Recognizing remnant bony trabeculation on CT will provide the best chance at arriving at the correct preoperative diagnosis ( Fig. Patients with aggressive VHs frequently become symptomatic, with lesions producing pain (55%) or neurologic deficits (45%). Additional aggressive imaging features may also be present and include involvement of the entire vertebral body, extension into the neural arch, cortical expansion, and an associated soft tissue mass. On imaging, this results in background soft tissue attenuation on CT and hypointense T1 signal on MR.

Aggressive VHs comprise a small subset (1%) of all VHs, in which fat becomes replaced by vascular stroma. If discovered incidentally and clinically asymptomatic, atypical VHs also require no further work-up. Although this may produce a diagnostic challenge, CT showing vertically oriented trabecula will frequently aid in establishing lesions as benign. Clinical worsening and growth during pregnancy is a well known phenomenon. Neurologic symptoms due to compression of the spinal cord, nerve roots, or both, leading to myelopathy and/or radiculopathy. Atypical hemangiomas have less fatty and greater vascular content, thereby demonstrating reduced T1 signal. Aggressive hemangioma can occur at any age, with peak prevalence in young adults, and is localized preferentially in the thoracic spine.

These are considered incidental and inconsequential, requiring no further diagnostic work-up or routine follow-up. Typical hemangiomas reflect the histology, demonstrating low attenuation interspersed between vertically oriented bony trabecula on CT, and hyperintense signal on T1- and T2-weighted MR images due to their fatty content ( Fig. (Reprinted with permission from Bullough PG.

Hemangioma spine