ACUTE SPINAL CORD COMPRESSION FROM AN

EXTRAOSSEOUS VERTEBRAL HEMANGIOMA WITH

HEMORRHAGIC COMPONENTS: A CASE REPORT
Tarkan Ergun, MD, a Hatice Lakadamyali, MD,a Huseyin Lakadamyali, MD,b and Amir Mukaddem, MD c

ABSTRACT

Objective: This case report presents a patient with acute compression myelopathy caused by acute hemorrhage of a
thoracic vertebral hemangioma extending into the epidural space.
Clinical Features: A 22-year-old male patient experiencing back pain for 5 months presented to our medical
facility complaining of sudden onset numbness and muscle weakness in the lower extremities.
Intervention and Outcome: Magnetic resonance imaging of the thoracic spine revealed a T5-level mass involving
predominantly the posterior vertebral elements, extending into the epidural area, and showing significant gadolinium
enhancement. Hemorrhagic signal changes were noted within the epidural component of the mass. In addition, the
epidural mass component was noted to significantly compress the spinal cord. The patient was referred for emergency
surgery with the preliminary diagnosis of epidural vertebral hemangioma with hemorrhagic component; a decompression
laminectomy was performed without preoperative angiography. The patient's complaints improved completely after
surgery, and radiotherapy was instituted for the residual tumor tissue.
Conclusion: The presence of acute or subacute myelopathic symptoms is usually suggestive for malignancy or
metastasis. However, in young patients, vertebral hemangioma, causing acute hemorrhage, should be considered in the
differential diagnosis. Decompression surgery should be done in such cases before neurological symptoms
become irreversible. (J Manipulative Physiol Ther 2007;30:602-606)
Key Indexing Terms: Hemorrhage; Spinal Cord Compression; Hemangioma

ertebral hemangioma (VH) is a developmental canal due to expansion of the vertebral corpus caused by the

V hamartoma consisting of vascular tissue. These

lesions have no malignant potential because they
do not grow by mitotic division.1 According to information
obtained from autopsy studies, the incidence of VH ranges
from 10% to 12%.2 These tumors usually produce no
symptoms and are mostly diagnosed incidentally. In rare
cases, a VH compresses the spinal cord and nerve roots,
which causes back pain, radiculopathy, and myelopathy.
The mechanisms underlying the compressive symptoms
in VH cases are mostly related to narrowing of the spinal
hemangioma.3 Acute spinal cord compression cases sec-
ondary to a hemorrhage into the epidural space as with our
patient are extremely rare4; thus, no standard therapy exists
for such cases. However, immediate surgical intervention is
necessary in cases of acute compressive myelopathy before
the symptoms become irreversible.
We present a patient with thoracic VH that extended into
the epidural space and caused acute spinal cord compression
as a result of bleeding from the lesion.

a
Specialist, Department of Radiology, Alanya Teaching and
Medical Research Center, Baskent University, Alanya, Turkey.
b
Specialist, Department of Pulmonology, Alanya Teaching and
Medical Research Center, Baskent University, Alanya, Turkey.
c examination revealed tenderness in the thoracic region on
Specialist, Department of Neurosurgery, Alanya Teaching and
Medical Research Center, Baskent University, Alanya, Turkey.
Submit requests for reprints to: Tarkan Ergun, MD, Specialist,
Baskent Universitesi, Alanya Hastanesi, Radyoloji Bolumu, 07400
Alanya, Antalya, Turkey. (eQmail: tarkanergun@yahoo.com).
Paper submitted December 16, 2006; in revised form May 2,
2007; accepted June 9, 2007.
0161-4754/$32.00
Copyright © 2007 by National University of Health Sciences.
doi:10.1016/j.jmpt.2007.06.007
CASE REPORT
A 22-year-old man, complaining of sudden numbness and
minimal muscle weakness in both legs and back pain of
5 months' duration presented to our institution. Physical
deep palpation and hyperactive deep tendon reflexes in the
lower extremities. Motor examination revealed a 4/5 muscle
weakness score in the lower extremities. The preliminary
diagnosis was herniation of the nucleus pulposus at the
thoracic region. Magnetic resonance imaging (MRI) of the
thoracic vertebral column revealed a T5-level soft-tissue
mass that involved both the anterior and posterior vertebral
elements, extended into the epidural space, caused expansion

