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Posterior mediastinal hemangioma mimicking neurogenic tumor: Report of two cases
European Journal of Radiology Extra 75 (2010) e55–e58
Contents lists available at ScienceDirect
European Journal of Radiology Extra journal homepage: intl.elsevierhealth.com/journals/ejrex
Posterior mediastinal hemangioma mimicking neurogenic tumor: Report of two cases Imene Ridene a,∗ , Amine Abassi a , Ines Baccouche a , Asma Zidi a , Saoussen Hantous-Zannad a , Adel Marghli b , Tarek Kilani b , Olfa Ismaïl c , Khaoula Ben Miled-M’rad a a
Department of Radiology, Abderrahmane Mami Hospital, Ariana 2080, Tunisia Department of Thoracic and Cardiovascular Surgery, Abderrahmane Mami Hospital, Ariana 2080, Tunisia c Department of Pathology, Abderrahmane Mami Hospital, Ariana 2080, Tunisia b
a r t i c l e
i n f o
Article history: Received 7 March 2010 Received in revised form 25 May 2010 Accepted 27 May 2010 Keywords: Posterior mediastinal mass Hemangioma Computed tomography Magnetic resonance imaging
a b s t r a c t We report two observations of unusual mass in the posterior mediastinum: hemangioma, with different imaging features. In one case, it was a sharply marginated mass of the paraspinal region with limited extension into the adjacent foramina. In the second case, it was a posterior mediastinal mass with a large intra-spinal extension. On CT, the two masses did not contain calcifications according to phleboliths. In CT and MRI, they showed moderate enhancement in the first case and intensive enhancement in the second case. On T2 weighted sequences, the two masses showed a very high signal. These imaging features are relatively unspecific but indicative to think about mediastinal hemangioma as important differential diagnosis. Therefore MRI is very important to give the clues for the diagnosis, even if neurogenic tumors are the most frequent masses in this location. © 2010 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Benign hemangiomas of the mediastinum are rare tumors with an incidence of 0.5% or less among mediastinal masses. The posterior mediastinal location, as it is the case for our patients, is even rarer. In this location, any mass is considered likely to be a neurogenic tumor and has to be distinguished from it. We present two cases of posterior mediastinal hemangioma mimicking neurogenic tumors. 2. Patients 2.1. Case no. 1 A 58-year-old woman was admitted because of a superior mediastinal mass that was incidentally discovered by chest radiography. Physical examination and laboratory data did not show any particularities. CT scan (Light Speed VCT-GE Healthcare) was performed and showed a well-circumscribed mass of the posterior mediastinum, 5 cm of diameter. This mass contained a solid component showing intensive enhancement after contrast administration (XENETIX300 iobitridol), and low attenuating component interpreted as necrosis (Fig. 1). No calcifications were noted.
Reconstructions demonstrated extension into the adjacent neural foramina which was enlarged with bone scalloping. The diagnosis of neurinoma was then suggested. MR examination of the chest was performed with a magnetom explorer Impact Siemens 1 Te (1995 updated in 1997). T1-weighted spin echo images (TR/TE: 655/15 ms) and T2 weighted turbo spin echo images (TR/TE: 4374/90 ms) were acquired throughout the chest in the axial sagittal and coronal planes. After administration of gadolinium, T1-weighted coronal and axial images were performed throughout chest. T1-weighted images revealed heterogeneous mass, the predominant component was of intermediate signal (Fig. 2), with intensive enhancement after gadolinium administration. This component appeared as being clearly hyperintense on T2 sequence (Fig. 3). There was a second component, interpreted as necrosis on CT, spontaneously hyperintense on T1-weighted images, very hypointense on T2 sequence, suggesting a hemorrhagic structure. The coronal images confirmed the extension into the foramina (Fig. 4). Neurinoma was suspected. A postero-lateral thoracotomy revealed a mass in the paraspinal region. Part of the tumor arised in the adjacent foramina. The tumor was completely removed. Histopathological examination confirmed that it was a capillary hemangioma. 2.2. Case no. 2
∗ Corresponding author. Tel.: +216 98369160/71821420; fax: +216 71821184. E-mail address: [email protected] (I. Ridene). 1571-4675/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrex.2010.05.010
A 66-year-old man with a two-month history of paresthesis of superior extremities and troubles in walking, came to
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I. Ridene et al. / European Journal of Radiology Extra 75 (2010) e55–e58
Fig. 1. Contrast-enhanced CT of the chest demonstrates a heterogeneously enhancing mass (arrow) in the posterior right paraspinal region with low attenuating component.
