Hemangiomas revisited: the useful, the unusual and the new. Part 1: overview and clinical and imaging characteristics

ACR Appropriateness Criteria® Soft Tissue Vascular Anomalies: Vascular Malformations and Infantile Vascular Tumors (Non-CNS)-Child

Soft tissue vascular anomalies may be composed of arterial, venous, and/or lymphatic elements, and diagnosed prenatally or later in childhood or adulthood. They are divided into categories of vascular malformations and vascular tumors. Vascular malformations are further divided into low-flow and fast-flow lesions. A low-flow lesion is most common, with a prevalence of 70%. Vascular tumors may behave in a benign, locally aggressive, borderline, or malignant manner. Infantile hemangioma is a vascular tumor that presents in the neonatal period and then regresses. The presence or multiple skin lesions in an infant can signal underlying visceral vascular anomalies, and complex anomalies may be associated with overgrowth syndromes. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Radiologic and Clinical Features of Infantile Hemangioma: Potential Pitfalls and Differential Diagnosis

Infantile hemangioma (IH) is the most common neoplasm in children, but it may mimic other types of vascular anomalies or nonvascular benign and malignant tumors. In most cases, the clinical appearance, time of onset, and pattern of involution facilitate its diagnosis. Imaging evaluation is not always needed since the IH features at clinical presentation are usually characteristic, but when needed, US and frequently MRI are the imaging modalities of choice. Clinical photography or photographic documentation plays a central role in monitoring these lesions over their clinical course. Photographic documentation can also add confidence and alert the radiologist when interpreting imaging studies. Some vascular anomalies, especially vascular malformations, are a frequent source of confusion, as these may resemble IHs clinically and at imaging. The lack of uniform terminology also hinders an accurate diagnosis. To unify the terminology and minimize confusion, the International Society for the Study of Vascular Anomalies created a helpful classification in 1994. In addition, radiologists need to be aware of and become familiar with other neoplasms in children that may resemble IH to avoid misdiagnosis and unnecessary procedures. Fibrous and lipomatous tumors are examples of benign tumors that can mimic IHs clinically and at imaging, whereas rhabdomyosarcoma, infantile fibrosarcoma, neuroblastoma, and lymphoproliferative disorders are examples of malignant neoplasms. The authors review the features of IH at clinical presentation and imaging evaluation, highlighting its different phases of evolution and stressing the importance of photographic documentation. The authors also review pitfalls of IH with helpful pearls for differentiation. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material. See the invited commentary by Khanna and Briones in this issue.

Incidental Findings in Pediatric Patients: How to Manage Liver Incidentaloma in Pediatric Patients

The World Federation for Ultrasound in Medicine and Biology (WFUMB) is addressing the issue of incidental findings (IFs) with a series of publications entitled "Incidental imaging findings-the role of ultrasound". IFs in the liver of newborns and children are rare and much less commonly encountered than in adults; as a result, they are relatively much more frequently malignant and life-threatening, even when they are of benign histology. Conventional B-mode ultrasound is the well-established first line imaging modality for the assessment of liver pathology in pediatric patients. US technological advances, resulting in image quality improvement, contrast-enhanced ultrasound (CEUS), liver elastography and quantification tools for steatosis have expanded the use of ultrasound technology in daily practice. The following overview is intended to illustrate incidentally detected liver pathology covering all pediatric ages. It aims to aid the examiner in establishing the final diagnosis. Management of incidentally detected focal liver lesions (FLL) needs to take into account the diagnostic accuracy of each imaging modality, the patient's safety issues (including ionizing radiation and nephrotoxic contrast agents), the delay in diagnosis, the psychological burden on the patient and the cost for the healthcare system. Moreover, this paper should help the pediatric clinician and ultrasound practitioner to decide which pathologies need no further investigation, which ones require interval imaging and which cases require further and immediate diagnostic procedures.