602
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Journal of Manipulative and Physiological Therapeutics
Volume 30, Number 8
Fig 1. A, Sagittal T1-weighted image shows a soft-tissue mass
extending into the epidural space, causing significant compression
and anterior displacement of the spinal cord (arrows). B, A
significant hyperintense hemorrhagic component is visible within
the epidural space; the mass cannot be suppressed in the T2-
weighted fat-suppression sequences.
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Ergun et al 603
Hemorrhagic Hemangioma
Fig 2. A post intravenous gadolinium injection T1-weighted image
of the same level reveals a significant osseous enhancement of the
vertebral corpus and posterior elements affected by the heman-
gioma and significant enhancement of the extraosseous component
of the hemangioma extending into the posterior epidural space and
right paravertebral region (arrow).
of the laminae and pedicles on both sides, and significantly
compressed the spinal cord. Magnetic resonance imaging
studies also revealed a T2-T7 level epidural soft-tissue mass
with multiple hyperintense areas of hemorrhage in the T1-
weighted sequences; these contained a small amount of fat
in the fat suppression sequences, which were enhanced by
the administration of intravenous contrast media (Figs 1A-B
and 2). The MRI features of the lesion suggested a VH, but
the expansive nature of the tumor and its extension into the
epidural space suggested a possible malignancy. The
clinical characteristics of the lesion did not indicate an
infectious process.
Taking into consideration the young age of the patient and
the radiological features of the lesion, we suspected a
hemorrhagic VH extending to the epidural area, and the
patient was referred for immediate surgery.
After determination of the surgical level using C-arm
fluoroscopy, the paraspinal muscles were dissected at the
T5-level with a posterior approach. Posterior decompres-
sion was accomplished by removing the vertebral laminae.
The posterior epidural tumoral tissue and hematoma were
resected as much as possible. The acute blood loss due
to intratumoral hemorrhage comprised 2 L, and a 2-unit
intraoperative blood transfusion was done. The region
was covered with thrombin-soaked gel foam to prevent
further hemorrhage.
The results of histopathologic examination of the
partially resected mass showed that the lesion was a VH.
604 Ergun et al
Hemorrhagic Hemangioma
Postoperative radiotherapy was instituted to prevent recur-
rence of the residual mass. The total radiotherapy dose was
given in 20 fractions of 40 Gy (5 fractions per week), and no
complications were encountered. The patient's symptoms
improved completely in the third day after surgery, and he
was symptom-free at the follow-up visit 6 months after
the operation.
DISCUSSION
A VH is usually a solitary lesion located in the
vertebral corpus, although it may occasionally involve the
posterior vertebral elements. Vertebral hemangiomas
develop most frequently in the thoracic vertebrae.5 Usually
asymptomatic for a lifetime, VHs may cause symptoms in
1% of cases, the most common symptom being back pain.
It may rarely cause neurological symptoms and compres-
sive myelopathy and thus should be considered in the
differential diagnosis of metabolic, inflammatory, and
neoplastic myelopathies.
The physiopathologic mechanism of a VH that com-
presses the spinal cord involves the angiomatous hypertro-
phy of the vertebral arch and the widening of the vertebral
corpus, which leads to the deformation and narrowing of the
vertebral canal, extension of the tumor into the epidural
space, collapse of the vertebral corpus, and (rarely)
expansion of the tumor vessels and subsequent epidural
hemorrhage. In our patient, the tumor caused the expansion
of the vertebral laminae and pedicles, and the resultant
significant expansion of the epidural area compressed the
spinal cord and nerve roots.
Hemangiomas that extend extradurally may cause spinal
pain, radiculopathy, progressive paraparesis, or acute para-
paresis as a result of their epidural mass effect. The
progression of VHs is often insidious.2 As in our patient,
the sudden hemorrhage or thrombosis of the hemangioma
can cause acute clinical symptoms resulting from the rapid
enlargement of the lesion.6,7
Ninety percent of the VHs that produce symptoms
develop in the thoracic vertebral column, as was the case
in our patient, and 75% of those lesions occur between levels
T3 and T9. The second most frequent site of development is
the lumbar vertebral column. Hemangiomas are usually