Fig. 4. Post-contrast T1-weighted coronal image: the mass grows through the intervertebral foramina (arrow).
Fig. 2. Axial T1-weighted image revealed posterior mediastinal mass with predominant component in intermediate signal, and central component of high intensity.
Fig. 3. Axial T2-weighted image at the same level. The predominant component appeared frankly hyperintense. The second one is of very low intensity suggesting a hemorrhagic structure.
be examined. A chest radiograph showed a superior mediastinal mass. A CT scan (Light Speed VCT-GE Healthcare) revealed a 6 cm posterior mediastinal solid mass, with no calcifications, with local destruction of the posterior part of the vertebral body, and showing moderate but homogenous enhancement after contrast administration (XENETIX300 iobitridol) (Fig. 5). MR examination of the chest was performed with a magnetom explorer Impact Siemens 1Te (1995 updated in 1997). T1-weighted spin echo images (TR/TE: 655/15 ms) and T2 weighted turbo spin echo
Fig. 5. Chest CT showing left posterior mediastinal mass with moderate but homogenous enhancement with contrast agent, with local destruction of the posterior part of the vertebral body (arrow) and foraminal extension.
I. Ridene et al. / European Journal of Radiology Extra 75 (2010) e55–e58
e57
Fig. 6. Axial T2 weighted image showing left hyperintense paraspinal mass extending through the foramina in the epidural space postero-laterally pushing the medulla controlaterally (arrow).
images (TR/TE: 4374/90 ms) were acquired throughout the chest in the axial sagittal and coronal planes. After administration of gadolinium, T1-weighted coronal and axial images were performed throughout chest. The mass appeared hypointense on T1-weighted sequences and of high intensity on T2-weighted images with large extradural extension. The gadolinium administration showed an intense and homogeneous tumor enhancement. The mass extended through the foramina in the epidural space postero-laterally like a dumbbell-shaped lesion pushing the medulla controlaterally without modification of its signal (Figs. 6–8). A postero-lateral thoracotomy revealed a mass in the posterior costovertebral angle extended from the second to the third intercostal space with extension into the neural foramina. Spino-laminectomy was performed. On gross examination, the mass appeared as red soft tissue. Complete excision was carried out. Histopathological examination has confirmed the diagnosis of a mixed hemangioma.
Fig. 7. Coronal T1-weighted image without gadolinium showing the epidural component of the mass as a dumbbell-shaped lesion.
3. Discussion Hemangiomas are vascular benign tumors. At histologic analysis, these tumors consist of large interconnecting vascular spaces with variable interspread stromal elements. They are categorized as capillary, cavernous or venous hemangiomas on the bases of the size of vascular spaces [1]. Ninety per cent of these tumors are cavernous or capillary hemangiomas [2]. Hemangiomas are benign tumors, but histologic examination must be performed to differentiate them from potentially malignant vascular tumors. The occurrence of hemangiomas in the mediastinum is rare, with an incidence of less than 0.5% of all mediastinal masses, and is located most frequently in the anterior mediastinum [3]. Mediastinal hemangiomas typically occur in young patients under 35 years in 75% of cases [2,4]. One half of patients have no symptoms at the initial examination. The others present no specific symptoms, such as cough, chest pain and dyspnea due to compression. Dysphagia, superior vena cava syndrome and neurologic symptoms due to intra-spinal tumor extension are rare complications, as it is the case in our second patient [5]. It is often difficult to diagnosis hemangioma preoperatively, as the lesion usually manifests as a non-specific mass. Mediastinal hemangiomas tend to be well-circumscribed lesions, but some of them possess a true capsule. Phlebolits are a potentially diagnostic feature, well identifiable on CT, but only seen in 10% of cases
Fig. 8. Coronal T1-weighted image with gadolinium at the same level showing intense enhancement of the mass.
