Neuro / Head & Neck for Thursday, June 4th, 2026

Contributed by Children's National Medical Center
Lina Obeidat, and Harut Haroyan.

History

History: a 15-year-old male with a one-year history of urinary frequency, sensation of incomplete bladder emptying and constipation. Notably, there is no saddle paresthesia.

Images (Click any image to enlarge)

Question

What is the finding on this X-ray?

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Correct answer

Salt and pepper appearance of L1 vertebral body.

Discussion

Vertebral hemangiomas, a type of venous malformation, are benign lesions that occur in 10% of the adult population but are rarely seen in children.

While typically small, painless and asymptomatic, in 1% as in this case, they can be aggressive. These aggressive lesions are expansile, cause bony resorption and have a soft tissue component potentially causing cord compression and neurological symptoms. Symptomatic vertebral hemangiomas often require surgical intervention which can be complicated by hemorrhage due to their hypervascular nature.

Characteristic imaging appearance of vertebral hemangiomas includes salt and pepper appearance on plain radiograph and CT scan indicative of the dilated vascular channels intersecting the trabecula of the bone. They are usually hyperintense on T1 and T2 sequences due to their fatty component. Aggressive hemangiomas can involve the entire vertebral body and posterior elements.

In this particular case, the diagnosis was challenging due obscuration of the bone by stool in the transverse colon and the absence of lateral views on routine abdomen radiographs in order to minimize radiation exposure.

Differential diagnosis

Classic CT and MRI appearance is diagnostic

Additional images

Sagittal MRI, T2 sequence of the lumbar spine showing hyperintense mass infiltrating the entire L1 vertebral body and posterior elements.
Sagittal MRI, T1 sequence of the lumbar spine showing some internal T1 hyperintensity, suggesting the presence of fat.
Axial T2 sequence of L1 showing extension of the mass into the epidural space and neural foramina.
Sagittal CT scan showing trabecular thickening and mild expansion of L1 vertebral body.
Axial CT scan showing involvement of the posterior elements.

References

  • Pastushyn AI, Slin’ko EI, Mirzoyeva GM. Vertebral hemangiomas: diagnosis, management, natural history and clinicopathological correlates in 86 patients. Surg Neurol. 1998;50(6):535–547. doi:10.1016/S0090-3019(98)00007-X
  • Schmid G, Pape H, Reinke A. Aggressive and giant hemangioma of the lumbar spine. Joint Bone Spine. 2020;87(5):489. doi:10.1016/j.jbspin.2020.04.003
  • Pannecoucke M, Valgaeren B, Petitjean E, Hertveldt K, Terwecoren A. Neuro-image: aggressive vertebral hemangioma. Acta Neurol Belg. 2024;124(6):1995–1997. doi:10.1007/s13760-023-02312-z
  • Friedman DP. Symptomatic vertebral hemangiomas: MR findings. AJR Am J Roentgenol. 1996;167(2):359–364. doi:10.2214/ajr.167.2.8686604