Vertebral angiomas are benign tumours of malformative origin, consisting of neoformed blood vessels of normal structure, without arteriovenous shunt. These lesions represent 50% of benign spinal tumours  and according to Dahlin  , 1% of primary bone tumours. They develop within the vertebra and modify it and can extend secondarily to the epidural space; their seat is usually dorsal. Their discovery is most often fortuitous. The majority of these lesions have no clinical translation and require no treatment. The progressive forms responsible for spinal cord compression are much rarer; they are part of neurosurgical management. We report our experience about an observation by emphasizing the role of imaging in assessing the degree of aggressiveness of the pathology.
2. Patient and Observation
A 13-year-old patient with no particular history, received in our department for a radiological check-up. The clinical examination revealed non-febrile lumbar pain, an insidiously installed motor deficit of the lower limbs that has gradually worsened over the past 6 months. The patient was investigated by CT followed by lumbar MRI. At the CT, we noted a destruction of the vertebral body and posterior arch of L3 associated with a backward shift from L2 to L3 (Figure 1). These lesions are associated with significant invasion of the peri-vertebral soft tissue and dural sheath with heterogeneous enhancement after injection of the iodized contrast agent (Figure 2).
Figure 1. Sagittal reconstruction CT of the lumbar spine which shows a destruction of L3 with retro-listhesis of L2 sue L3.
Figure 2. TDM axial section with PCI injection, showing flooding of the vertebral peri-peri soft tissue that rises heterogeneously after PC injection.
On MRI, it is objectified an almost complete collapse of the L3 vertebra with a multi-loculated anterior residual part (Figure 3 & Figure 4). The contents of this vertebrae protrude posteriorly occupying the central lumbar canal and the pediculo-lamar space. This heterogeneous formation is in hypo-signal T1 (Figure 3), hyper-signal partly T2 (Figure 4) and is partially enhanced on the injected series (Figure 5). Histologically, the section designs examined under a healthy epidermis show a clearly benign tumor proliferation made of anastomosed vascular sales with regular papillary projections bordered by cells without cytonuclear atypia of malignancy noted. Mitosis is very low, estimated at 1 in 10 fields at high magnification. There are no foci of necrosis on the tumor surface. This aspect suggested a hemangioma. The patient received preoperative embolization supplemented by vertebroplasty. The post-therapeutic evolution has been marked by a progressive improvement in neurological symptomatology. The patient is followed on an outpatient basis per month, without however resuming studies.
Figure 3. Sagittal sequence in T1 with an almost complete collapse of the L3 vertebra with invasion of the soft tissues in hypo-signal T1.
Figure 4. T2 sagittal sequence, objectivizing the almost complete collapse of the L3 vertebra with a residual anterior part and the invasion of the soft parts in hyper-signal T2.
Figure 5. T1 axial sequence with Gado showing a heterogeneous enhancement of soft tissue flooding.
The vertebral hemangiomas represent 50% of the benign tumors and according to Dahlin  , 1% of the primary bone tumors. Aggressive vertebral hemangiomas are rare  . HV can affect all age groups  . This lesion is rare in children  or even exceptional before the age of 10 years. However, our patient’s age was 13 years. A predominance in young adults, with a discrete female predominance, two women to one man has been reported  . Its incidence increases gradually with age  . It is usually found in middle-aged adults between the fourth and fifth decade; about one-third of the lesions are revealed in the fifth decade  . In our case, the site of the lesion was rather lumbar (L3) unlike the one whose dorsal location is most frequent from T3 to T9  . Cervical localization has rarely been described in the literature   . As for HV compressive, they are located in 90% of cases at the level of the backbone and more precisely between T3 and T9. The attack is in single rule: this is seen in 75% of cases  , as in our observation. Clinical symptomatology is most often represented by spinal cord compression. This was noted in our patient. It is more rarely manifested by back pain or radiculalgia  . The pathophysiology of neurological signs involves several parameters. In general, this is an epidural extension as we noted in our observation. On the other hand, vertebral compression or compressive haematomas rarely occur  . Concentric bone hypertrophy can be involved in the genesis of symptomatology  . Aggressive vertebral hemangioma has a typical appearance on standard radiographs  . It sits on the vertebral body, which is demineralized and has vertical spans, creating the characteristic grid appearance that is lost in places. In rare cases, it is a spindle-shaped appearance indicating an extension towards the soft para-vertebral tissues. The CT study, when the appearance is not typical, makes it possible to specify the extent of bone damage (pedicles, posterior arch), epidural extension, hyper-vascularization and tissue stroma of the lesion   .
On MRI, the aggressive angioma has a hyposignalT1 and a hypersignal T2 due to its vascular content, unlike most asymptomatic angiomas which have a fat content in hypersignal T1 and T2  . MRI also makes it possible to look for the posterior arch and possible spinal cord compression as in our case. The diagnosis of certainty is based on histological examination. Vertebroplasty is a good treatment for hemangiomas leading to a painful spinal syndrome  . while compression angioma treatment consists of surgical decompression, often preceded by selective arterial embolization  .
Symptomatic vertebral hemangioma with neurological disorders is rare. The diagnosis must be made early and based on imaging, which allows for accurate lesion assessment and histological examination. The objective of the treatment is twofold, to provide spinal cord decompression and to treat symptomatic angioma.
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