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I. Ridene et al. / European Journal of Radiology Extra 75 (2010) e55–e58
[4]. These tumors may also show non-specific punctuate calcifications in 20% of cases, which must be carefully differentiated from those occurring in cartilaginous or teratoid lesions [4]. None of our patients had calcifications within the mass. Identification of intralesional fat on CT or MRI is uncommun, not more than 10% of cases. The presence of fat in a mediastinal mass is a potentially confounding finding because it is seen more commonly in other mediastinal masses, particularly teratoma [4]. Mediastinal hemangiomas show a pattern of homogenous signal intensity similar to that of skeletal muscle on T1-weighted images and intense hyperintensity on T2 weighted images. Although mediastinal hemangiomas show an enhancement effect on the T1-weighted image with gadolinium, the contrast media produce variable enhancement on CT. It is thought that MRI is more sensitive to contrast media than CT [5]. The posterior mediastinal location of hemangioma, as in our patients, is very rare [6]. Most of the posterior mediastinal tumors are of neurogenic origin. Moreover, some neurogenic tumors, namely pheochromocytomas and paragangliomas, may demonstrate MR characteristics similar to those of a hemangioma: hypointensity on T1-weighted images and hyperintensities on T2weighted images. In our patients, the vascular tumor extended into the foramina in one case and in the epidural space in the second case, simulating neurogenic tumor. This invasive behaviour is rarely seen in hemangioma, but characteristic of neurogenic tumors, schwannoma and neurofibroma representing the vast majority causes of spinal neural foraminal widening and dumbbell-shaped tumors [7]. Hemangioma can be located primarily in the epidural space as described in many observations [8], and may grow through the widening foramina. Because of the bigger posterior extradural space, the epidural hemangioma is generally located at the dorsal spinal canal encircling the spinal cord on a large part of the mass, with a predominant longitudinal extension. Because of the softer texture of the hemangioma and the limited epidural space, the mass shows lobulated spindle shape with two taper ends [8]. On the other hand, the neurogenic tumor tends to occur lateral to the spinal canal and is smoothly shaped and less lobulated [8]. These morphologic features of lobulated margins and partially spinal cord-encircling epidural mass with a larger posterior component in the spinal canal could be the clue to the differential diagnosis of the epidural angioma from neurogenic tumor [9]. In our second case, the
epidural component of the mass, shows similar characteristics. In literature, neither mediastinal extension of epidural hemangioma nor epidural extension of mediastinal hemangioma was reported. 4. Conclusion Mediastinal hemangiomas should be considered as a differential diagnosis of mediastinal mass in all locations. The diagnosis may be suggested by an unusually high attenuation of the mass on contrast-enhanced CT and by the high hyperintensity on the T2 weighted images on MRI examination. To ensure the diagnosis in MRI, the dynamic study of enhancement would show gradually increasing and persistent enhancement of the mass. In the case of posterior mediastinal hemangioma with intra-spinal extension, the morphology of the epidural component helps in suggesting the diagnosis, avoiding dangerous preoperative biopsy. Conflict of interest The author(s) or author(s) institutions have no conflicts of interest. References [1] Cheung YC, Ng SH, Wan YL, Tan CF, Wong HF, Ng KK. Dynamic CT features of mediastina hemangioma: more information for evaluation. J Clin Imag 2000;24:276–8. [2] Sabharwal GK, Strousse PJ. Posterior mediastinal hemangioma. Pediatr Radiol 2005;35:1263–6. [3] Cohen AJ, Sbaschnig RJ, Hochholzer L, Lough FC, Albus RA. Mediastinal hemangiomas. Ann Thorac Surg 1987;43:656–9. [4] McAdams HP, Rosado-de-Christenson ML, Moran CA. Mediastinal hemangioma: radiographic and CT features in 14 patients. Radiology 1994;193:399–402. [5] Abe K, Akata S, Ohkubo Y, et al. Venous hemangioma of the mediastinum. Eur Radiol 2001;11:73–5. [6] Ishii K, Maeda K, Hashihira M, et al. MRI of mediastinal cavernous hemangioma. Pediatr Radiol 1990;20:556–7. [7] Kivrak AS, Koc O, Emlik D, Kiresi D, Odev K, Kalkan E. Differential diagnosis of dumbbell lesions associated with spinal neural foraminal widening: imaging features. Eur J Radiol 2009;71:29–41. [8] Feng J, Xu YK, Li L, et al. MRI diagnosis and preoperative evaluation for pure epidural cavernous hemangiomas. Neuroradiology 2009;51:741–7. [9] Shin JH, Lee HK, Rhim SC, Park SH, Choi CG, Suh DC. Spinal epidural cavernous hemangioma: MR findings. J Comput Assist Tomogr 2001;25:257–61.