located in the vertebral bodies and may extend into the
posterior elements. They rarely affect all the posterior
elements, extending into the epidural space, as in our case.
Vertebral hemangiomas appear as parallel vertical lines or
as a honeycomb in the vertebral corpus in plain roentgen-
ograms. Its characteristic computed tomography appearance
is a “polka dot” appearance within the bony structure due to
thickened trabeculae, secondary to cystic vascular structures.
The MRI images of a VH reveal a lesion that is isointense
with the spinal cord in T1-weighted images, hyperintense in
T2-weighted images, and characterized by significant
contrast enhancement after the intravenous injection of
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Journal of Manipulative and Physiological Therapeutics
October 2007
contrast media.8 The MRI studies provide additional
information about the aggressiveness of the hemangioma,
depict the location and extraosseous extension of the tumor,
and reveal the extent of the neural compression caused by the
lesion. Aggressive tumors with a potential to compress the
spinal cord appear as highly vascular soft-tissue masses in
the MRI sequences; these are identified by their isointense
presence in the T1-weighted images, hyperintense signal
in the T2-weighted series, and significant contrast enhance-
ment after an intravenous contrast injection. The fat
component, the presence of which is a good prognostic
sign, is hyperintense in both the T1- and T2-weighted
series and is suppressed in the fat-suppression series.9 The
hemorrhagic component appears hyperintense in both
sequences, as with our case, but cannot be suppressed in
the fat-suppression sequences.
The clinical and radiological findings in our patient were
concordant. The MRI high-vascular soft-tissue component
ratio of the mass was high, which indicates aggressive tumor
behavior. The fat-tissue component ratio of the mass was
low, and the hemorrhagic component ratio of the mass
was significant.
The differential diagnosis of spinal tumors is principally
based on the localization of the tumor (Fig 3). They are
classified in this concern as intramedullary, intradural/
extramedullary, and extradural (osseous) spinal tumors.10
Intramedullary spinal cord tumors comprise nearly 25% of
all spinal tumors, mostly being ependymomas in the adults
and astrocytomas in children. Intramedullary tumors gen-
erally cause expansion of the spinal cord. Most encountered
intradural/extramedullary tumors are schwannomas and
neurofibromas. These lesions usually expand the spinal
neural foramina and erode the vertebral bodies. Radiologi-
cally, they are visualized as smooth-contoured lesions that
may show cystic changes.6 The second most frequent
intradural/extramedullary tumor is meningioma, being
second to nerve sheath tumors. Its most frequent location
is the thoracic region. It has a broad dural base, a typical
isointense appearance in the T1-weighted sequence, a
hypointense appearance in the T2-weighted sequences
(with respect to the spinal cord), and shows significant
homogeneous gadolinium enhancement after an intravenous
injection. Its dural tail can be traced. In contrast to nerve
sheath tumors, meningiomas extend rarely into the extra-
dural region.8
Extradural tumors are the most frequently seen spinal
tumors. The osseous lesions can either be primary or
metastatic. Vertebral hemangioma is the most commonly
encountered lesion. The second most common tumor is
osteoblastoma, which accounts for 10% of the spinal
osseous tumors. It is an expansile osteolytic lesion with
occasional epidural component. It has low/medium signal
intensity in the T1-weighted and high signal intensity in the
T2-weighted series and may show gadolinium enhance-
ment. Aneurysmal bone cyst is an expansile and aggressive
Journal of Manipulative and Physiological Therapeutics
Volume 30, Number 8
Fig 3. Drawings of the normal thoracic spinal column: axial view
(A) and sagittal view (B).
bone lesion having multilocular blood spaces. It is mostly
encountered in the lumbar region and shows a tendency to
affect the neighboring vertebra, passing through the
intervertebral disk. Its characteristic computed tomography
appearance is a multiloculated expansile cystic mass lesion
containing fluid-fluid levels.11 The giant-cell bone tumor is
mostly located in the sacrum. The vertebral body lesion
extends to the posterior elements, into the disk space, and to
the neighboring vertebral body. Its characteristic radiological
appearance is an expansile lytic lesion with no significant
sclerotic border. It may have solid and cystic components.
