Vertebral Hemangioma¶

Definition¶

Vertebral hemangiomas are the most common benign tumor of the vertebral body, consisting of vascular channels interspersed among thickened vertical trabeculae and fat. They are found incidentally in approximately 10–12% of spinal MRI studies and are overwhelmingly asymptomatic. Rarely, aggressive hemangiomas can extend into the epidural space and cause cord compression.

Imaging Findings¶

Typical (Incidental) Hemangioma¶

MRI:

T1-weighted — High signal (bright) due to fat content between the vascular channels
T2-weighted — High signal (bright) due to both fat and slow-flowing blood
The combination of high T1 AND high T2 signal is characteristic and essentially diagnostic

CT:

Classic "polka-dot" pattern on axial images — thickened vertical trabeculae in cross-section appear as scattered dots within a low-attenuation (fatty) matrix
"Corduroy" or "jail bar" pattern on sagittal images — vertical striations from the thickened trabeculae

Vertebral hemangioma CT and MRI — Typical vertebral hemangioma. (A) Sagittal CT showing the corduroy sign. (B) Axial CT showing the polka-dot sign. (C–D) Sagittal and axial T1-weighted MRI showing hyperintense signal. (E–F) Sagittal and axial T2-weighted MRI also showing hyperintensity. (Source: Kato et al., J Orthop Surg Res, 2024. CC BY 4.0)

Aggressive (Atypical) Hemangioma¶

Features suggesting an aggressive hemangioma that may cause symptoms:

Low T1 signal — Indicates less fat content and more vascular tissue
Epidural extension — Soft tissue extending into the epidural space
Entire vertebral body involvement — Replacing the whole body rather than a focal area
Cortical expansion or erosion
Posterior element involvement
Enhancement — More avid, sometimes homogeneous enhancement

Aggressive vertebral hemangioma MRI — Aggressive vertebral hemangioma of L4. (A) Sagittal T1 MRI showing hypointensity of the entire vertebral body. (B) Sagittal T2 showing hyperintensity with epidural extension. (C–D) Axial T1 and T2 showing bilateral pedicle involvement and anterior epidural extension. (Source: Kato et al., J Orthop Surg Res, 2024. CC BY 4.0)

Clinical Pearl

The classic high T1 / high T2 signal hemangioma is a "do not touch" lesion — no follow-up, biopsy, or treatment is needed. The danger is the atypical hemangioma with low T1 signal, which can mimic a metastasis. Key distinguishing features include the characteristic CT trabecular pattern (polka-dot/corduroy) and the absence of cortical destruction or pedicle involvement. If there is any doubt, CT can resolve the diagnosis.

Epidemiology¶

Present in 10–12% of the population
More common in the thoracic and lumbar spine
Slightly more common in women
Most are discovered incidentally and require no treatment

Management¶

Typical hemangiomas — No treatment or follow-up needed
Aggressive hemangiomas with cord compression — Treatment options include embolization, radiation therapy, vertebroplasty, or surgical decompression

Key Points¶

Vertebral hemangiomas are the most common benign vertebral tumor
High T1 and high T2 signal on MRI is characteristic (fat + vascular)
"Polka-dot" pattern on axial CT and "corduroy" pattern on sagittal CT are diagnostic
Atypical hemangiomas with low T1 signal can mimic metastases — CT can help differentiate
Aggressive hemangiomas with epidural extension are rare but may require treatment

References¶

Kato K, Teferi N, Challa M, Eschbacher K, Yamaguchi S. Vertebral hemangiomas: a review on diagnosis and management. J Orthop Surg Res. 2024;19:310. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC11127296/
Cloran FJ, Pukenas BA, Loevner LA, Aquino C, Schuster J, Mohan S. Aggressive spinal haemangiomas: imaging correlates to clinical presentation with analysis of treatment algorithm and clinical outcomes. Br J Radiol. 2015;88(1055):20150470. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC4743441/
Tafti D, Cecava ND. Spinal Hemangioma. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2023. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532997/
Vertebral haemangioma. Radiopaedia.org. Available from: https://radiopaedia.org/articles/vertebral-haemangioma-2
Quinn SF. Vertebral hemangioma. Radsource MRI Web Clinic. November 2006. Available from: https://radsource.us/vertebral-hemangioma/