Contents lists available at ScienceDirect
European Journal of Radiology Extra journal homepage: intl.elsevierhealth.com/journals/ejrex
Posterior mediastinal hemangioma mimicking neurogenic tumor: Report of two cases Imene Ridene a,∗ , Amine Abassi a , Ines Baccouche a , Asma Zidi a , Saoussen Hantous-Zannad a , Adel Marghli b , Tarek Kilani b , Olfa Ismaïl c , Khaoula Ben Miled-M’rad a a
Department of Radiology, Abderrahmane Mami Hospital, Ariana 2080, Tunisia Department of Thoracic and Cardiovascular Surgery, Abderrahmane Mami Hospital, Ariana 2080, Tunisia c Department of Pathology, Abderrahmane Mami Hospital, Ariana 2080, Tunisia b
a r t i c l e
i n f o
Article history: Received 7 March 2010 Received in revised form 25 May 2010 Accepted 27 May 2010 Keywords: Posterior mediastinal mass Hemangioma Computed tomography Magnetic resonance imaging
a b s t r a c t We report two observations of unusual mass in the posterior mediastinum: hemangioma, with different imaging features. In one case, it was a sharply marginated mass of the paraspinal region with limited extension into the adjacent foramina. In the second case, it was a posterior mediastinal mass with a large intra-spinal extension. On CT, the two masses did not contain calcifications according to phleboliths. In CT and MRI, they showed moderate enhancement in the first case and intensive enhancement in the second case. On T2 weighted sequences, the two masses showed a very high signal. These imaging features are relatively unspecific but indicative to think about mediastinal hemangioma as important differential diagnosis. Therefore MRI is very important to give the clues for the diagnosis, even if neurogenic tumors are the most frequent masses in this location. © 2010 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Benign hemangiomas of the mediastinum are rare tumors with an incidence of 0.5% or less among mediastinal masses. The posterior mediastinal location, as it is the case for our patients, is even rarer. In this location, any mass is considered likely to be a neurogenic tumor and has to be distinguished from it. We present two cases of posterior mediastinal hemangioma mimicking neurogenic tumors. 2. Patients 2.1. Case no. 1 A 58-year-old woman was admitted because of a superior mediastinal mass that was incidentally discovered by chest radiography. Physical examination and laboratory data did not show any particularities. CT scan (Light Speed VCT-GE Healthcare) was performed and showed a well-circumscribed mass of the posterior mediastinum, 5 cm of diameter. This mass contained a solid component showing intensive enhancement after contrast administration (XENETIX300 iobitridol), and low attenuating component interpreted as necrosis (Fig. 1). No calcifications were noted.
Reconstructions demonstrated extension into the adjacent neural foramina which was enlarged with bone scalloping. The diagnosis of neurinoma was then suggested. MR examination of the chest was performed with a magnetom explorer Impact Siemens 1 Te (1995 updated in 1997). T1-weighted spin echo images (TR/TE: 655/15 ms) and T2 weighted turbo spin echo images (TR/TE: 4374/90 ms) were acquired throughout the chest in the axial sagittal and coronal planes. After administration of gadolinium, T1-weighted coronal and axial images were performed throughout chest. T1-weighted images revealed heterogeneous mass, the predominant component was of intermediate signal (Fig. 2), with intensive enhancement after gadolinium administration. This component appeared as being clearly hyperintense on T2 sequence (Fig. 3). There was a second component, interpreted as necrosis on CT, spontaneously hyperintense on T1-weighted images, very hypointense on T2 sequence, suggesting a hemorrhagic structure. The coronal images confirmed the extension into the foramina (Fig. 4). Neurinoma was suspected. A postero-lateral thoracotomy revealed a mass in the paraspinal region. Part of the tumor arised in the adjacent foramina. The tumor was completely removed. Histopathological examination confirmed that it was a capillary hemangioma. 2.2. Case no. 2
∗ Corresponding author. Tel.: +216 98369160/71821420; fax: +216 71821184. E-mail address: [email protected] (I. Ridene). 1571-4675/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrex.2010.05.010
A 66-year-old man with a two-month history of paresthesis of superior extremities and troubles in walking, came to
e56
I. Ridene et al. / European Journal of Radiology Extra 75 (2010) e55–e58
Fig. 1. Contrast-enhanced CT of the chest demonstrates a heterogeneously enhancing mass (arrow) in the posterior right paraspinal region with low attenuating component.
