In the long bones, osseous hemangiomas can be classified as medullary (~50%), periosteal (~35%), and intracortical (~15%).
Medullary osseous hemangiomas occur most commonly in the diaphysis (48% of cases), with metadiaphyseal (30%), metaphyseal (12%), metaepiphyseal (4%), epimetadiaphyseal (3%) and epiphyseal (1%) lesions occurring less commonly. On radiographs, medullary lesions can have corduroy and radiating trabecular thickening similar to those seen in the vertebral bodies and skull, respectively, but this is an uncommon presentation. A more common appearance is a bubbly pattern of bone lysis that creates a honeycomb, lattice-like, or "hole-within-hole" appearance. This bone lysis can appear as linear and circular densities on radiographs, representing vascular channels seen longitudinally and en face, respectively. The appearance can mimic that of lymphoma, osteomyelitis and metastatic disease.
On CT, medullary hemangiomas appear as expansile lytic areas surrounded by coarse trabecular bone. A "polka dot" appearance, when seen, can suggest the diagnosis.
On MRI, the vascular channels are hypointense on T1-weighted images and hypointense to very hyperintense on T2-weighted images depending on the speed of blood flow. The trabeculations may be seen as areas of low signal.
Less common radiographic appearances include punched-out lucencies that can mimic metastatic disease or multiple myeloma; large, lytic, lesions with sclerotic borders that can mimic giant cell tumor, unicameral or aneurysmal bone cyst, or fibrous dysplasia; and permeative pattern that can mimic multiple myeloma, metastatic carcinoma, lymphoma, or Ewing sarcoma. In these cases, the rarity of osseous hemangioma would preclude its inclusion in the differential diagnosis.
Periosteal and intracortical lesions also occur most commonly in the diaphyis (~75%), wit the anterior tibial diaphysis being a common location. Metadiaphyseal (~15%) and metaphyseal (~10%) lesions can also be seen. On radiographs, they present as small, well-defined lytic lesions that may also be associated with cortical thickening and/or periosteal reaction. The differential diagnosis includes stress fracture, osteoid osteoma, or cortical abscess.
On MRI, intracortical lesions appear as increased signal within the normally dark cortex.
Should be considered in the differential diagnosis of fat-containing bone lesions.
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