Vascular Malformations and Hemangiomas
A Practical Approach in a Multidisciplinary Clinic
Lane F. Donnelly1,2,3,
Denise M. Adams1,4 and
George S. Bisset, III1,2
1
Clinic for the Treatment of Vascular Malformations, Duke University Medical
Center, Durham, NC 27710.
2
Department of Radiology, Division of Pediatric Radiology, Duke University
Medical Center, Durham, NC 27710.
3
Present address: Department of Radiology, Children's Hospital Medical Center
and the University of Cincinnati, 3333 Burnet Ave., Cincinnati, OH
45229-3039
4
Department of Pediatrics, Division of Hematology-Oncology, Duke University
Medical Center, Durham, NC 27710.
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Fig. 1A. —4-month-old female infant with extensive distribution of infantile
hemangioma revealed on MR imaging. Photograph shows hemangioma of right
perirectal region, which was extent of disease suggested on physical
inspection. Because of foot drop on physical examination, MR imaging of lumbar
spine was performed.
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Fig. 1B. —4-month-old female infant with extensive distribution of infantile
hemangioma revealed on MR imaging. Coronal (B) and axial (C)
T2-weighted fat-saturated fast spin-echo MR images (3000/98 [TR/TE]) show
abnormally increased signal intensity (long arrow, B) in
subcutaneous region of right buttock. Extensive hemangioma throughout
retroperitoneum of pelvis and abdomen is seen as abnormally high signal
intensity (short arrows, B and C). Mass was found to
engulf sacrum, rectum, uterus, and vagina. Note prominent veins that appear as
signal voids.
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Fig. 1C. —4-month-old female infant with extensive distribution of infantile
hemangioma revealed on MR imaging. Coronal (B) and axial (C)
T2-weighted fat-saturated fast spin-echo MR images (3000/98 [TR/TE]) show
abnormally increased signal intensity (long arrow, B) in
subcutaneous region of right buttock. Extensive hemangioma throughout
retroperitoneum of pelvis and abdomen is seen as abnormally high signal
intensity (short arrows, B and C). Mass was found to
engulf sacrum, rectum, uterus, and vagina. Note prominent veins that appear as
signal voids.
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Fig. 2A. —Venous malformation involving posterior abdominal wall in 3-year-old
boy with pain and progressively enlarging lesion. Photograph shows skin
involvement with red discoloration and enlargement of underlying soft
tissues.
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Fig. 2B. —Venous malformation involving posterior abdominal wall in 3-year-old
boy with pain and progressively enlarging lesion. Axial T2-weighted
fat-saturated fast spin-echo MR image (3500/72 [TR/TE]) shows
high-signal-intensity mass predominantly involving skin and subcutaneous
tissue. Note involvement of underlying abdominal wall musculature (large
arrow) and prominent draining veins (small arrows).
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Fig. 3. —Kaposiform hemangioendothelioma involving lip and left face in
8-month-old female infant who had been treated with steroids for
Kasabach-Merritt syndrome. Photograph shows superficial involvement causing
skin to appear red. Note deep component distorting region inferiro to left
ear. Region inferior to left lip developed fissures.
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Fig. 4A. —Infantile hemangioma in 21-day-old male neonate. Photograph shows
lobulated mass extending from region of knee. Lack of superficial involvement
renders lesion bluish rather than strawberry red.
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Fig. 4B. —Infantile hemangioma in 21-day-old male neonate. Axial T1-weighted
MR image (500/14 [TR/TE]) shows mass (arrows) with signal intensity
similar to that of skeletal muscle. Note low signal intensity and prominent
veins.
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Fig. 4C. —Infantile hemangioma in 21-day-old male neonate. Axial T2-weighted
fat-saturated fast spin-echo MR image (4000/98) shows heterogeneous
high-signal-intensity mass (arrows) confined to subcutaneous tissue.
Because lesion did not have classic temporal pattern of growth on physical
examination, biopsy was performed to confirm diagnosis of hemangioma.
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Fig. 5A. —Venous malformation of left anterior pelvis in 10-year-old girl.
Axial T1-weighted MR image (500/8 [TR/TE]) shows mass (arrows)
confined to subcutaneous tissues. Mass is isointense in signal intensity to
adjacent muscle. Note prominent draining veins.
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Fig. 5B. —Venous malformation of left anterior pelvis in 10-year-old girl.
Axial T2-weighted fat-saturated fast spin-echo MR image (4000/98) shows mass
(arrows) consisting of multiple high-signal-intensity serpentine
structures. Mass is confined to subcutaneous tissue. Note prominent draining
veins.
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Fig. 6A. —Lymphatic malformation involving arm and chest wall of 4-month-old
female infant. Photograph shows enlargement and multilobulated contour of left
upper extremity.
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Fig. 6B. —Lymphatic malformation involving arm and chest wall of 4-month-old
female infant. Coronal T2-weighted fat-saturated fast spin-echo MR image
(4316/98 [TR/TE]) shows multilocular cystic-appearing mass (m) involving
subcutaneous tissues of left upper extremity. Note chest wall involvement
(arrow).
