Aggressive vertebral hemangioma

Aggressive vertebral hemangioma

Accurate preoperative diagnosis is essential because they are highly vascular with a high tendency for intraoperative bleeding.

Management of aggressive VHs involves pre-op embolization, spinal surgery, and reconstruction. Pain management, physical rehabilitation, and close neurological follow-up are imperative to near-total recovery 1).

Surgery is required in cases of rapid or progressive neurological symptoms like compressive myelopathy or radiculopathy.

Vertebral hemangioma resection can be a real challenge for spine surgeons, given the high potential of massive intraoperative bleeding. For this reason, preoperative transarterial embolization of this tumor is supported by the available literature 2).

A navigation-guided drill is highly helpful for real-time monitoring of ongoing tumor resection. It enables safely resection of the tumor, especially in the anterior cortical surface of the vertebral body, and easily resections even hard tumors. This method results in reducing residual tumors and maintaining safe resection 3).

Radiotherapy can be used in patients with slowly progressive neurological deficits.

While CT-guided direct alcohol injection is effective in the management of symptomatic and aggressive vertebral hemangiomas, spinal angiography and trans-arterial embolization of the blood supply to the vertebral body hemangioma, prior to the direct transpedicular alcohol embolization of the lesion, improves the safety of the procedure 4).

Other emerging options in cases of aggressive hemangiomas include radiofrequency ablation with a hemostatic agent (e.g. FLOSEAL, Baxter, USA), and bone autograft placement 5).

Minimally invasive procedures may be successful in smaller lesions 6).

The case of a pregnancy who was diagnosed with an aggressive vertebral hemangioma that further led to progressive paraparesis. We had to take the fact that she was pregnant into account in the diagnostic procedure, the choice of examination method, and also the method of therapy. The goal of this case report is threefold: (1) provide an overview of the possible methods of management, specifically imaging, which will aid in diagnosis and based on that, (2) determine the appropriate therapy, and (3) review the risks and benefits of each will be presented when choosing individual approaches 7).


Goraya GS, Singhal S, Paul BS, Paul G. Aggressive Vertebral Hemangioma: The Mystery of Spastic Legs Unveiled by a Purple Shoulder. Cureus. 2022 Jan 24;14(1):e21568. doi: 10.7759/cureus.21568. PMID: 35228927; PMCID: PMC8873442.

Fiore G, Bertani GA, Tariciotti L, Borsa S, Paolucci A, Taramasso L, Locatelli M, Pluderi M. Vertebral Body Infarction after Transarterial Preoperative Embolization of a Vertebral Hemangioma. J Neurol Surg A Cent Eur Neurosurg. 2021 Dec 12. doi: 10.1055/s-0041-1739215. Epub ahead of print. PMID: 34897610.

Nagashima Y, Nishimura Y, Haimoto S, Eguchi K, Awaya T, Ando R, Akahori S, Hara M, Natsume A. Piecemeal resection of aggressive vertebral hemangioma using real-time navigation-guided drilling technique. Nagoya J Med Sci. 2021 Nov;83(4):861-868. doi: 10.18999/nagjms.83.4.861. PMID: 34916728; PMCID: PMC8648519.

Srinivasan G, Moses V, Padmanabhan A, Ahmed M, Keshava SN, Krishnan V, Joseph BV, Raju KP, Rajshekhar V. Utility of spinal angiography and arterial embolization in patients undergoing CT guided alcohol injection of aggressive vertebral hemangiomas. Neuroradiology. 2021 Nov;63(11):1935-1945. doi: 10.1007/s00234-021-02788-7. Epub 2021 Aug 24. PMID: 34427707.

Canbay S, Kayalar AE, Gel G, Sabuncuoğlu H. A novel surgical technique for aggressive vertebral hemangiomas. (2019) Neurocirugia (Asturias, Spain). 30 (5): 233-237. doi:10.1016/j.neucir.2018.08.003

Vasudeva VS, Chi JH, Groff MW. Surgical treatment of aggressive vertebral hemangiomas. Neurosurg Focus. 2016 Aug;41(2):E7. doi: 10.3171/2016.5.FOCUS16169. PMID: 27476849.

Ridzoňová L, Fedičová M, Andráš T, Urdzík P, Gdovinová Z. Lower-limb progressive paraparesis management and diagnosis overview in a pregnant woman with vertebral haemangioma. Womens Health (Lond). 2022 Jan-Dec;18:17455057221099018. doi: 10.1177/17455057221099018. PMID: 35574823.

World Health Organization grade 3 meningioma

World Health Organization grade 3 meningioma

Papillary meningioma

Rhabdoid meningioma

Anaplastic meningioma

Mast cells (MCs) were present in as many as 90 % of all high grade meningiomas mainly found in the perivascular areas of the tumor. A correlation between peritumoral edema and MCs was found.

Accumulation of MCs in meningiomas could contribute to the aggressiveness of tumors and to brain inflammation that may be involved in the pathogenesis of additional disorders 1).

From the available data, surgical resection followed by RT and salvage therapy can lead to extended survival 2).