Subcutaneous fat necrosis of the newborn: a pictorial essay of an under-recognized entity

Subcutaneous fat necrosis of the newborn is a self-limited disorder predominantly affecting full-term and post-term neonates during the first 6 weeks after birth. Subcutaneous fat necrosis can be focal or multifocal and affect one or both sides with a predilection for areas of pressure in certain anatomical areas. Subcutaneous fat necrosis of the newborn is associated with perinatal asphyxia and other neonatal and maternal risk factors. Subcutaneous fat necrosis of the newborn presents as a self-limited area of dermal edema followed by indurated subcutaneous plaques, or nontender and mobile nodules, sometimes with skin discoloration [1-3]. The diagnosis is based on the child's history and physical examination, but when in doubt, imaging is helpful. US is the imaging modality of choice to confirm the diagnosis of subcutaneous fat necrosis of the newborn because it provides the best resolution of superficial lesions, requires no sedation and lacks ionizing radiation. US can also help evaluate and characterize other pathologies affecting the superficial subcutaneous soft tissues at this age. Familiarity with subcutaneous fat necrosis of the newborn is important to make a prompt and precise diagnosis and avoid unnecessary imaging tests or invasive procedures.

Palpable pediatric chest wall masses

Pediatric chest wall lesions are varied in etiology ranging from normal and benign to aggressive and malignant. When palpable, these lesions can alarm parents and clinicians alike. However, most palpable pediatric chest lesions are benign. Familiarity with the various entities, their incidences, and how to evaluate them with imaging is important for clinicians and radiologists. Here we review the most relevant palpable pediatric chest entities, their expected appearance and the specific clinical issues to aid in diagnosis and appropriate treatment.

Conservative management of congenital hepatic hemangioma complicated by ascites

Involution of a rapidly involuting congenital hemangioma is an unknown cause of neonatal ascites. As involution phase is completed by 14 months after birth, conservative management with diuretics and drainage is possible and may avoid surgical resection.

Update of pediatric soft tissue tumors with review of conventional MRI appearance-part 2: vascular lesions, fibrohistiocytic tumors, muscle tumors, peripheral nerve sheath tumors, tumors of uncertain differentiation, and undifferentiated small round cell sarcomas

There are numerous soft tissue tumors and tumor-like conditions in the pediatric population. Magnetic resonance imaging is the most useful modality for imaging these lesions. Although certain soft tissue lesions exhibit magnetic resonance features characteristic of a specific diagnosis, most lesions are indeterminate, and a biopsy is necessary for diagnosis. We provide a detailed update of soft tissue tumors and tumor-like conditions that occur in the pediatric population, emphasizing each lesion's conventional magnetic resonance imaging appearance, using the recently released 5^th edition of the World Health Organization Classification of Soft Tissue and Bone Tumors as a guide. In part one of this review, pediatric tumor-like lesions, adipocytic tumors, fibroblastic and myofibroblastic tumors, and perivascular tumors are discussed. In part two, vascular lesions, fibrohistiocytic tumors, muscle tumors, peripheral nerve sheath tumors, tumors of uncertain differentiation, and undifferentiated small round cell sarcomas are reviewed. Per the convention of the WHO, these lesions involve the connective, subcutaneous, and other non-parenchymatous organ soft tissues, as well as the peripheral and autonomic nervous system.

Neonatal vascular anomalies manifesting as soft-tissue masses

The broad and heterogeneous spectrum of vascular anomalies ranges from an innocuous localized cutaneous discoloration to complex, extensive and life-threatening diagnoses. While many of these lesions are present at birth, smaller and deeper lesions might be clinically occult for months or years. Certain vascular anomalies commonly manifest in the prenatal or neonatal period and often have suggestive clinical and imaging features that can aid the radiologist in making a correct diagnosis. The characteristics of such lesions presenting very early in life, particularly those manifesting as soft-tissue masses, are the focus of this review.

Vascular anomalies: clinical perspectives

Vascular anomalies are classified as vascular tumors or vascular malformations according to their cellular features and biological behavior. Detailed history and clinical assessment allow for the proper clinical diagnosis of most vascular anomalies and guide the choice of imaging to evaluate them. This article discusses the general information needed from a clinical history and physical exam to formulate a diagnosis of vascular anomaly. Then, the authors review the clinical findings from the most common vascular tumors and vascular malformations.

