CASE 109

By: Dr. Nizar Al-Nakshabandi MD, FRCPC

Case courtesy Dr. JangHo Suh

HISTORY: 79-year-old with headache and swelling in the skull.

What are your findings?

What is the differential diagnosis?

What are the causes?

FINDINGS:

The lateral and Towne’s view radiograph of the skull [A and B] as well as the transaxial CT head bone window [C]] demonstrate a 4 x 3 cm expansile lytic lesion in posterior aspect of the skull at the occipital bone that has a honeycomb and soap bubble appearance. CT demonstrates the Sunburst appearance.

Axial T2 and T1-weighted images [D and E] demonstrate the lesion to be isointense on T1-weighted images to the surrounding subcutaneous tissue and of high signal intensity on T2-weighted images. Following gadolinium enhancement images [F] avid enhancement occurs into the lesion.

DIFFERENTIAL DIAGNOSIS:

·        Intraosseous skull hemangioma.

·        Osteosarcoma of the skull.

·        Metastasis to the skull.

DIAGNOSIS:

Intraosseous skull hemangioma.

PEARLS AND DISCUSSION:

Intraosseous hemangiomas are extremely rare tumors. They account for 0.2% of all bone tumors and 10% of benign skull tumors, in the frontal and parietal bones of the calvarium. They are classified as venous, cavernous, capillary type. This depends on their vascular network. Histologically, there are hamartomata’s tissue within the endothelium. They may contain fat. They are slow-growing and generally asymptomatic. A lump may be felt if there is expansion of the outer table. Diagnosis is usually made post surgically.

Imaging appearances is as above. Angiography may be used as a tool for diagnosis and embolization.

Treatment is by radiation therapy, embolization, surgical resection, or intralesional alcohol injection under image guidance.

FURTHER READING:

1.      Wyke BD. Primary hemangioma of skull. A rare cranial tumour. AJR Am J Roentgenol. 1946; 61:302–316

2.      Liu JK. Primary Intraosseous Skull Base Cavernous He is a knee and E a mangioma: Case Report Skull Base. 2003 Nov; 13(4): 219–228.

3.      Politi M, Romeike BF, Papanagiotou P et-al. Intraosseous hemangioma of the skull with dural tail sign: radiologic features with pathologic correlation. AJNR Am J Neuroradiol. 2005;26 (8): 2049-52