For a systematic review, studies analyzing the effectiveness of adjuvant radiotherapy and stereotactic radiosurgery in grade 3 (gr. 3) meningioma were reviewed. Thirty studies met the inclusion criteria for qualitative synthesis, and 6 studies were assessed in quantitative analysis. In quantitative analysis, the weighted average of hazard ratios for adjuvant RT in univariate analyses of overall survival (OS) was 0.55 (CI: 0.41; 0.69). The median 5-year OS after adjuvant RT in gr. 3 meningiomas were 56.3%, and the median OS ranged from 24 to 80 months for patients treated with adjuvant RT versus 13 to 41.2 months in patients not treated. For stereotactic radiosurgery, the 3-year progression-free survival was 0% in one study and 57% in another. The 2-year OS ranged from 25 to 75% in 2 studies. The quality of evidence was rated as “very low” in 14 studies analyzed, and considerable allocation bias was detected. Treatment toxicity was reported in 47% of the studies. The severity, according to the CTCAE, ranged from grades I-V and 5.3 to 100% of patients experiencing complications. Adjuvant RT is usually considered the standard of care for WHO grade 3 meningiomas, although supporting evidence was of low quality. Better evidence from registries and prospective trials can improve the evidence base for adjuvant fractionated radiotherapy in malignant meningioma3).


Polyzoidis S, Koletsa T, Panagiotidou S, Ashkan K, Theoharides TC. Mast cells in meningiomas and brain inflammation. J Neuroinflammation. 2015 Sep 17;12(1):170. doi: 10.1186/s12974-015-0388-3. PubMed PMID: 26377554.

Rosenberg LA, Prayson RA, Lee J, Reddy C, Chao ST, Barnett GH, Vogelbaum MA, Suh JH. Long-term experience with World Health Organization grade III (malignant) meningiomas at a single institution. Int J Radiat Oncol Biol Phys. 2009 Jun 1;74(2):427-32. doi: 10.1016/j.ijrobp.2008.08.018. PMID: 19427553.

Bergner A, Maier AD, Mirian C, Mathiesen TI. Adjuvant radiotherapy and stereotactic radiosurgery in grade 3 meningiomas – a systematic review and meta-analysis. Neurosurg Rev. 2022 May 11. doi: 10.1007/s10143-022-01773-9. Epub ahead of print. PMID: 35543810.

Low-Grade Glioma Radiotherapy Dose

Low-Grade Glioma Radiotherapy Dose

Adjuvant radiation is often used in patients with low-grade gliomas with high-risk characteristics with a recommended dose of 45-54 Gy. Byrne et al. used the National Cancer Database (NCDB) to see which doses were being used and if any difference was seen in outcome.

They queried the NCDB for patients with WHO Grade 2 primary brain tumors treated with surgery and adjuvant radiotherapy. We divided the cohort into dose groups: 45-50 Gy, 50.4-54 Gy, and > 54 Gy. Multivariable logistic regression was used to identify predictors of low and high-dose radiation. Propensity matching was used to account for indication bias.

Results: We identified 1437 patients meeting inclusion criteria. The median age was 45 years and 62% of patients were > 40 years old. Nearly half of patients (48%) had astrocytoma subtype and 70% had a subtotal resection. The majority of patients (69%) were treated to doses between 50.4 and 54 Gy. Predictors of high dose radiation (> 54 Gy) were increased income, astrocytoma subtype, chemotherapy receipt, and treatment in a later years (2014). The main predictors of survival were age > 40, astrocytoma subtype, and insurance type. Patients treated to a dose of > 54 Gy had a median survival of 73.5 months and was not reached in those treated to a lower dose (p = 0.0041).

This analysis showed that 50.4-54 Gy is the most widely used radiation regimen for the adjuvant treatment of low-grade gliomas. There appeared to be no benefit to higher doses, although unreported factors may impact the interpretation of the results 1).

Postoperative policies of “wait-and-see” and radiotherapy for low-grade glioma are poorly defined. A trial in the mid 1980s established the radiation dose.

A phase III prospective randomized trial of low- versus high-dose radiation therapy for adults with supratentorial low-grade astrocytoma, oligodendroglioma, and oligoastrocytoma found somewhat lower survival and slightly higher incidence of radiation necrosis in the high-dose RT arm. The most important prognostic factors for survival are histologic subtype, tumor size, and age 2).

Two prospective trials found no difference in OS or PFS between different XRT doses (EORTC trial 3): 45 Gy in 5 weeks vs. 59.4 Gy in 6.6 weeks; Intergroup study 4) 50.4 vs. 64.8 Gy).


Byrne E, Abel S, Yu A, Shepard M, Karlovits SM, Wegner RE. Trends in radiation dose for low-grade gliomas across the United States. J Neurooncol. 2022 Feb 23. doi: 10.1007/s11060-022-03962-4. Epub ahead of print. PMID: 35199246.

Shaw E, Arusell R, Scheithauer B, O’Fallon J, O’Neill B, Dinapoli R, Nelson D, Earle J, Jones C, Cascino T, Nichols D, Ivnik R, Hellman R, Curran W, Abrams R. Prospective randomized trial of low- versus high-dose radiation therapy in adults with supratentorial low-grade glioma: initial report of a North Central Cancer Treatment Group/Radiation Therapy Oncology Group/Eastern Cooperative Oncology Group study. J Clin Oncol. 2002 May 1;20(9):2267-76. PubMed PMID: 11980997.

Karim ABMF, Maat B, Hatlevoll R, et al. A random- ized trial on dose-response in radiation therapy of low-grade cerebral glioma: European Organization for Research and Treatment of Cancer (EORTC) Study 22844. Int J Radiation Oncology Biol Phys. 1996; 36:549–556

Shaw E, Arusell R, Scheithauer B, O’Fallon J, O’Neill B, Dinapoli R, Nelson D, Earle J, Jones C, Cascino T, Nichols D, Ivnik R, Hellman R, Curran W, Abrams R. Prospective randomized trial of low- versus high-dose radiation therapy in adults with supra- tentorial low-grade glioma: initial report of a North Central Cancer Treatment Group/Radiation Therapy Oncology Group/Eastern Cooperative Oncology Group study. J Clin Oncol. 2002; 20:2267–2276
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