, replacing it with fatty tissue and vascular stroma; the remaining vertical trabeculae thicken in a compensatory fashion. This histopathologic structure directly determines imaging findings: thickened vertical trabeculae create the 'polka dot' sign on axial CT and the 'corduroy' pattern on sagittal images. The fat and vascular stroma components produce hyperintense signal on both T1 and T2 MRI — fat is bright on T1, vascular stroma is bright on T2, and this combination is virtually pathognomonic. Aggressive hemangiomas contain more vascular component and less fat; therefore, the typical bright T1 signal is lost, and they demonstrate marked T2 hyperintensity with avid contrast enhancement. Aggressive forms can breach the bone cortex, extend into the epidural space, and cause spinal cord compression.
On axial CT, cross-sections of thickened vertical trabeculae appear as punctate areas of increased density within the vertebral body. This pattern is pathognomonic for vertebral hemangioma and is usually sufficient for definitive diagnosis.
On axial CT, thickened vertical trabeculae within the vertebral body appear as round, punctate areas of increased density in cross-section. Low-density fatty tissue is present between trabeculae. This pattern is pathognomonic for vertebral hemangioma and usually requires no further imaging.
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On axial CT, punctate densities within the vertebral body due to thickened vertical trabeculae are consistent with the 'polka dot' sign of vertebral hemangioma.
On sagittal and coronal CT reconstructions, a vertical striation pattern is seen within the vertebral body. Thickened vertical trabeculae appear as parallel high-density lines, with intervening low-density fatty tissue forming bands. This is termed the 'corduroy' or 'corduroyed vertebra' pattern.
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On sagittal reconstructions, vertical striations within the vertebral body ('corduroy' pattern) are consistent with vertebral hemangioma.
On T1-weighted sequences, marked hyperintensity is seen within the vertebral body. This bright signal reflects the short T1 relaxation time of fatty tissue in the hemangioma stroma. Typical (inactive) hemangiomas show homogeneous T1 hyperintensity, while aggressive hemangiomas may be isointense or hypointense on T1 due to decreased fat content.
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On T1-weighted sequences, marked hyperintensity within the vertebral body due to fatty stroma is consistent with typical vertebral hemangioma.
On T2-weighted sequences, marked hyperintensity is seen within the vertebral body. T2 hyperintensity reflects the slow-flowing blood and fluid content within the vascular channels of the hemangioma. Typical hemangiomas show simultaneous bright signal on both T1 and T2 ('light bulb' sign). Aggressive hemangiomas demonstrate very marked T2 hyperintensity.
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On T2-weighted sequences, marked hyperintensity within the vertebral body is attributable to vascular stroma.
On STIR sequences, typical hemangiomas remain moderately hyperintense; despite fat signal suppression, the vascular component continues to produce bright signal. Aggressive hemangiomas show very marked hyperintensity on STIR because the vascular component predominates. Signal intensity on STIR is an important criterion for aggressive-typical differentiation.
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On STIR sequences, the vertebral body lesion remains hyperintense due to its vascular component.
On chemical shift (in-phase/opposed-phase) imaging, typical vertebral hemangiomas show signal drop on opposed-phase. This reflects the coexistence of fat and water protons within the same voxel in the lesion. Aggressive hemangiomas may not show chemical shift signal drop due to low fat content.
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On chemical shift imaging, signal drop within the vertebral lesion on opposed-phase is consistent with intralesional fat content.
Typical hemangiomas show mild-to-moderate enhancement; aggressive hemangiomas demonstrate avid, homogeneous enhancement. Enhancement originates from the vascular component. In aggressive hemangiomas, epidural extension becomes more conspicuous with enhancement and spinal cord compression is evaluated.
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On post-contrast images, enhancement within the vertebral lesion is attributable to its vascular component.
On diffusion-weighted imaging, typical vertebral hemangiomas do not show significant diffusion restriction. ADC values are normal or increased. High signal may be seen on DWI due to T2 shine-through, but there is no corresponding low signal on the ADC map. This feature is helpful in differentiating hemangioma from metastasis and lymphoma.
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On DWI, the vertebral lesion does not demonstrate significant diffusion restriction, with no findings favoring metastasis or malignant process.
Criteria
Asymptomatic, confined to vertebral body, fat-predominant stroma, hyperintense on T1 and T2, prominent polka dot/corduroy pattern
Distinct Features
Most common type (95%+). Bright T1 signal from fatty tissue, bright T2 signal from both fat and vascular stroma. No follow-up or treatment required. Reported as incidental finding.
Criteria
Symptomatic (pain, neurological deficit), T1 hypointense (low fat), T2 very hyperintense (vascular predominant), epidural extension, posterior element involvement, avid enhancement, expansion filling entire vertebral body
Distinct Features
Rare type (1-5%). Vascular component predominant, little fat. Typical bright T1 signal is lost. Epidural extension may cause spinal cord compression. May require embolization or surgery. Can grow during pregnancy due to hormonal stimulation.
Criteria
Aggressive hemangioma + spinal cord or nerve root compression, neurological deficit findings, myelopathy or radiculopathy clinical presentation
Distinct Features
May require urgent intervention. Epidural component compresses the spinal cord. On MRI, T2 hyperintense epidural mass with cord signal change (T2 hyperintensity increase/edema). Preoperative embolization recommended. Radiotherapy is an alternative treatment option.
Distinguishing Feature
Metastases are T1 hypointense (hemangioma is T1 hyperintense), show diffusion restriction on DWI (no restriction in hemangioma), tend to be multiple and irregular in morphology
Distinguishing Feature
Myeloma is T1 hypointense, T2 hyperintense (unlike hemangioma T1 is not bright), diffusion restriction on DWI, multiple involvement, bone marrow infiltration, abnormal serum/urine protein electrophoresis
Distinguishing Feature
Intraosseous lipoma is T1 hyperintense (like hemangioma) but shows complete signal loss on T2 fat suppression, has no vascular component, and lacks the trabecular thickening pattern
Distinguishing Feature
Fibrous dysplasia shows homogeneous ground-glass density appearance, lacks trabecular thickening pattern, no polka dot sign, usually found in long bones
Distinguishing Feature
Osteoblastoma usually involves posterior elements (hemangioma is in the body), expansile lytic lesion, peripheral sclerosis, does not show polka dot pattern, painful
Urgency
non-urgentManagement
observation for typical; embolization/surgery for aggressive with cord compressionBiopsy
Not NeededFollow-up
none for typical; MRI follow-up for aggressive/atypical; urgent evaluation for neurological symptomsTypical vertebral hemangiomas (95%+) are benign incidental findings requiring no follow-up or treatment. Aggressive hemangiomas (1-5%) may be symptomatic and can cause epidural extension with spinal cord compression; embolization, radiotherapy, or surgical decompression may be required in such cases. Atypical-appearing hemangiomas (T1 hypointense) must be distinguished from metastases. Multiple vertebral hemangiomas may represent a normal variant with no clinical significance.
Typical vertebral hemangiomas are incidental and require no treatment. Aggressive hemangiomas (T1 hypointense, epidural extension, posterior element involvement) are rare and may cause spinal cord compression — radiotherapy, embolization, or surgery may be needed. Incidentally detected typical hemangiomas require no follow-up.