Successful arterial embolisation of giant liver haemangioma. Report of a case with five-year computed tomography follow-up

A 28-year old man presented with a symptomatic giant haemangioma. On June 26, 1983, at laparotomy, no resection was attempted because the lesion involved the right lobe of the liver and a part of segments II and III. The patient underwent a right hepatic arterial embolisation with gelatine sponge particles. During follow-up, the patient remained asymptomatic. Five-year review by CT-scan showed a diminution of the size of the haemangioma and hypertrophy of the left lobe. On October 21, 1988, the patient was reoperated on for liver abscess and complete necrosis of the haemangioma. A right hepatectomy was performed. In conclusion, the long-term effect of hepatic arterial embolisation, as demonstrated in our case by regular CT-scans, is useful in cases of diffuse haemangioma as an alternative to hazardous major liver resection. To our knowledge, the long-term effect of hepatic arterial embolisation on symptoms and tumor size have never been reported for giant liver haemangioma.

CT diagnosis of rib anomalies, tumors, and infection in children

The computed tomography (CT) findings of 3 patients with Ewing's sarcoma and 10 patients with a variety of benign rib lesions including osteomyelitis, hemangiomatosis, eosinophilic granuloma, aneurysmal bone cyst, neurofibromatosis, enchondroma, and Jarcho-Levin syndrome are presented. CT is of great value in demonstrating characteristic findings of several benign rib lesions. Also, CT accurately shows the destructive pattern of the rib lesion, the presence of pleural effusion, and the local spread of the soft tissue mass. When an aggressive rib lesion with pleural effusion is encountered in an infant or child, Ewing's sarcoma must be excluded unless this lesion has characteristic radiographic findings and a strong clinical history that suggest another diagnosis. The CT findings and differential diagnosis of rib lesions are discussed. Three-dimensional CT well demonstrated the appearance of congenital rib anomalies.

Magnetic resonance angiography of cerebral developmental venous anomalies: its role in differential diagnosis

CT, MRI and contrast angiography of 20 patients with 21 developmental venous anomalies (DVAs), so-called venous angiomas, were compared with magnetic resonance angiography employing a two-dimensional time-of-flight technique (2D-MRA). MRA was diagnostic in 17 DVAs, when both the primary 2D slices and the maximum-intensity-projection images were read. Contrast angiography still provides the best visualization of both DVA components: dilated medullary veins and transcerebral draining vein; however, it is an invasive procedure and delivers no information about brain parenchyma. We regard MRI as necessary in cases with a suspected DVA because of the high rate of association with cavernomas: 33% in this study. Acute neurological symptoms were caused by haemorrhage from an associated cavernoma and not from the DVA in 4 such cases. Thus MRA combined with MRI obviates angiography in most cases and offers a noninvasive diagnostic strategy adequate for DVAs.

CT pixel mapping in the diagnosis of small angiomyolipomas of the kidneys

In six small renal angiomyolipomas (7-17 mm) the superiority of displaying the CT numbers of pixels within a lesion (pixel mapping) over the usual region of interest (ROI) measurement is described in the detection of small amounts of fat tissue. On precontrast 5 mm CT the ROI measurements were > 0 in four cases whereas pixel maps revealed pixels with values < 0 in six cases.

Prenatal sonographic diagnosis of fetal hepatic hemangioma

Although hepatic hemangioma represents the most common tumor of the liver during childhood, the prenatal diagnosis of this condition has been rarely reported in the literature. In this report, we describe a case of hepatic hemangioma presenting as a small hyperechogenic mass (1.1 x 0.9 cm) in the fetal liver in which the diagnosis was made at 33 weeks' gestation by ultrasound. Subsequent postnatal evaluation by Doppler ultrasound confirmed the diagnosis and follow-up examinations have documented its spontaneous regression. The prenatal diagnosis of a liver mass allows not only the evaluation of changes in size or pattern of the mass itself during pregnancy but also its prompt evaluation after birth.

Bilateral retinal embolization associated with intralesional corticosteroid injection for capillary hemangioma of infancy

A 2-month-old female infant underwent intralesional corticosteroid injection for a capillary hemangioma that was causing amblyopia of the right eye from ptosis, globe displacement, and astigmatism. Forty-eight hours after the injection, the infant's parents noted that she was visually inattentive. On examination, she could not fixate or follow with either eye, and an afferent pupillary defect was present in the left eye. Ophthalmoscopy showed scattered areas of intraretinal hemorrhage in the right eye and extensive preretinal and intraretinal hemorrhages in the left eye. Ten months after injection, the hemangioma had greatly regressed, and visual acuity in the right eye was felt to be normal. The left eye had unsteady fixation with a persistent afferent pupillary defect and macular scarring. Retrograde flow of the corticosteroid suspension through the hemangioma's feeder vessels, probably originating from both ophthalmic arteries, is the most likely explanation for this complication.