Chronic excruciating forearm pain in a child with intra-neural hemangioma: A challenging case report

INTRODUCTION AND IMPORTANCE

Cavernous hemangioma is a rare form of hemangioma. It usually arises in the central nervous system, but the tumor has also been reported in the liver, retina and skin with a lower prevalence. Its occurrence into the peripheral nerves has only been reported a few times. Herein, we report an extremely rare case of intra-neural hemangioma in the ulnar nerve and discuss the complications we faced following surgery.

CASE PRESENTATION

We present a 6-year-old boy with history of severe progressive left forearm pain in the last two years. Imaging studies revealed a soft tissue mass and histopathological exam was in favor of a cavernous hemangioma. Patient underwent surgery to excise the tumor. Despite temporary response, he began to experience excruciating pain shortly after surgery which caused him to adopt bizarre postures.

CLINICAL DISCUSSION

In the more common form of nerve involvement in a hemangioma, the nerve is displaced and surrounded by the tumor. However, in cases with intra-neural involvement, the nerve would have to be sacrificed. This case report brings some rare but important characteristics of a hemangioma in to attention, such as the intra-neural location, possibility of recurrence and aggravating pain with bizarre positions as a result.

CONCLUSION

In cases of intra-neural hemangioma, there is a chance that the patient experiences recurrence and/or excruciating pain following surgery. The orthopedic surgeon should be prepared for the possibility of nerve transfer, repeat surgeries and the need for prolonged palliative pain suppression modalities in the approach to intra-neural hemangioma.

Neuroaxial Infantile Hemangiomas: Imaging Manifestations and Association with Hemangioma Syndromes

BACKGROUND AND PURPOSE

Infantile hemangiomas are common lesions in the pediatric population; in rare cases, an infantile hemangioma can be detected along the neural axis. The purposes of our study included determination of the incidence, location, and imaging appearance of neuroaxial infantile hemangiomas and their syndromic association. We also assessed additional features of cerebral and cardiovascular anomalies that may be associated with neuroaxial lesions.

MATERIALS AND METHODS

A retrospective cohort study was performed, searching the radiology database for patients with segmental infantile hemangiomas referred for assessment of possible hemangioma syndromes. We retrospectively reviewed brain and spine MR imaging studies, with particular attention paid to neuroaxial vascular lesions, as well as the relevant clinical data. Neuroaxial hemangioma imaging findings were described, and comparison of segmental cutaneous infantile hemangioma location with the imaging findings was performed in patients with confirmed hemangioma syndromes and in patients with isolated skin infantile hemangioma.

RESULTS

Ninety-five patients with segmental infantile hemangioma were included in the study, 42 of whom had a hemangioma syndrome; of those, 41 had posterior fossa brain malformations, hemangioma, arterial lesions, cardiac abnormalities, and eye abnormalities (PHACE) syndrome and 1 had diffuse neonatal hemangiomatosis. Neuroaxial involvement was detected in 20/42 patients (48%) with hemangioma syndromes and in no subjects with isolated segmental infantile hemangioma (P < .001). The most common intracranial hemangioma location was within the ipsilateral internal auditory canal (83%).

CONCLUSIONS

Many pediatric patients with segmental infantile hemangioma in the setting of hemangioma syndromes, especially those with PHACE, had neuroaxial hemangiomas. This finding may potentially lead to requiring additional clinical evaluation and management of these patients.

Subclinical Ultrasound Characteristics of Infantile Hemangiomas That May Potentially Affect Involution

OBJECTIVES

Infantile hemangiomas (IHs) are the most common benign tumors in children. Color Doppler ultrasound is a noninvasive imaging modality that can show subclinical anatomic parameters in a wide range of dermatologic conditions. The purpose of this study was to describe the ultrasound characteristics of IHs and look for subclinical features with the potential to influence the involution and therapeutic response.

METHODS

A review of the ultrasound database of children with clinical and ultrasound IH diagnoses was conducted. The clinically reported duration and the ultrasound assessment of the proliferative phase were compared. Descriptive and statistical analyses of qualitative and quantitative parameters of the series were performed. Significance was set at P < .05.

