Vertebral hemangioma is the most common primary benign tumor of the vertebral body, incidentally found in 10-12% of the population. It is a hamartomatous lesion composed of fat tissue and thin-walled vascular channels (capillaries and venules) between thickened vertical trabeculae. On CT, the 'polka-dot' pattern formed by thickened dot-like trabeculae on axial images and vertical striation ('corduroy' or 'jail bar' appearance) on sagittal images are pathognomonic. On MRI, it shows T1 hyperintensity due to fat component and T2 hyperintensity due to combined vascular stroma and fat — this 'bright on both T1 and T2' combination is diagnostic for benign hemangioma. Aggressive hemangiomas are rare (1-2%), predominantly vascular stroma instead of fat — showing low T1 signal and may cause epidural extension with cord compression. Typical hemangiomas are asymptomatic requiring no treatment; aggressive type may need vertebroplasty, embolization, or surgical decompression.
Age Range
20-70
Peak Age
50
Gender
Female predominant
Prevalence
Very Common
Vertebral hemangioma is a hamartomatous lesion consisting of thin-walled vascular channels (capillaries and venules), fat tissue between these channels, and thickened vertical bone trabeculae within the vertebral body. The mechanism leading to accumulation of vascular channels and fat tissue replacing normal bone marrow is not fully understood, but local mesenchymal stem cell differentiation toward vascular and adipocytic lineages is thought to play a role. Vertical trabecular thickening is a compensatory response to mechanical stress created by surrounding vascular channels — horizontal trabeculae are resorbed while vertical trabeculae thicken and strengthen. This vertical trabecular pattern creates the characteristic CT appearance: thick dot-like trabeculae on axial images ('polka-dot'), vertical striation on sagittal images ('corduroy' pattern). On MRI, T1 hyperintensity results from fat tissue — short T1 relaxation time of fat protons produces bright signal. T2 hyperintensity comes from two components: (1) T2 signal of fat protons and (2) T2 signal of slow-flowing blood in vascular channels — both are bright on T2. Signal drop on fat-suppressed sequences confirms fat presence. Aggressive hemangiomas are predominantly vascular stroma instead of fat — decreased fat results in lower T1 signal. In aggressive type, vascular proliferation may extend beyond cortex into the epidural space causing cord compression. Only 1-2% of hemangiomas are clinically significant despite the high population prevalence.
Cross-sectional view of thickened vertical trabeculae within vertebral body on axial CT — regularly spaced dots. Pathognomonic.
On axial CT images, regularly spaced thick dot-like structures (polka-dot pattern) are seen within the vertebral body. These dots represent cross-sectional views of thickened vertical trabeculae. Fat-density (-30 to -70 HU) hypodense areas exist between the dots. The lesion is usually well-defined and may involve part or all of the vertebral body. Cortical integrity is preserved in typical hemangioma.
Report Sentence
A lesion showing polka-dot pattern (thickened vertical trabeculae) on axial and vertical striation on sagittal images with fat-density hypodense areas in the ... vertebral body, consistent with typical vertebral hemangioma.
T1-weighted sequences show a hyperintense (bright) lesion within the vertebral body. T1 hyperintensity results from fat component and is the most reliable MR finding of benign hemangioma. In aggressive hemangioma, T1 signal decreases (iso-hypointense) as fat diminishes — this is a critical differentiating criterion.
Report Sentence
A T1 hyperintense/low signal lesion in the ... vertebral body with/without signal drop on fat-suppressed sequences; consistent with typical/aggressive vertebral hemangioma.
T2-weighted sequences show a hyperintense lesion within the vertebral body. T2 hyperintensity results from both fat and vascular stroma components. STIR sequences show signal decrease after fat suppression — but not complete suppression due to vascular component.
Report Sentence
A T2 hyperintense lesion in the ... vertebral body showing partial signal drop on STIR sequences; consistent with vertebral hemangioma.
On contrast-enhanced sequences, vertebral hemangioma shows mild-to-moderate enhancement. The vascular component retains contrast. Enhancement is more prominent in aggressive hemangioma. Rim enhancement may be seen in epidural extension. Enhancement degree assists in aggressivity assessment.
Report Sentence
The hemangioma in the ... vertebral body shows mild/moderate/prominent enhancement on contrast-enhanced sequences; epidural extension is not observed/is observed.
On fat-suppressed sequences (STIR or fat-sat), signal drop is observed in typical hemangioma — confirming fat presence. In aggressive hemangioma, signal drop is minimal or absent because fat is decreased with predominantly vascular stroma. Fat suppression behavior is critical in typical vs aggressive hemangioma differentiation.
Report Sentence
The lesion in the ... vertebral body shows prominent/minimal signal drop on fat-suppressed sequences, consistent with typical/aggressive vertebral hemangioma.
Criteria
T1 and T2 hyperintense, polka-dot CT, signal drop on fat-suppressed, asymptomatic.
Distinct Features
Fat-predominant, 98-99% prevalence, no treatment needed, incidental finding
Criteria
T1 low signal (decreased fat), T2 very bright, epidural extension, cord compression, symptomatic.
Distinct Features
Vascular stroma predominant, 1-2%, requires vertebroplasty/embolization/surgery, posterior element involvement possible
Criteria
Aggressive type + neurological deficit (cord/nerve root compression). May require urgent decompression.
Distinct Features
Prominent epidural component, spinal stenosis, myelopathy signs (cord signal changes)
Distinguishing Feature
Spondylodiscitis shows T1 low signal (edema), disc involvement and enhancement, end-plate destruction, fever/leukocytosis; hemangioma T1 bright (fat), no disc involvement, no destruction
Distinguishing Feature
Spinal TB shows anterior vertebral destruction, large cold abscess, gibbus deformity; hemangioma has no destruction, polka-dot pattern, no abscess
Distinguishing Feature
Ependymoma is intramedullary (within cord), cord expansion, cap sign; hemangioma in vertebral body (extramedullary), no cord expansion, polka-dot pattern
Urgency
routineManagement
surveillanceBiopsy
Not NeededFollow-up
no-follow-upTypical vertebral hemangiomas are incidental findings requiring no treatment or follow-up — should be noted in report as 'benign vertebral hemangioma, clinically insignificant'. Aggressive type is rare (1-2%) and vertebroplasty (cement injection), preoperative embolization, and/or surgical decompression are performed for epidural extension and cord/nerve root compression. Distinguishing aggressive hemangioma from metastasis is critical — T1 hyperintensity (fat presence) is the most reliable criterion favoring typical hemangioma.
Typical vertebral hemangiomas are asymptomatic and require no treatment — should be reported as incidental finding with no follow-up recommended. Aggressive hemangiomas (1-2%) are rare and may cause epidural extension and cord/nerve root compression; vertebroplasty, embolization, or surgical decompression may be applied. Aggressive type is distinguished by low T1 signal (predominantly vascular stroma instead of fat).