Value of routine sonography in the diagnosis and conservative management of renal angiomyolipoma

A prospective study was undertaken to assess the value of ultrasonography in the clinical monitoring of angiomyolipomas. 26 patients with angiomyolipomas as diagnosed by sonography and verified by computerized tomography (CT) were followed up by sonographic monitoring over a mean period of 45 months. One case was associated with tuberous sclerosis. Inclusion criteria for conservative management had been clinically asymptomatic angiomyolipomas smaller than 5 cm. Significant tumor growth and a change of the sonographic pattern during follow-up was seen in 2 patients. After renewed follow-up CT scanning failed to reveal negative density values, both patients were nephrectomized. Histologic examination showed hemorrhage in the tumor. The remaining 24 patients (92%) showed no changes in the sonographic patterns. Minor tumor growth of 0.5 cm on average was seen in 6 patients over a mean follow-up period of 52 months. Surgical intervention was refrained from in these 24 patients due to the consistent sonographic pattern and the absence of clinical symptoms. Once the angiomyolipoma is verified by CT, sonographic monitoring suffices if the sonostructure remains unchanged. Minor asymptomatic angiomyolipomas today no longer require surgical intervention as this benign tumor has a pathognomonic sonographic appearance.

Primary retroperitoneal neoplasms: how close can we come in making the correct diagnosis

The primary retroperitoneal tumors form a rare and diverse group of neoplasms, the origin of which is independent of the various retroperitoneal organs and unrelated to systemic diseases, such as lymphomas, lymphadenopathy, or metastases. Radiologic investigation, mainly cross-sectional imaging and, to a lesser extent, angiography is essential in the diagnosis and management of these tumors. The radiologist often is challenged to identify the origin and specific tissue composition of the imaged neoplasms. When the radiologic findings are combined with patient information and clinical data, the correct diagnosis may be made in many cases. Imaging-guided percutaneous needle biopsy further enhances the diagnostic yield of the various imaging modalities by establishing the diagnosis without the need for exploration.

Congenital subglottic hemangioma: frequency of symmetric subglottic narrowing on frontal radiographs of the neck

OBJECTIVE

This study was undertaken to determine how often symmetric subglottic airway narrowing is present in cases of infantile subglottic stenosis and to determine if the radiographic finding has any association with the anatomic location of the hemangioma.

MATERIALS AND METHODS

All cases (n = 12) of endoscopically proved subglottic hemangioma from 1976 to 1991 were collected from the records at Children's Hospital of Michigan. In 10 cases, high-kilovoltage magnification studies or frontal radiographs of the neck were available for review by two observers who classified the subglottic narrowing as either symmetric or asymmetric. The radiographic findings in these 10 cases were then compared with the location and extent of the lesion as described endoscopically.

RESULTS

In 50% of cases (n = 5), narrowing of the subglottic airway was symmetric. In four of these the hemangioma was either situated on the posterior wall or was circumferential, and in the remaining one an associated marked fibrotic reaction to a lateral wall lesion was present. All other lesions were on the lateral wall, and asymmetric subglottic airway narrowing was consistently shown on radiographs.

CONCLUSION

Our results show that subglottic hemangioma often manifests as a symmetric subglottic airway narrowing and that the anatomic location of the hemangioma appears to be associated with the appearance on radiographs.

Renal angiomyolipoma--a case report

Renal angiomyolipoma is a benign tumour of the kidney which is often mistaken for a renal cell carcinoma resulting in an unnecessary nephrectomy. It can be diagnosed preoperatively and managed conservatively without surgery. Large symptomatic renal angiomyolipomas can often be treated by renal-sparing surgery. We report a case of a large renal angiomyolipoma diagnosed preoperatively and excised completely with preservation of the kidney.

The distinction between benign and malignant liver tumors on sonography: value of a hypoechoic halo

OBJECTIVE

The purpose of this study was to determine the diagnostic value of the sonographic halo sign (defined as any hypoechoic rim in the periphery of a lesion) in distinguishing between benign and malignant isoechoic and hyperechoic liver lesions on sonography.

MATERIALS AND METHODS

Sonograms of the liver in 50 patients with proved benign liver tumors and in 50 patients with proved malignant liver tumors (seven primary liver neoplasms, 43 metastases) selected during a 13-month period were retrospectively analyzed by four radiologists who had no knowledge of the patients' clinical findings or the final diagnoses. Only a single sonogram was studied in each case. The presence or absence of a hypoechoic halo on the sonogram was the only criterion for distinguishing malignant from benign hepatic lesions.