Fig. 4. Post-contrast T1-weighted coronal image: the mass grows through the intervertebral foramina (arrow).
Fig. 2. Axial T1-weighted image revealed posterior mediastinal mass with predominant component in intermediate signal, and central component of high intensity.
Fig. 3. Axial T2-weighted image at the same level. The predominant component appeared frankly hyperintense. The second one is of very low intensity suggesting a hemorrhagic structure.
be examined. A chest radiograph showed a superior mediastinal mass. A CT scan (Light Speed VCT-GE Healthcare) revealed a 6 cm posterior mediastinal solid mass, with no calcifications, with local destruction of the posterior part of the vertebral body, and showing moderate but homogenous enhancement after contrast administration (XENETIX300 iobitridol) (Fig. 5). MR examination of the chest was performed with a magnetom explorer Impact Siemens 1Te (1995 updated in 1997). T1-weighted spin echo images (TR/TE: 655/15 ms) and T2 weighted turbo spin echo
Fig. 5. Chest CT showing left posterior mediastinal mass with moderate but homogenous enhancement with contrast agent, with local destruction of the posterior part of the vertebral body (arrow) and foraminal extension.
I. Ridene et al. / European Journal of Radiology Extra 75 (2010) e55–e58
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Fig. 6. Axial T2 weighted image showing left hyperintense paraspinal mass extending through the foramina in the epidural space postero-laterally pushing the medulla controlaterally (arrow).
images (TR/TE: 4374/90 ms) were acquired throughout the chest in the axial sagittal and coronal planes. After administration of gadolinium, T1-weighted coronal and axial images were performed throughout chest. The mass appeared hypointense on T1-weighted sequences and of high intensity on T2-weighted images with large extradural extension. The gadolinium administration showed an intense and homogeneous tumor enhancement. The mass extended through the foramina in the epidural space postero-laterally like a dumbbell-shaped lesion pushing the medulla controlaterally without modification of its signal (Figs. 6–8). A postero-lateral thoracotomy revealed a mass in the posterior costovertebral angle extended from the second to the third intercostal space with extension into the neural foramina. Spino-laminectomy was performed. On gross examination, the mass appeared as red soft tissue. Complete excision was carried out. Histopathological examination has confirmed the diagnosis of a mixed hemangioma.
Fig. 7. Coronal T1-weighted image without gadolinium showing the epidural component of the mass as a dumbbell-shaped lesion.
3. Discussion Hemangiomas are vascular benign tumors. At histologic analysis, these tumors consist of large interconnecting vascular spaces with variable interspread stromal elements. They are categorized as capillary, cavernous or venous hemangiomas on the bases of the size of vascular spaces [1]. Ninety per cent of these tumors are cavernous or capillary hemangiomas [2]. Hemangiomas are benign tumors, but histologic examination must be performed to differentiate them from potentially malignant vascular tumors. The occurrence of hemangiomas in the mediastinum is rare, with an incidence of less than 0.5% of all mediastinal masses, and is located most frequently in the anterior mediastinum [3]. Mediastinal hemangiomas typically occur in young patients under 35 years in 75% of cases [2,4]. One half of patients have no symptoms at the initial examination. The others present no specific symptoms, such as cough, chest pain and dyspnea due to compression. Dysphagia, superior vena cava syndrome and neurologic symptoms due to intra-spinal tumor extension are rare complications, as it is the case in our second patient [5]. It is often difficult to diagnosis hemangioma preoperatively, as the lesion usually manifests as a non-specific mass. Mediastinal hemangiomas tend to be well-circumscribed lesions, but some of them possess a true capsule. Phlebolits are a potentially diagnostic feature, well identifiable on CT, but only seen in 10% of cases
Fig. 8. Coronal T1-weighted image with gadolinium at the same level showing intense enhancement of the mass.
