Figure 3 - available via license: Creative Commons Attribution 4.0 International
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Preoperative DSA image. A-B: Right external carotid artery angiography showing a rich blood supply and obvious contrast staining, mainly from the occipital arteries. C: During the venous phase, the lesion can be seen draining into the suboccipital venous plexus and the paravertebral venous plexus. D-E: Vertebral artery angiography showing that the muscular branch of the vertebral artery supplied the blood, and the blood supply was low; F: Vertebral arteriography showing poor filling of the lesion during the venous stage. DSA = digital substraction angiography.
Source publication
Rationale:
Intermuscular hemangioma (IH) usually occurs in the muscles of the limbs and trunk, but can rarely occur in the occipital region. IH in the occipital region is easily misdiagnosed as arteriovenous malformation (AVM).
Patient concerns:
A 31-year-old woman had a right occipital mass for 5 months without pulsation.
Diagnosis:
Head comp...
Contexts in source publication
Context 1
... authors have no funding and conflicts of interest to disclose. A further DSA examination revealed that the blood supply of the lesion was mainly from the occipital artery and less from the muscle branches of the vertebral arteries (Fig. 3). The lesion was considered an AVM based on its imaging characteristics and was recommended for surgical removal. The surgery was carried out under general anesthesia. The lesion could be touched when the occipital skin was incised during the operation. The lesion showed a clear boundary. The occipital artery touched the anterior margin ...
Context 2
... to the tumor nature of the IH, different blood supplying arteries will supply different parts of the IH, and the IH can therefore only be partially clearly displayed on angiography of different blood supplying arteries. As shown in Figure 3, the IH showed different areas on occipital artery and vertebral artery angiography. However, in DSA images of an AVM, because different blood supply arteries are connected with the nidus of the AVM, the nidus of the AVM can be seen on arteriography of different blood supply arteries. ...
Similar publications
Cerebral arteriovenous malformations (AVMs) are frequently associated with concurrent aneurysms. These aneurysms are commonly haemodynamically related to the AVM and can be classified into extranidal or intranidal in reference to the AVM nidus. An aneurysm arising from an artery that does not angiographically contribute to the blood flow to the AVM...
Citations
... Angiography (not mandatory) could show enlarged but non-tortuous arterial afferences and inhomogeneous capillary type tissular blush without an early venous drainage. Pathological features (required in case of doubtful imaging) had to be consistent with the diagnosis of ICTH (1,2,15), showing an increased number of capillary-sized vessels, consisting of plump endothelial cells (positive for CD31 on immunohistochemistry when performed) and pericytes (16), separating skeletal muscle fibres. Immunohistochemistry for lesional endothelial cells for GLUT-1 and podoplanin (D2-40) should be negative if performed (17). ...
Intramuscular capillary-type haemangiomas (ICTH) are rare vascular anomalies that can easily be misdiagnosed as other entities. A systematic review was performed of all cases of ICTH in the literature since its first description in 1972. An adjudication committee reviewed cases to include only ICTHs. Among 1,143 reports screened, 43 were included, involving 75 patients. The most frequent differential diagnosis was intramuscular venous malformations. The mean age of patients at diagnosis was 21.2 years. ICTH was mainly described as a gradually increasing mass (81.8%), painless (73.9%), that could occur anywhere in the body but most frequently on the head and neck (44.0%). Magnetic resonance imaging (MRI) was mainly used for diagnosis (69.1%) and displayed specific features. The most frequent treatment was complete surgical removal (73.9%), which could be preceded by embolization, and led to complete remission without recurrence in all but 1 case.
... For patients with ICa stenosis and occlusion, the history of ICa stenosis and occlusion was chronic and progressive due to arteriosclerosis; in these patients, the ECa was normal and had no stenosis at the origin. No tumor or vascular diseases, such as scalp or intramuscular hemangioma (10,11), arteriovenous malformation (12), or DAVF (13), were associated with the oa. accordingly, the patients were divided into a mild and moderate ICa stenosis (ICa stenosis <70%) group, a severe ICa stenosis (ICa stenosis 70-99%) group and an ICa occlusion group (Fig. 1) (14). ...
The understanding of the basic anatomy of the occipital artery (OA) is crucial, and computed tomography angiography is an effective tool for this purpose. In the present study, a comparison between healthy subjects and patients with internal carotid artery (ICA) stenosis and occlusion was made. The following parameters were measured: Age, sex, diameters and lengths of the OA in different locations, distance from the edge of the foramen magnum to the OA and the distance from the midline to the OA at the level of the superior nuchal line. A total of 205 participants who met the inclusion criteria were selected for further investigation. In addition, 50 healthy subjects (100 sides, left and/or right) were selected as the control group. A total of 155 patients (180 sides, left and/or right) were selected as the stenosis and occlusion groups, including the mild and moderate ICA stenosis group (50 sides, left and/or right), severe ICA stenosis group (80 sides, left and/or right) and the ICA occlusion group (50 sides, left and right). General information, measured parameters and statistical analysis results are provided for these groups. No significant differences were observed in the anatomical parameters of the OA among these groups. Thus, in addition to providing anatomical data, the present study demonstrates that stenosis and the occlusion of the ICA do not significantly alter the anatomy of the OA.
... [2,3] Hemangiomas of skeletal muscles, intramuscular hemangioma (IH) account for less than 1% of the total hemangiomas and occur mainly in the trunk and limbs. [4,5] Occurrence in the head and neck areas are relatively infrequent (15% of IH), but within these areas, the masseter muscle is the most commonly affected site, followed by the trapezius and temporalis muscles. [6] IH are usually found as an incidental benign palpable mass, but accurate diagnosis before surgery is difficult due to non-specific symptoms, deep anatomical positions, and a low frequency of occurrence. ...
Rationale:
Hemangiomas are usually found in cutaneous or mucosal layers, less than 1% of hemangiomas develop in skeletal muscles. Intramuscular hemangioma (IH) in the head and neck areas is relatively infrequent, accounting for 15% of IH. Most of them are identified as a benign mass, and rapid changes in size or internal bleeding are rare.
Patient concerns:
A 60-year-old female patient presented with a 2-week history of sudden onset posterior neck pain. There was no neurological deficit except limited neck motion due to pain. The palpable mass was noted on the paraspinal muscles of cervicothoracic junction, which was located midline to left side portion with tenderness.
Diagnoses:
Magnetic resonance imaging demonstrated a round shaped, multi-lobulated, and well-defined mass lesion (4.1 × 2.6 × 0.9 cm) embedded from the inter-spinous space of T1-2 to the left paraspinal muscles. The lesion was iso-intense on T2-weighted images (WI), iso- to slightly low-intense on T1-WI, heterogeneous enhancement of intra- and peri-mass lesion on contrast-enhanced T1-WI. Vascular structures presented as signal voids were identified internally and around the mass lesion. Histological examination revealed a mixed-type hemangioma.
Interventions:
The mass was removed completely including some of the surrounding muscles where boundaries were unclear between the mass and surrounding muscles with ligation of peritumoral vessels. Dark-brown colored blood was drained from the ruptured tumor capsule during the dissection. There was no bony invasion.
Outcomes:
The preoperative symptoms improved immediately after the operation. There is no residual or recurrence lesion by the 15-months follow-up.
Lessons:
IH with hemorrhagic transformation in the head and neck is extremely rare. In the case of intramuscular tumors accompanied by a sudden onset of severe acute pain, we recommend considering a differential diagnosis of IH with hemorrhagic transformation. Complete resection of the tumor mass including surrounding muscles is required to prevent recurrence.