RESULTS

For 95 of 100 hepatic lesions, the four radiologists were almost (three vs one) or completely (four vs zero) in agreement about the presence or absence of a hypoechoic halo. In the five cases where there were conflicting decisions (two vs two), a final decision (four vs zero) was achieved by reviewing the entire series of sonographic images. A halo could be detected in 44 malignant tumors (88%) and in only seven benign tumors (14%) (sensitivity, 88%; specificity, 86%; positive and negative predictive values, 86% and 88%, respectively). The sonographic halo sign was particularly helpful in distinguishing hemangiomas (n = 29) from metastases (n = 43) (positive and negative predictive values, 95% and 87%, respectively).

CONCLUSION

The results of this study suggest that the halo sign on sonograms is useful to distinguish benign from malignant isoechoic or hyperechoic tumors.

Selective arterial embolization in the treatment of aneurysmal bone cyst and angioma of bone

Nineteen aneurysmal bone cysts and five angiomas of bone were treated by selective arterial embolization. The median follow-up was 22 months. In 17 patients healing occurred with complete relief of symptoms; in 11 of these almost complete ossification of the lesion resulted. In the remaining cases, little or no ossification was apparent but ossification may take 1 year or more to occur. No recurrence was observed in any of these cases. Recurrence occurred only in two cases. In one, growth of the recurrence stopped after a second embolization, and the X-rays showed no change. Selective arterial embolization represents a treatment of choice in aneurysmal bone cyst and angioma of bone especially of the spine, sacrum, or pelvis. In these sites embolization replaces surgery which might be hazardous due to intraoperative bleeding.

[Delayed CT--a technique for the detection of hepatic metastases]

Plain CT and subsequent dynamic (or enhanced) CT demonstrated liver tumors in 43 patients: hepatocellular carcinoma in 24 patients, metastatic liver tumors in 15 patients and hemangioma of the liver in 4 patients. Delayed CT was furthermore performed 4 hours later to investigate its significance in the diagnosis of hepatic metastases by primarily comparing it with plain CT. The difference in CT numbers between the lesion and the normal hepatic parenchyma at delayed-type scanning 31.48 +/- 7.41 HU in metastatic liver tumors, which was significantly higher than 17.37 +/- 11.32 HU in hepatocellular carcinoma (p < 0.001). TDI after delayed CT was -0.43 +/- 0.13 in metastatic liver tumors and -0.26 +/- 0.15 in hepatocellular carcinoma, between which a significant difference was noted (p < 0.01). Delayed CT presented similar images to those obtained from plain CT in 14 of the 24 patients with hepatocellular carcinoma (58.3%) and a less clear tumor boundary in the remaining 10 patients (41.7%). On the other hand, the tumor boundary became clearer in 12 of the 15 patients with metastatic liver tumors (80.0%) at delayed-type scanning, than after plain CT, although the images remained almost unchanged in the remaining 3 patients (20.0%). The findings obtained from delayed CT in hemangioma of the liver were little different from those obtained from plain CT. This study suggested that delayed CT might better detect metastatic liver tumors than could plain CT. Delayed CT is recommended when metastases from other organs to the liver are suspected, and particularly when such metastatic liver tumors are small in size and multiple.

Differential diagnosis of hepatic tumors (hepatoma, hemangioma, and metastasis) with CT: value of two-phase incremental imaging

Two-phase dynamic incremental CT is a technique in which CT scans are obtained 45 sec and 6 min after commencing the rapid bolus injection of contrast medium. We analyzed the contrast enhancement patterns of three types of hepatic tumors (72 hepatomas, 39 hemangiomas, and 28 metastases) in 139 patients to determine if any differences in the patterns are useful in the differential diagnosis of these lesions. Dynamic incremental CT scanning was performed after 100 ml of iodinated contrast material was administered i.v. with a power injector at a rate of 2 ml/sec. A 1-sec scanning time was used with a 1.6-sec inter-scan delay, which allowed table motion between scans. CT scans (eight to 16 sections) were obtained 45-110 sec (early phase) and 6-7 min (delayed phase) after commencing the injection of contrast medium. The enhancement patterns of hepatomas were as follows: 32% were totally hyperdense in the early phase and totally hypodense in the delayed phase, while 24% were totally hypodense in both phases. Most of the hepatomas (88%) appeared as totally hypodense lesions in the delayed phase. In the case of hemangiomas, 56% were peripherally hyperdense in the early phase; in the delayed phase, 36% were isodense and 31% were totally hyperdense. Most hemangiomas (85%) were not totally hypodense in the early phase, and no hemangioma was totally hypodense in both phases. In the early phase, 61% of metastases were hypodense. In the delayed phase, 57% were hypodense. Metastases most commonly were totally hypodense in both phases (43%). We conclude that contrast enhancement patterns of hepatomas, hemangiomas, and metastases seen on two-phase dynamic incremental CT scans are useful in the differential diagnosis of these tumors.