RESULTS

A total of 204 IHs were included. Twenty percent had arteriovenous shunts; 15% had afferent branches from main regional arteries; and almost 30% showed involvement of deep structures. Sixty-one percent of IHs were in the head and neck. Deep hemangiomas showed significantly thicker lesional vessels. A prolonged proliferative stage was significantly associated with a higher presence of arteriovenous shunts and a higher peak systolic velocity of the arterial vessels (≥15 cm/s) within the lesions.

CONCLUSIONS

Color Doppler ultrasound can support the detection of subclinical anatomic features that may potentially influence the involution and response to treatment of IHs. Some of these characteristics may serve as potential markers to predict and manage IHs in prolonged proliferative stages.

Contrast-enhanced ultrasound of benign and malignant liver lesions in children

Contrast-enhanced ultrasound (CEUS) is increasingly being used in children. One of the most common referrals for CEUS performance is characterization of indeterminate focal liver lesions and follow-up of known liver lesions. In this setting, CEUS is performed with intravenous administration of ultrasound contrast agents (UCAs). When injected into a vein, UCA microbubbles remain confined within the vascular network until they dissipate. Therefore, visualization of UCA within the tissues and lesions corresponds to true blood flow. CEUS enables continuous, real-time observation of the enhancement pattern of a focal liver lesion, allowing in most cases for a definite diagnosis and obviating the need for further cross-sectional imaging or other interventional procedures. The recent approval of Lumason (Bracco Diagnostics, Monroe Township, NJ) for pediatric liver CEUS applications has spurred the widespread use of CEUS. In this review article we describe the role of CEUS in pediatric liver applications, focusing on the examination technique and interpretation of main imaging findings of the most commonly encountered benign and malignant focal liver lesions. We also compare the diagnostic performance of CEUS with other imaging modalities for accurate characterization of focal liver lesions.

Color Doppler Evaluation of Arterial Resistive Index in Infantile Hemangioma: A Useful Parameter to Monitor the Response to Oral Propranolol?

Infantile hemangioma (IH) is the most common benign vascular tumor in childhood. In more than 85% of all cases, IHs undergo spontaneous involution, but nearly 10-12% of IHs develop complications and require immediate therapy. Oral propranolol is currently the first-line treatment for IHs. Color Doppler ultrasound is the gold standard in the diagnosis of deep IH, and it is used to evaluate the morphological change and the modification of vascularization that occur during its evolution and treatment. To date, only few data in the literature described the changes of intralesional arterial resistive index (RI) during treatment with propranolol; particularly, some authors have shown an increase of intralesional arterial RI in IHs with clinical regression during treatment with propranolol. The objective of this paper is to evaluate the changes of RI of the intralesional arteries of the IHs during the treatment with oral propranolol. We retrospectively analyzed a total of 64 IHs in 60 patients treated with oral propranolol with a good clinical response. Gray-scale ultrasonography and color Doppler imaging were performed before and during the therapy. The intralesional RIs were measured before and during the treatment. For each lesion, we recorded the RI values, and then we calculated the mean RI value for any single lesion. We compared the mean RI value observed at the baseline with the mean RI value of the last detectable sampling at color Doppler. We also compared between them the mean RI values observed during intermediate ultrasound. The RI values were compared in 44 lesions, with at least two significant samplings of RI. In the 44 lesions compared, we did not find statistically significant variations in the mean RI values between the baseline control and the values recorded at the last post-treatment control. The time trend of mean RI values of the intermediate color Doppler analysis performed between the first pre-treatment control and the last measurable control did not show any statistically significant variation in the trend of mean RI values. Contrarily to what has been described by some authors, in our experience, we have not observed an increase of RI in IHs treated with oral propranolol.

Vascular anomalies of the head and neck

The head and neck are the most common site of involvement for vascular tumors and malformations, with more than half of all vascular anomalies seen in this region. Lesions in this location can cause significant disfigurement and can be associated with airway obstruction, impairment in vision or hearing, swallowing disorders and hemorrhage. Accurate diagnosis is critical in determining treatment, and interdisciplinary care is essential for optimal management. We review clinical and imaging features that are key to establishing the correct diagnosis, and review treatment modalities, with emphasis on interventional and surgical procedures.

