Radionuclide Blood Pool Imaging

A patient with new onset seizures was found to have
radiographic findings of a calvarial hemangioma. Be-
cause of the history, additional diagnostic tests were
employed, which excluded cerebral lesions. Findings
characteristic of hemangioma on blood pool imaging
were felt to confirm the diagnosis.

Hemancona OF BONE is one of the rarer benign
primary bone tumors. When located in the skull,
this lesion has typical radiographic findings that are
usually specific. Occasionally, the lesion can be con-
fused with other benign and malignant lesions. In
these cases, more extensive diagnostic examinations
or surgery may be necessary. We report a case where
the use of radionuclide blood pool imaging helped con-
firm the suspected diagnosis of calvarial hemangioma
and alleviated the need for further diagnostic studies.

Case Report

A 70-year-old man was admitted for new onset of
seizures. He had a history of heart disease complicated
by hypertension with congestive heart failures and ar-
rhythmias. Eventually, the seizures were attributed to
the cardiac abnormalities.

In the initial evaluation, radiographs revealed a left
frontal calvarial lesion (Figs. 1A, B). This was inter-
preted as a hemangioma of the skull. However, the
history of seizures prompted further investigation.
Cerebral CT scan was normal. Tc-99m glucoheptonate
brain imaging revealed a rounded area of increased
activity peripherally over the left frontal region (Fig.
2). Tce-99m methylene diphosphonate bone imaging
revealed equal uptake in the lesion as in surrounding
bone (Fig. 3). A study with in vivo technetium labeled
RBCs revealed an area of activity on blood flow
studies and increasing accumulation of activity with
time in the bony lesion on static images (Fig. 4). This
helped confirm the diagnosis and completed evaluation
of the lesion.

Reprint requests: James D. Massie, M.D., Department of Radiol-
ogy, University of Tennessee Center for the Health Sciences, 865
Jefferson Avenue, Memphis, Tennessee 38163.

of Calvarial Hemangioma

MORRIS L. GAVANT, M.D., JAMES D. MASSIE, M.D.,
AND BARRY GERALD, M.D.

From the Department of Radiology,
University of Tennessee Center

for the Health Sciences,

Memphis, Tennessee

Discussion

Hemangioma is a benign primary tumor composed
of formed blood vessels. Classified as cavernous or
capillary, depending on the basis of size of vessels’
lumen, they make up less than 1% of primary bone
tumors (1-3). Most of these are seen in the spine and
skull.

Characteristically, a well circumscribed blister or
bleb off the outer table of the skull, with prominent
vertical trabeculations in a honeycomb or sunburst ap-
pearance, are present. Tangential views are best in
showing the findings. The differential diagnosis may
include metastasis, multiple myeloma, osteogenic sar-
coma, calvarial changes from meningioma, epider-

Fig. 1A. AP radiograph.
Left frontal supraorbital
well-circumscribed circular
radiolucent lesion with
smooth elevation of outer
table of skull. Thin rim of
sclerosis Is present around
lytic area.

Fig. 1B. Lateral view. Mul-
tiple thickened bony trabecu-
lations seen on end.

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CLINICAL NUCLEAR MEDICINE

October 1983

Vol. 8

Fig. 2, Brain imaging. Left to right: Anterior left lateral, and right lateral views. Peripheral localized uptake in area of lesion as

seen on radiographs.

Fig. 3. Bone imaging. Left lateral and LAO tangential view of
palpable lesion. Area of smooth irregularity in area of bone le-
sion seen only on.this view (arrow).

moid, osteoma, and fibrous dysplasia. With the
characteristic radiographic findings and clinical his-
tory, the diagnosis can be made without difficulty
(1,3). In unusual cases, angiography and even surgery
have been performed in the evaluation of the lesion
(4-6).

Hemangiomata elsewhere in the body, particularly in
the liver, have been shown to have characteristic find-
ings of little to no activity on radionuclide angiograms
with slow accumulation of activity in the tumor over
time (7-8). These findings were also present in our
case. The little activity during angiography is thought
to be caused by hemodilution of the bolus of tagged
RBCs in the larger non-tagged blood pool of the lesion
secondary to slow flow or small afferent feeding ves-
sels. This is a manifestation of perfusion of the lesion.
Theoretically, larger lesions or tumors with larger affe-

rent vessels could have increased activity during
radionuclide angiography (6-8).

Over time, activity accumulates in this vascular le-
sion as tagged and non-tagged RBCs completely mix in
the blood pool. Thus, a totally thrombosed heman-
gioma should not show increasing activity (7-8).

Calvarial hemangioma usually has characteristic ra-
diographic findings. In the unusual lesion or in a pa-
tient with questionable symptoms related to the bony
abnormality, blood pool imaging may be of value in
confirming that one is dealing with this benign tumor.

References

1, Sherman RS, Wilner D: The roentgen diagnosis of hemangioma
of bone. AJR 86: 1146, 1961.

. Spjut HJ, Dorfman JD, Fechner RE, et al: Tumors of bone and
cartilage. In Firminger HI (ed); Atlas of Tumor Pathology.
Washington, AFIP, 1971, pp 325-329,

. Wilner D: Radiology of Bone Tumors and Allied Disorders.

Philadelphia, Saunders, 1982, pp 660-704.
Rosenbaum AE: Angiography of haimangiomata of the cal-
varium. Brit J Radiol 42: 682, 1969.
. Atallah NK, Nassar SI: Calvarial hemangioma with blood sup-
ply from branches of internal carotid artery: case report.
Neurosurg 34: 823, 1971.
. Schneider RC, Gabrielson TO, Hicks SP: Calvarial heman-
gioma: the value of selective external carotic angiography in
surgical excision of the lesion. Neurology 23: 352, 1973.
7. Freeman LM, Bernstein RG, Hayt DB: Diagnosis of hepatic
hemangioma with combined scanning technique. Radiology
95; 127, 1970.

8. Front D, Royal HD, Israel O, et al: Scintigraphy of hepatic
hemangiomas: the value of Tc-99m-labeled red blood cells:
concise communication. J Nucl Med 22: 684, 1981.

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Fig. 4. Blood poo! study. immediate image (A). LAO position; focal area of increased activity seen over bony lesion. Delayed
image LAO (B). Increase In activity compared to earlier Image in lesion. Left lateral view (C). Area of increased activity is in same

location as lesion on radiographs.

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