A 30-year-old patient presented to his physician with a single, asymptomatic, palpable mass of the right neck, referring that it had gradually increased in size over a 6 months period. CT, MRI and DSA examinations were performed and the findings are presented.
The patient's history was uneventful, also for local neck trauma. Examination revealed a well-defined, painless, rubbery, deep seated mass in the right part of the neck. The skin over the mass was normal, non-pulsatile and with no discoloration. There was no thrill or bruit. Signs of regional lymphadenopathy or associated neurological deficit were not depicted. The patient did not refer restriction in the head and superior limb movement.
CT examination identified a large, clearly defined mass situated among the muscles of the right part of the neck (within the scalenus medius muscle). After the intravenous injection of contrast material the mass revealed heterogeneous, strong enhancement with presentation of large vessels (Fig. 1, arrows).
On MRI the mass was hyperintense when compared with signal intensity of normal muscle, on both T1- and T2-weighted images (Fig. 2, 3). Contrast MRI demonstrated a diffusely enhancing well-defined soft tissue lesion, situated within the scalenus medius muscle (Fig. 4).
DSA examination demonstrated the hypervascular nature of the lesion and the feeding vessels originating from the thyrocervical and costocervical trunks (Fig. 5).
The patient underwent complete surgical excision of the lesion along with the surrounding muscle fibres. The histopathological examination revealed mixed type hemangioma (Fig. 6).
Hemangiomas are benign congenital neoplasms.
Intramuscular hemangioma is a distinctive type representing about 1% of all hemangiomas. It occurs within the skeletal muscle and more frequently in the trunk and extremities because of the larger muscle mass in those areas.
Intramuscular hemangioma of head and neck represent 15% of all intramuscular hemangiomas. They most often are presented in the masseter muscle (36%), the trapezius (12%), the sternocleidomastoid (10%) and the temporalis (8%). Hemangiomas of the buccinator and periorbital muscles have also been described.
Intramuscular hemangiomas usually present in the second or third decade of life with a slight male preponderance. It is considered to be a congenital tumor arising from embryonic rests. There is also the theory that traumatic and hormonal influences may contribute to the cause or growth of these lesions.
Histologically they are subdivided into small vessel or capillary hemangiomas, large vessel or cavernous hemangiomas and a mixed type, which contains both small and large vessels. Capillary hemangiomas are the commonest type while cavernous and mixed types account for only 19 and 5%, respectively.
The mixed type hemangiomas have the same characteristics as cavernous type hemangiomas but a high recurrence rate (28%). In addition to the vascular component, adipose tissue is quite common but intravascular thrombi, fibrous tissue, lymphoid follicles, and calcification are less commonly found.
Plain radiography is non-diagnostic but reveals a mass lesion, with calcification in about 15% of cases.
CT examination shows the tumor as an enhanced, well-circumscribed mass and is useful in differentiating it from other soft-tissue tumors such as lipomas, which displays low-density attenuation. CT examination may underestimate the extent of the mass.
Magnetic resonance imaging (MRI) detects better the extension and delineation of these masses. The MRI findings consist of an intermediate signal mass on T1 weighted images and an intense signal mass with well-defined margins, clearly differentiated from the surrounding normal muscles, on T2 weighted images. Heterogeneous signals corresponding to blood flow in dilated tortuous vessels are noted on both T1 and T2 weighted images. Other focal inhomogeneities may represent fibrous tissue, smooth muscle components or calcification, all of which are quite frequent in hemangiomas.
Angiography may help before surgical intervention giving more information about the nature of the tumor or detecting a large feeder vessel connected to the tumor. Preoperative embolization can also be performed angiography to minimise blood loss.
Complete surgical excision of the lesion along with the surrounding muscle fibres is the best way of treatment. Ligation of the feeding vessel is also necessary. Minor feeder vessels left in place may be responsible for recurrence which has been reported up to 18%.
Intramuscular hemangioma
In the patient's right neck region, a localized soft tissue mass is observed. Non-contrast and contrast-enhanced CT scans demonstrate a well-defined lesion whose density (signal) differs somewhat from the surrounding muscle tissue, with obvious enhancement following contrast administration. On MRI, the lesion appears with intermediate signal on T1-weighted images, increased signal on T2-weighted images, and has a clear boundary, distinctly separated from the surrounding muscle layer. Furthermore, inhomogeneous internal signal suggests uneven signal caused by vascular flow or other components (e.g., fibrous tissue, possible calcification, etc.). Digital Subtraction Angiography (DSA) confirms this as a vascular-rich lesion, connected to peripheral feeding vessels.
Considering the patient's age (30 years), clinical course (gradual expansion over 6 months), palpation findings (a palpable soft tissue mass without significant pain), CT/MRI characteristics suggestive of a vascular lesion, and pathological examination (if indicating capillary/cavernous or mixed hemangioma), the most likely diagnosis is:
Intramuscular Hemangioma of the Neck.
For further confirmation, pathological slides or intraoperative findings can be evaluated through complete surgical excision of the lesion and subsequent tissue examination.
For confirmed intramuscular hemangiomas, the primary treatment is complete surgical excision, including:
Postoperative rehabilitation should follow an individualized, step-by-step exercise prescription guideline:
Throughout the rehabilitation process, monitor local wound healing and muscle usage. In case of recurrence of the mass, severe pain, or persistent swelling, seek medical attention promptly. For patients with poor cardiopulmonary function or unsatisfactory postoperative recovery, exercise volume should be reduced accordingly and undertaken under professional guidance.
FITT-VP Guidelines: During rehabilitation, the frequency (F), intensity (I), time (T), type (T), volume, and progression (VP) of exercises should be adjusted flexibly according to the patient's condition:
Disclaimer: This report is a reference analysis based on the current information and does not replace face-to-face evaluation or professional and specialized medical advice. If you experience any discomfort or doubt, please consult a professional physician or visit a reputable medical institution for evaluation.
Intramuscular hemangioma
