Female patient with chronic headache undergoing an x-ray of the skull and an MRI examination of the brain.
A woman was referred from the neurology department with a history of chronic headache and a small ‘bump’ on the left side of the parietal bone. A lateral X-ray showed and sharply delineated lytic lesion with a ‘spoke wheel’ appearance. Subsequently an MRI study was ordered to evaluate for possible intracranial extension. We performed sagittal T1w, axial T1w, T2w , FLAIR and diffusion weighted images. After intravenous injection of a gadolinium contrast medium T1w images were obtained in the three orthogonal directions. A large enhancing mass on the internal side of the parietal bone was seen with marked compression of the left parietal lobe of the brain. The patient underwent surgical resection with graft placement. The patient had an uneventful recovery.
Hemangioma is a benign tumor of blood vessels. Almost every organ including soft tissue and bone can be affected. Four different types are described: the capillary, cavernous, arteriovenous and venous type. Capillary hemangioma consists of small vessels with a flat endothelium. These lesions are commonly found in the skin. They are most prominent in the first few years of life an between 75% to 90% tends to involute. Cavernous hemangiomas are dilated, blood-filled spaces and are found in the deeper soft tissue structures and the calvarium. This type is commonly seen intraosseously. Sometimes cavernous hemangiomas contain phleboliths. These cavernous hemangiomas do not show spontaneous involution. When the fetal capillary bed persists inside the lesion, the lesion is called an arteriovenous hemangioma. This lesion is most frequently seen in the soft tissues. Tortuous feeding vessels and early draining veins are the main characteristics. Venous hemangiomas appear in adults and have thick walled vessels on pathology. The retroperitoneum, mesentery and the muscles of the lower limbs are typically affected. Most osseous hemangiomas are of the cavernous type of hemangioma. They are frequently seen in the 4th and 5th decade. There is a slight female preponderance. These lesions are usually asymptomatic and present as an incidental finding. The vertebrae, calvarium and flat and long bones are sites of predilection. When located vertebrally, vertebral collaps with compression of the exiting nerve root or the spinal medulla is the main complication. In some cases osseous hemangioma presents as a palpable mass. Vertebral hemangiomas account for 28% of the skeletal hemangiomas and are found in 5 to 12% of autopsy specimens. In one third of the cases, multiple lesions are seen. The thoracic and lumbar regions are typically affected. On conventional radiography a typical ‘corduroy’ pattern is seen. On CT scan thickened vertical trabeculae (‘polka dot’ appearance) are identified. Paget’s disease is the main differential diagnosis of vertebral hemangiomas. The MRI signal of vertebral hemangiomas is high on T2 (due to the vascular component) and is variable on T1 weighted images depending on the amount of fat. Cavernous hemangiomas are very rarely seen in flat and long bones. If present in these bones, they may be located in rib structures, the clavicle, the mandible and the tibia, femur and humerus. The radiological appearance may range from an osteolytic lesion to a lesion with radiated (spoke wheel) trabecular thickening or with a honeycomb pattern. Fibrous dysplasia, cartilaginous tumor and giant cell tumor are included within the differential. Cavernous hemangiomas of the calvarium are osteolytic lesions with a typical radiated (spoke wheel) pattern. They have sharp margins and sometimes presents as a palpable lump on the head. The frontal and parietal diploe are most frequently involved. Only if the lesion is purely lytic, the diagnosis may be hazardous. The vast majority of osseous cavernous hemangiomas is asymptomatic and no further treatment is required. They may sometimes presents with neurological symptoms. Curettage, resection, radiation therapy and vertebroplasty may be treatment options in such cases.
Cavernous hemangioma of the calvarium.
The patient is a 60-year-old female who presented with long-term chronic headaches. This examination included cranial X-ray and brain MRI:
No significant intracranial parenchymal compression or deformation is noted, and adjacent brain tissue generally shows no obvious edema. There is no clear evidence of related soft tissue swelling or other intracranial mass effect.
Based on the imaging features and the patient’s clinical presentation of chronic headaches, the following diagnoses or differential diagnoses are considered:
Considering the patient’s age, clinical symptoms (chronic headaches), and imaging characteristics (radial/spoke-wheel trabecular thickening on cranial X-ray, high signal on T2WI with enhancement on MRI), the most likely diagnosis is cavernous hemangioma of the skull.
For a more definitive diagnosis, a surgical or preoperative biopsy could be performed for pathological confirmation.
For patients without significant symptoms and stable lesions, close observation may be chosen. If any of the following situations occur, further intervention should be considered:
Specific treatment options include one or a combination of the following:
Patients with chronic headaches or those recovering post-surgery may require appropriate rehabilitation management. The main goals include:
Based on the FITT-VP principles (Frequency, Intensity, Time, Type, and Progression), an example is as follows:
For patients undergoing surgery, postoperative activities should be introduced gradually under medical guidance. Pay special attention to protecting the operative site, especially avoiding excessive stretching or external impact on the head and neck. Before initiating higher-intensity exercises, consult a physical therapist for further assessment and follow the instructions of neurosurgery or orthopedic teams.
Disclaimer: The above content is for reference only and does not replace in-person consultation or professional medical advice. If needed, please consult a specialist or visit a hospital for proper evaluation.
Cavernous hemangioma of the calvarium.