The solid component has medium signal intensity in the
T1-weighted series and is hypointense in the T2-weighted
series, in opposite to chordoma, plasmocytoma, and meta-
static lesions.
Chordomas are most frequently located in the sacrococcy-
geal region and have 60% amorphous calcifications content.
Chondrosarcoma destroys the bone structure, and its chon-
droid matrix can be traced. Advanced cases may have soft-
tissue components. The lesion shows ring- or arch-shaped
septal contrast enhancements with intravenous gadolinium.
Osteosarcoma has an osteoblastic tendency and shows
hypointense MRI signal intensity in both the T1- and T2-
weighted sequences.10 The typical MRI signal of metastatic
bone tumors, such as myeloma, breast cancer, lung cancer,
prostate cancer, and leukemia/lymphoma, is hypointense in the
T1-weighted and hyperintense in the T2-weighted sequences,
the lesions being of different size and separate.12
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Ergun et al 605
Hemorrhagic Hemangioma
Asymptomatic VHs do not need follow-up imaging or
therapy. Symptomatic ones, on the other hand, can be treated
either with surgery, transarterial embolization, radiotherapy,
vertebroplasty, or direct ethanol injection. Vertebral heman-
giomas causing pain only and having no extraosseous
extension can be treated with transarterial embolization,
vertebroplasty, or radiotherapy, whereas those with progres-
sive neurological deficits should be treated with surgery.13
The percutaneous vertebroplasty technique involves
injection of acrylic cement, usually polymethylmethacrylate
(PMMA), into the vertebral body. The mechanism of action
of this procedure is not entirely clear, but it is believed that
stabilization of microfractures, prevention of further com-
pression, and PMMA-chemical ablation of pain-sensitive
neural roots in the vertebral body provide cure to the pain.
However, this procedure does not obliterate the hemangioma
and does not prevent its further progression; thus, it is
preserved for lesions causing pain only and is not suitable for
lesions showing extraosseous extension. 14 In addition,
PMMA-related spinal cord injuries have been reported
secondary to PMMA escaping into the spinal canal.
Vertebral hemangioma is a radiosensitive lesion, which
is why radiotherapy is one of the therapeutic modalities and
is especially preferred in the lesions causing pain only.2 It is
also reported to be effective in VH lesions that cause
neurological deficit. However, because its effect appears late
in the course of therapy, its use alone in cases of VH with
neurological symptoms is debated. The average radiation
dose is 30 to 40 Gy. This suggested that dose of radiation
bears no risk for spinal cord injury, but radiation-related
sarcoma development in the late period has been reported.15
The preferred therapeutic modality in cases with progres-
sive neurological deficit should be preoperative transarterial
embolization followed by surgical decompression.13 The
surgical approach (anterior or posterior) or the surgical
procedure of choice depends on the localization of the
lesion and the rate of progression of the neurological
derangement. In all cases with fast and progressive
neurological deficit, laminectomy and immediate decom-
pression are mandatory.2,16
In cases of neurological deficit secondary to neural canal
stenosis caused by osseous tumor growth only (without
extraosseous tumor extension), simple decompression lami-
nectomy would be sufficient. However, when extraosseous
tumor components are present, postoperative radiotherapy
should be instituted after reducing the aggressive (vascular)
tumor components because it prevents growth and recur-
rence of the residual tumor. In cases of extraosseous tumors
originating from the vertebral corpus and cord compression
due to extraosseous tumor extension, corpectomy or
vertebrectomy should be preferred. The most basic reason
for perioperative morbidity in VH surgery is intraoperative
blood loss or postoperative epidural hematoma. These
complications are decreased using preoperative transarterial
embolization.16 The period between initial neurological
606 Ergun et al
Hemorrhagic Hemangioma
symptoms and irreversible neurological deficit in tumor-
related compression myelopathy is several weeks.5 But in
acute compression due to acute hemorrhage, as with our
case, irreversible injury develops much faster. Thus, in our
opinion, although no standard management exists (extremely
rarely encountered) for such cases, decompression laminect-
omy should be done without embolization attempt.