Spectrum of Imaging Manifestations of Vascular Malformations and Tumors Beyond Childhood: What General Radiologists Need to Know

Vascular anomalies encompass a collection of diagnoses that differ greatly in terms of clinical presentation, natural history, imaging findings, and management. The purpose of this article is to review diagnostic imaging findings of vascular malformations and vascular tumors, excluding the central nervous system, that occur beyond childhood. A widely accepted classification system created by the International Society for the Study of Vascular Anomalies provides a framework for this review, focusing on the entities most likely to be encountered by general radiologists, although several rare but clinically important entities are also reviewed.

Congenital hemangioma of the face-Value of fetal MRI with prenatal ultrasound

We report the presentation, workup, and pre/perinatal management of a fetus with a large congenital hemangioma of the face. Hemangiomas are benign vascular neoplasms frequently encountered in neonates and infants. The less common congenital variant develops in utero and can present on prenatal ultrasound with diagnostic uncertainty as well as clinical implications for delivery. The differential diagnosis for these solid vascular masses when located in the head and neck includes myofibroma, kaposiform hemangioendothelioma, teratoma, and encephalocele. Potential clinical issues relate to size and location of the mass and include airway obstruction, disruption in development or compression of the globe, invasion into the cranial vault, bleeding and ulceration, and high output heart failure. Prenatal ultrasound and MRI play an important role in the diagnosis of congenital hemangiomas and planning for delivery and immediate postnatal cares.

Piezosurgery for Intraosseous Venous Malformation of the Mandible

Intraosseous venous malformation of the mandible is rare. A 59-year-old woman was referred to our hospital for evaluation of a radiolucent lesion in the left body of the mandible that had been detected on a routine radiologic dental checkup. The patient wished for follow-up rather than operation. After 2 years’ follow-up, the radiolucent lesion had slowly grown, and the patient decided to have an operation. The lesion was removed surgically using the piezosurgery system, and conservation of the inferior alveolar nerve was achieved under general anesthesia. After operation, she reported an initial change in sensation (paresthesia). The sensitivity was recovered after 6 months. Patient prognosis has been good to date, with no symptoms indicating recurrence. We used to treat intraosseous venous malformations using the piezosurgery system. The present report describes a patient with intraosseous venous malformation of the mandible by complete excision and conservation of the nerve. It was useful to use piezosurgery for conservation of inferior alveolar nerve.

Imaging of Submandibular and Sublingual Salivary Glands

The submandibular and sublingual salivary glands are major salivary glands with a wide spectrum of pathologic conditions. The corresponding spaces along the floor of mouth have complex anatomy, best evaluated with cross-sectional imaging. The spectrum of diseases in these regions varies from simple infection to advanced malignancy, not just from the gland itself but also from the surrounding structures. The most common abnormalities in these spaces are inflammatory and infectious, and computed tomography is currently the most common imaging modality used. The anatomy of these spaces is much better depicted with MR; however, all the modalities have their unique roles.

Intracranial hemorrhage in neonates: A review of etiologies, patterns and predicted clinical outcomes

Intracranial hemorrhage (ICH) in neonates often results in devastating neurodevelopmental outcomes as the neonatal period is a critical window for brain development. The neurodevelopmental outcomes in neonates with ICH are determined by the maturity of the brain, the location and extent of the hemorrhage, the specific underlying etiology and the presence of other concomitant disorders. Neonatal ICH may result from various inherited and acquired disorders. We classify the etiologies of neonatal ICH into eight main categories: (1) Hemorrhagic stroke including large focal hematoma, (2) Prematurity-related hemorrhage, (3) Bleeding diathesis, (4) Genetic causes, (5) Infection, (6) Trauma-related hemorrhage, (7) Tumor-related hemorrhage and (8) Vascular malformations. Illustrative cases showing various imaging patterns that can be helpful to predict clinical outcomes will be highlighted. Potential mimics of ICH in the neonatal period are also reviewed.