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Fig. 7A. —Change in appearance after percutaneous ethanol sclerosis of venous
malformation in 7-year-old girl with pain. Photograph before procedure shows
bluish discoloration of skin with underlying fullness.
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Fig. 7B. —Change in appearance after percutaneous ethanol sclerosis of venous
malformation in 7-year-old girl with pain. Photograph 4 days after sclerosis
with only 7 ml of ethanol shows marked increase in swelling, hematoma, and
area of skin ulceration. Findings all resolved over next several weeks;
patient's pain resolved and fullness decreased.
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Fig. 8A. —Percutaneous sclerosis of venous malformation of foot of an
18-year-old female dancer with pain. Sagittal T2-weighted fat-saturated fast
spin-echo MR image (4000/98 [TR/TE]) obtained before procedure shows
serpentine areas of high signal intensity (arrows).
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Fig. 8B. —Percutaneous sclerosis of venous malformation of foot of an
18-year-old female dancer with pain. Image from percutaneous venogram obtained
during sclerosis shows tangle of venous structures and draining veins. Note
angiocatheter (arrow).
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Fig. 8C. —Percutaneous sclerosis of venous malformation of foot of an
18-year-old female dancer with pain. Sagittal T2-weighted fat-saturated fast
spin-echo MR image (4000/98) obtained 7 months later than A and
B shows resolution of serpentine high-signal-intensity structures and
replacement with low-signal-intensity structures (arrows), most
likely fibrotic scars.
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Fig. 9A. —High-flow vascular malformation of foot in 12-year-old boy. Sagittal
T1-weighted MR image (750/12 [TR/TE]) shows multiple tubular flow voids
(arrows). Note absence of discrete mass.
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Fig. 9B. —High-flow vascular malformation of foot in 12-year-old boy.
Short-axis T2-weighted fat-saturated fast spin-echo MR image (3200/76) shows
multiple tubular flow voids (arrow) with surrounding edema.
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Fig. 9C. —High-flow vascular malformation of foot in 12-year-old boy.
Arteriogram shows abnormal increase in arterial flow to mid region of
foot.
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Fig. 10A. —Embolization of arteriovenous malformation of liver in female
neonate who presented with severe congestive heart failure requiring tracheal
intubation and arterial pressers. Color Doppler sonogram of liver before
embolization shows large feeding artery (long arrow) communicating
with large draining vein (short arrow).
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Fig. 10B. —Embolization of arteriovenous malformation of liver in female
neonate who presented with severe congestive heart failure requiring tracheal
intubation and arterial pressers. Arteriogram before embolization performed
with catheter in hepatic artery shows tangle of arterial structures in liver
and large draining vein (arrows).
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Fig. 10C. —Embolization of arteriovenous malformation of liver in female
neonate who presented with severe congestive heart failure requiring tracheal
intubation and arterial pressers. Arteriogram after embolization shows
elimination of flow through arteriovenous malformation. Patient's congestive
heart failure resolved immediately and she is currently doing well 1 year
later.
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Fig. 10D. —Embolization of arteriovenous malformation of liver in female
neonate who presented with severe congestive heart failure requiring tracheal
intubation and arterial pressers. Color Doppler sonogram after procedure shows
thrombosis of large draining vein (arrow).
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Fig. 11A. —Blue rubber bleb nevus syndrome in 11-year-old boy. Photograph of
tongue shows lobulated mass (arrows) in posterior tongue.
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Fig. 11B. —Blue rubber bleb nevus syndrome in 11-year-old boy. Axial
T2-weighted fat-saturated fast spin-echo MR image (4550/84 [TR/TE]) shows
venous malformation as lobulated, high-signal-intensity mass
(arrows). Patient also suffered bleeding from multiple
gastrointestinal sources because of other venous malformations of
gastrointestinal tract.
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Fig. 11C. —Blue rubber bleb nevus syndrome in 11-year-old boy. Photograph of
plantar surface of feet shows multiple venous malformations.
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Fig. 12A. —PHACE (posterior fossa abnormalities, facial hemangiomas, arterial
abnormalities, cardiovascular defects, and eye abnormalities) syndrome in
1-month-old female infant. Photograph of face shows hemangioma of right orbit
and ear. Eye is closed because of mass effect from hemangioma.
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Fig. 12B. —PHACE (posterior fossa abnormalities, facial hemangiomas, arterial
abnormalities, cardiovascular defects, and eye abnormalities) syndrome in
1-month-old female infant. Axial T2-weighted fast spin-echo MR image (2800/100
[TR/TE]) with fat saturation through orbits shows lobulated
high-signal-intensity hemangioma (large arrow) surrounding right
globe. Note abnormal high signal intensity in subcutaneous region surrounding
right ear (small arrows).
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Fig. 12C. —PHACE (posterior fossa abnormalities, facial hemangiomas, arterial
abnormalities, cardiovascular defects, and eye abnormalities) syndrome in
1-month-old female infant. Photograph shows supraumbilical midline raphe.
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Copyright © 2000 by the American Roentgen Ray Society.