[Spinal extradural angiolipoma: a case report]

This 60-year-old man had been well until four years prior to admission, when he developed slowly progressive weakness of the lower extremities. On admission he was found to have a spastic paraparesis, sensory disturbance below the level of T10 and mild sphincter dysfunction. Conventional myelography and CT myelography demonstrated an epidural mass located from T5 to T8 vertebral level. MRI revealed that the epidural mass was fusiform and markedly enhanced by the contrast medium. Laminectomy was performed and a fibrous tumor red in color was subtotally removed. Histological findings were consistent with those of angiolipoma. Angiolipoma is a rare tumor in the central nervous system and is regarded as a clinical entity different from a spinal lipoma. Occurrence of angiolipoma in the central nervous system has been reported in 40 cases in the world literature. Thirty nine cases of them occurred in the spinal canal, especially in the dorsal epidural space of the thoracic region. The fusiform shape demonstrated in this case might also be characteristic of angiolipoma in this region.

[Benign tumors of the liver. Clinical and radiological data]

Cysts and haemangiomas, which are frequent benign tumours of the liver, must be separated from hepatic adenoma and focal nodular hyperplasia. The former are usually diagnosed by ultrasonography and/or computed tomography (CT), and they exceptionally require surgery. The latter, much rarer, are similar in that both occur in young women and have the same imaging characteristics: CT does not always show the sign that confirms the diagnosis of focal nodular hyperplasia (i.e. a central "scar" vascularized at CT-angiography); scintigraphy would provide the diagnosis, but it is at fault in 30 to 40% of the cases. Excluding a malignant tumour (hepatocellular carcinoma or fibrolamellar hepatocarcinoma) is sometimes difficult. Often more than a certainty, it is a collection of convergent clinical and radiological data that leads to the correct diagnosis.

[Liver angiography--technique, indications and significance in focal liver processes]

Retrospective analysis of 155 liver angiographies and the literature data was carried out to appraise the current relevance of liver angiography in digital subtraction technique (i.a. DSA) for diagnosis of focal liver changes. A focal liver lesion was detected by angiography in 58 out of the 80 patients (72.5%) we investigated with a confirmed hepatic space occupation; an angiography correlate of the tumour type diagnosed was shown in 41 out of 69 (59.4%) of malignancies confirmed by surgery or biopsy histology; in the benign lesions, the angiographic diagnosis was consistent with the histological result in five out of six cases. DSA is thus usually clearly inferior to the tomographic sonography, CT and MRI in detection and qualification of the tumour type. However, it is still indispensable for planning operations or chemoembolization and for exact imaging of the portal perfusion conditions because of the frequent vascular anomalies in the anatomy of the liver.

Progressive enlargement of a circumscribed choroidal hemangioma. A clinicopathologic correlation

A man with a circumscribed choroidal hemangioma was followed up for almost 10 years as the tumor showed gradual, progressive enlargement in both diameter and thickness. In spite of photocoagulation therapy, a total retinal detachment and blindness ensued. Enucleation was performed because the possibility of amelanotic choroidal melanoma could not be absolutely excluded. Although the tumor thickness measured by ultrasonography before enucleation was 4.5 mm, the lesion measured only 2.0 mm in thickness in the pathology laboratory. Circumscribed choroidal hemangioma rarely demonstrates clinical evidence of growth. It appears that the tumor enlargement noted in this case was due to venous congestion in the tumor and not to cell multiplication.

[Intraoperative ultrasonography in brain surgery]

Intraoperative ultrasound was used in 33 patients. 19 lesions were primary malignant brain tumours, including 12 gliomas, three astrocytomas and four oligodendrogliomas. There were five metastases, three meningeomas, two dysembryoplastic neuroepithelial tumours and two angiomas. One patient had an arachnoid cyst, and another an infarct. The main advantage of carrying out intraoperative ultrasound examination is that it helps to localize the tumour, particularly in small subcortical lesions where the brain surface may appear normal. Ultrasound is less useful for characterizing the tumour, although the various tumours do show some differences. As a rule, the glioblastomas are inhomogeneous and poorly marginated, while low grade gliomas are more homogeneous and well marginated. Also meningeomas and metastases tend to be homogeneous and well marginated. Periofocal oedema is hyperechogenic compared with brain tissue, with an intensity between that of normal brain tissue and tumour mass. Cyst, calcification and haemorrhage are easily demonstrated.