Rapidly involuting congenital haemangioma of the liver

Rapidly involuting congenital haemangiomas (RICHs) are rare benign vascular tumours of infancy. They are generally asymptomatic, but can present with thrombocytopaenia and coagulopathy. Significant complications including life-threatening bleeding, high-output heart failure and liver failure, though rare, can occur. RICHs generally regress by 12-14 months of age and can be managed clinically with symptomatic treatment, watchful waiting and close monitoring of the size of the haemangioma. Medical management (corticosteroids, propranolol) has not shown to be effective, in contrast to infantile haemangioma which will not regress spontaneously and has been noted to respond to medical therapy. Awareness of this diagnosis is important to prevent unnecessary medical and surgical intervention. Here, we present a case of a full-term infant with RICH who presented with thrombocytopaenia and abnormal coagulation profile. The coagulopathy was treated symptomatically, while the lesion was observed with serial ultrasounds and gradually decreased in size.

Up-To-Date Practical Imaging Evaluation of Neonatal Soft-Tissue Tumors: What Radiologists Need to Know

OBJECTIVE

The purposes of this article are to provide an up-to-date overview of neonatal soft-tissue tumors, including information regarding their unique nature, and to present practical imaging techniques and characteristic imaging findings.

CONCLUSION

Neonatal soft-tissue tumors are a unique set of neoplasms that often have characteristic clinical and imaging findings. Imaging evaluation, mainly with ultrasound and MRI, plays an important role in the initial diagnosis, staging, preoperative assessment, and follow-up evaluation. Clear understanding of practical imaging techniques combined with up-to-date knowledge of characteristic imaging findings can help the radiologist provide a timely and accurate diagnosis of these neoplasms and can lead to optimal neonatal patient care.

2014 Revised Classification of Vascular Lesions from the International Society for the Study of Vascular Anomalies: Radiologic-Pathologic Update

Since the publication of the seminal work on the histology-based classification of vascular anomalies by Mulliken and Glowacki in 1982 and the subsequent adoption of an expanded and modified version in 1996 by the International Society for the Study of Vascular Anomalies, an increasing number of vascular lesions have been recognized as histologically distinct entities. Furthermore, there have been significant advances in detailing the behavior and underlying genetics of previously identified lesions. These developments have required restructuring and expansion of the classification scheme so that appropriate therapies may be studied and implemented in affected patients. The new classification retains the broad categories of neoplasms and malformations but now divides the tumor group into benign, locally aggressive or borderline, and malignant, with the malformation group being divided into simple, combined, those of major named vessels, and those associated with other anomalies. Additionally, a category has been created for lesions in which the histology and behavior do not yet allow clear separation into neoplasm or malformation (thus named "provisionally unclassified vascular anomalies"). The known clinical courses and imaging, histologic, and genetic findings of the most common and/or clinically relevant lesions in the newly adopted revised system are reviewed in this article. (©)RSNA, 2016.

Intracranial extra-axial hemangioma in a newborn: A case report and literature review

Background:

Congenital hemangiomas are benign vascular tumors, and the intracranial counterpart was described in very few cases.

Case Description:

A newborn presented with an intracranial tumor associated with an arachnoid cyst, diagnosed by antenatal ultrasound at 37 weeks of gestation. Surgery was indicated due to increased head circumference and bulging fontanelle, and a complete resection of an extra-axial red–brown tumor was performed at the 3^rd week of life. Microscopy revealed a hemangioma.

Conclusion:

Hemangioma is a rare differential diagnosis that must be considered in extra-axial intracranial tumors affecting infants and neonates. The radiological features are not helpful in differentiating from other tumors, and surgery is indicated when the diagnosis is uncertain or whenever there are signs of increased intracranial pressure.

Magnetic resonance imaging of pediatric soft-tissue vascular anomalies

Magnetic resonance (MR) imaging can be used in the management of pediatric soft-tissue vascular anomalies for diagnosing and assessing extent of lesions and for evaluating response to therapy. MR imaging studies often involve a combination of T1- and T2-weighted images in addition to MR angiography and fat-suppressed post-contrast sequences. The MR imaging features of these vascular anomalies when combined with clinical findings can aid in diagnosis. In cases of complex vascular malformations and syndromes associated with vascular anomalies, MR imaging can be used to evaluate accompanying soft-tissue and bone anomalies. This article reviews the MR imaging protocols and appearances of the most common pediatric soft-tissue vascular anomalies.