The recently instituted ethanol vertebroplasty, used in
cases of VHs causing both pain and neurological deficit, is
reported to be rather effective,17 but it is not preferably used
because posttherapeutic complications such as Brown-
Sequard syndrome and pathological fractures may occur
causing serious morbidities.
CONCLUSION
Despite its rather characteristic MRI appearance, VH can
cause diagnostic confusion in cases with epidural extension.
Its compression myelopathy symptoms are characteristically
slow in progression. Presence of acute or subacute myelo-
pathic symptoms is classically suggestive for malignancy or
metastasis, but in young patients, VH with hemorrhagic
component in the epidural area should be considered. In such
cases, decompression surgery should be done as soon as
possible before neurological symptoms become irreversible.
Practical Applications
• Hemangioma is usually located in the vertebral
body and may extend to the posterior elements; it
rarely affects all the posterior elements extending
into the epidural space, as in our case.
• Clinical spinal cord compression findings second-
ary to VH are characteristically slow in progression.
• The most frequent cause of spinal cord compression
in VH cases is expansion of the vertebral corpus due
to the hemangioma. Acute myelopathy caused by
acute hemorrhage into the epidural space is rare.
• In cases of acute compression myelopathies, decom-
pression surgery should be done as soon as possible
before neurological deficits get irreversible.
• The presence of acute compression myelopathy is
primarily suggestive for malignancy or metastasis.
However, VH with hemorrhagic component in the
epidural area should be considered.
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Journal of Manipulative and Physiological Therapeutics
October 2007
REFERENCES
1. Harrison MJ, Eisenberg MB, Ullman JS, Oppenheim JS,
Camins MB, Post KD. Symptomatic cavernous malformations
affecting the spine and spinal cord. Neurosurgery 1995;37:
195-204.
2. Fox MW, Onofrio BM. The natural history and management
of symptomatic and asymptomatic vertebral hemangiomas.
J Neurosurg 1993;78:36-45.
3. Raco A, Ciappetta P, Artico M, Salvati M, Guidetti G,
Guglielmi G. Vertebral hemangiomas with cord compression:
the role of embolization in five cases. Surg Neurol 1990;
34:164-8.
4. Castel E, Lazennec JY, Chiras J, Enkaoua E, Saillant G. Acute
spinal cord compression due to intraspinal bleeding from a
vertebral hemangioma: two case-reports. Eur Spine J 1999;8:
244-8.
5. Bandiera S, Gasbarrini A, De Iure F, Cappuccio M, Picci P,
Boriani S. Symptomatic vertebral hemangioma: the treatment
of 23 cases and a review of the literature. Chir Organi Mov
2002;87:1-15.
6. Minh NH. Cervicothoracic spinal epidural cavernous heman-
gioma: case report and review of the literature. Surg Neurol
2005;64:83-5.
7. Carlier R, Engerand S, Lamer S, Vallee C, Bussel B, Polivka M.
Foraminal epidural extra osseous cavernous hemangioma of the
cervical spine: a case report. Spine 2000;25:629-31.
8. Talacchi A, Spinnato S, Alessandrini F, Iuzzolino P, Bricolo A.
Radiologic and surgical aspects of pure spinal epidural
cavernous angiomas. Report on 5 cases and review of the
literature. Surg Neurol 1999;52:198-203.
9. Laredo JD, Assouline E, Gelbert F, Wybier M, Merland JJ,
Tubiana JM. Vertebral hemangiomas: fat content as a sign of
aggressiveness. Radiology 1990;177:467-72.
10. Bloomer CW, Ackerman A, Bhatia RG. Imaging for spine
tumors and new applications. Top Magn Reson Imaging 2006;
17:69-87.
11. Kransdorf MJ, Sweet DE. Aneurysmal bone cyst: concept,
controversy, clinical presentation, and imaging. AJR Am J
Roentgenol 1995;164:573-80.
12. Rovira A, Rovira A, Capellades J, Zauner M, Bella R, Rovira
M. Lumbar extradural hemangiomas: report of three cases.
AJNR Am J Neuroradiol 1999;20:27-31.
13. Acosta FL, Dowd CF, Chin C, Tihan T, Ames CP, Weinstein
PR. Current treatment strategies and outcomes in the manage-
ment of symptomatic vertebral hemangiomas. Neurosurgery
2006;58:287-95.
14. Cohen JE, Lylyk P, Ceratto R, Kaplan L, Umanskyt F, Gomori
JM. Percutaneous vertebroplasty: technique and results in
192 procedures. Neurol Res 2004;26:41-9.
15. Vergel De Dios AM, Bond JR, Shives TC, McLeod RA, Unni
KK. Aneurysmal bone cyst. A clinicopathologic study of
238 cases. Cancer 1992;69:2921-31.
16. Chen TC. Prostate cancer and spinal cord compression.
Oncology 2001;15:841-55.
17. Doppman JL, Oldfield EH, Heiss JD. Symptomatic vertebral
hemangiomas: treatment by means of direct intralesional
injection of ethanol. Radiology 2000;214:341-8.