Propranolol for infantile hemangioma: Current state of affairs

Infantile hemangioma (IH) is the most common benign tumor seen in infancy. This review provides up-to-date information on the pathophysiology, variations in clinical presentation, and natural history of IH, elaborating on associated anomalies, such as PHACE(S) syndrome and LUMBAR syndrome. Because of the benign and self-limiting characteristics seen in more than 90% of cases of IH, a conservative approach is usually chosen. However, some circumstances, such as ulceration, vision loss, breathing difficulties, or potential disfigurement, will require treatment during the proliferative phase. For decades, treatment of IH has primarily consisted of corticosteroids or surgery. Since 2008, propranolol has become the treatment of first choice. In this article, we bring to light the crucial changes in the treatment of IH over the past years. To date, there is still a lack of data on the possible long-term effects of propranolol treatment in young infants. A theoretical probability of the central nervous system being affected (that is, impairment of short- and long-term memory, psychomotor function, sleep quality, and mood) has recently been suggested. This review highlights research topics concerning these long-term adverse effects. Finally, information is provided on the potential instruments to measure IH severity and activity in clinical trials and/or in clinical practice and the recently developed and first-validated IH-specific quality-of-life questionnaire.

Hemangiomas and the eye

Infantile hemangiomas are a common vascular birthmark with heterogeneous presentations and unique growth characteristics with early rapid growth and eventual self-involution. Hemangiomas that develop around the eye have the potential for inducing amblyopia by several mechanisms and may eventually result in permanent visual impairment in otherwise healthy infants. Segmental periocular hemangiomas carry the additional risk of associated structural anomalies and PHACE syndrome. In recent years, the treatment of periocular hemangiomas has been revolutionized by the serendipitous discovery of the effectiveness of beta-blockers (systemic and topical), with most experts viewing these as first-line therapies. The management of periocular hemangiomas should involve a close partnership between an ophthalmologist and dermatologist or other relevant specialists familiar with the unique clinical features, differential diagnosis, treatment approaches, and potential complications.

Infantile haemangioma: their presentation and management

Haemangiomas are the commonest type of vascular tumour in infancy. This article summarizes the pathophysiology and classification of the subtypes as early identification of high-risk lesions is essential for consideration of treatment to prevent short- and long-term complications from the condition.

Color Doppler Ultrasound Follow-Up of Infantile Hemangiomas and Peripheral Vascularity in Patients Treated with Propranolol

BACKGROUND

Infantile hemangiomas (IHs) are the most common vascular tumors in childhood. Diagnosis of IHs is usually clinical, however, to determine the actual dimensions of the lesion or the anatomic changes that occur during its evolution and treatment, a color Doppler ultrasound (CDU) examination can be performed. To date, there are few publications that assess the sonographic response to propranolol in IHs, and to our knowledge, none that consider simultaneous evaluation of both intralesional and normal peripheral blood vessels in these cases.

OBJECTIVE

Evaluation of the anatomic effect of propranolol in IHs and peripheral blood vessels using CDU.

METHODS

A cohort study was performed in 10 pediatric patients with a diagnosis of IH in whom systemic therapy with propranolol was indicated. The patients underwent a baseline and 3-month follow-up CDUs of the tumor and the main peripheral vessels of the right upper extremity.

RESULTS

The group was composed of 7 (70%) girls and 3 (30%) boys. The average CDU decrease in size of the longitudinal axis was 11%; of the transverse axis, 24%; tumor thickness, 30%; and intralesional vessel thickness, 46%. Hemangioma volume measured by CDU decreased an average of 51%. The thickness of the peripheral vessels did not change significantly between the baseline and 3-month follow-up CDUs.

CONCLUSION

CDU permits noninvasive quantification of the changes in IHs and peripheral vessels in patients receiving propranolol therapy. In our cohort of cases there was a significant reduction in tumor volume; however, peripheral vascularity was not significantly affected.

Giant cranial and cerebellar hemangioma treated with propranolol

INTRODUCTION

Infantile hemangiomas are the most common benign tumors in children. However, cranial involvement of such lesions is rare. Current treatment options for hemangiomas in various locations that would be endangering or disfiguring include follow-up, surgical removal, or administration of corticosteroids, interferon-α, thalidomide, vincristine, propranolol, and laser therapy.

METHODS

We describe an infant who presented with an extensive cranial hemangioma (proven by a biopsy). The child was treated with propranolol.

RESULTS

Clinical and radiological follow-up for over a year showed significant reduction in tumor size without adverse clinical symptoms.

CONCLUSION

Propranolol is a valid treatment for large cranial hemangiomas, avoiding the risks involved in surgeries.

Update on the classification of hemangioma

Despite the fact that a biological classification of congenital vascular tumors and malformations was first published in 1982 by Mulliken and Glowacki, significant confusion still prevails due to the indiscriminate and interchangeable use of the terms hemangioma and vascular malformation. Hemangiomas are true neoplasms of endothelial cells and should be differentiated from vascular malformations which are localized defects of vascular morphogenesis. On an analysis of various scientific articles and latest edition of medical text books an inappropriate use of various terms for vascular lesions was found, contributing further towards the confusion. The widely accepted International Society for the Study of Vascular Anomalies (ISSVA) classification differentiates lesions with proliferative endothelium from lesions with structural anomalies and has been very helpful in standardizing the terminologies. In addition to overcoming obstacles in communication when describing a vascular lesion, it is important that we adhere to the correct terminology, as the therapeutic guidelines, management and follow-up of these lesions differ.

The fundamentals of fetal magnetic resonance imaging: Part 2

Careful assessment of fetal anatomy by a combination of ultrasound and fetal magnetic resonance imaging offers the clinical teams and counselors caring for the patient information that can be critical for the management of both the mother and the fetus. In the second half of this 2-part review, we focus on space-occupying lesions in the fetal body. Because developing fetal tissues are programmed to grow rapidly, mass lesions can have a substantial effect on the formation of normal adjacent organs. Congenital diaphragmatic hernia and lung masses, fetal teratoma, and intra-abdominal masses are discussed, with an emphasis on differential etiologies and on fundamental management considerations.

Giant intracranial hemangioma in a neonate

In this report we detail the case of an infant presenting with a giant intracranial congenital hemangioma and describe the clinical features and surgical management. Congenital hemangiomas are benign vascular tumors that typically present as skin lesions in neonates and infants. On rare occasions they present as intracranial tumors. The possibility that these tumors may undergo spontaneous regression poses a treatment dilemma.

Vascular anomalies: hemangiomas and beyond--part 2, Slow-flow lesions

OBJECTIVE

The purpose of this article is to review the medical literature and the current classification of the vascular anomalies to clarify common misconceptions and provide guidance for imaging and treatment. In this second article of a two-part series, we focus on slow-flow vascular anomalies.

CONCLUSION

Nonuniformity of terminology across the medical literature hampers understanding of vascular anomalies. A familiarity with the classification and biology on which it is based are essential for accurate and precise diagnosis.

Multimodality imaging of vascular anomalies

Vascular malformations and hemangiomas are common in children but remain a source of confusion during diagnosis, in part because of the lack of a uniform terminology. With the existing treatments for hemangiomas and vascular malformations, it is important to make the correct diagnosis initially to prevent adverse physical and emotional sequelae in not only the child but also the family. The diagnosis of vascular malformations is made primarily by the clinician and based on the physical exam. Imaging is carried out using predominantly ultrasound (US) and magnetic resonance imaging (MRI), which are complementary modalities. In most cases of vascular anomalies, US is the first line of imaging as it is readily available, less expensive, lacks ionizing radiation and does not require sedation. MRI is also of great help for further characterizing the lesions. Conventional arteriography is reserved for cases that require therapeutic intervention, more commonly for arteriovenous malformations. Radiographs usually play no role in diagnosing vascular anomalies in children. In this article, the author describes the terminology and types of hemangiomas and vascular malformations and their clinical, histological features, as well as the imaging approach and appearance.