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I. Ridene et al. / European Journal of Radiology Extra 75 (2010) e55–e58
[4]. These tumors may also show non-specific punctuate calcifications in 20% of cases, which must be carefully differentiated from those occurring in cartilaginous or teratoid lesions [4]. None of our patients had calcifications within the mass. Identification of intralesional fat on CT or MRI is uncommun, not more than 10% of cases. The presence of fat in a mediastinal mass is a potentially confounding finding because it is seen more commonly in other mediastinal masses, particularly teratoma [4]. Mediastinal hemangiomas show a pattern of homogenous signal intensity similar to that of skeletal muscle on T1-weighted images and intense hyperintensity on T2 weighted images. Although mediastinal hemangiomas show an enhancement effect on the T1-weighted image with gadolinium, the contrast media produce variable enhancement on CT. It is thought that MRI is more sensitive to contrast media than CT [5]. The posterior mediastinal location of hemangioma, as in our patients, is very rare [6]. Most of the posterior mediastinal tumors are of neurogenic origin. Moreover, some neurogenic tumors, namely pheochromocytomas and paragangliomas, may demonstrate MR characteristics similar to those of a hemangioma: hypointensity on T1-weighted images and hyperintensities on T2weighted images. In our patients, the vascular tumor extended into the foramina in one case and in the epidural space in the second case, simulating neurogenic tumor. This invasive behaviour is rarely seen in hemangioma, but characteristic of neurogenic tumors, schwannoma and neurofibroma representing the vast majority causes of spinal neural foraminal widening and dumbbell-shaped tumors [7]. Hemangioma can be located primarily in the epidural space as described in many observations [8], and may grow through the widening foramina. Because of the bigger posterior extradural space, the epidural hemangioma is generally located at the dorsal spinal canal encircling the spinal cord on a large part of the mass, with a predominant longitudinal extension. Because of the softer texture of the hemangioma and the limited epidural space, the mass shows lobulated spindle shape with two taper ends [8]. On the other hand, the neurogenic tumor tends to occur lateral to the spinal canal and is smoothly shaped and less lobulated [8]. These morphologic features of lobulated margins and partially spinal cord-encircling epidural mass with a larger posterior component in the spinal canal could be the clue to the differential diagnosis of the epidural angioma from neurogenic tumor [9]. In our second case, the
epidural component of the mass, shows similar characteristics. In literature, neither mediastinal extension of epidural hemangioma nor epidural extension of mediastinal hemangioma was reported. 4. Conclusion Mediastinal hemangiomas should be considered as a differential diagnosis of mediastinal mass in all locations. The diagnosis may be suggested by an unusually high attenuation of the mass on contrast-enhanced CT and by the high hyperintensity on the T2 weighted images on MRI examination. To ensure the diagnosis in MRI, the dynamic study of enhancement would show gradually increasing and persistent enhancement of the mass. In the case of posterior mediastinal hemangioma with intra-spinal extension, the morphology of the epidural component helps in suggesting the diagnosis, avoiding dangerous preoperative biopsy. Conflict of interest The author(s) or author(s) institutions have no conflicts of interest. References [1] Cheung YC, Ng SH, Wan YL, Tan CF, Wong HF, Ng KK. Dynamic CT features of mediastina hemangioma: more information for evaluation. J Clin Imag 2000;24:276–8. [2] Sabharwal GK, Strousse PJ. Posterior mediastinal hemangioma. Pediatr Radiol 2005;35:1263–6. [3] Cohen AJ, Sbaschnig RJ, Hochholzer L, Lough FC, Albus RA. Mediastinal hemangiomas. Ann Thorac Surg 1987;43:656–9. [4] McAdams HP, Rosado-de-Christenson ML, Moran CA. Mediastinal hemangioma: radiographic and CT features in 14 patients. Radiology 1994;193:399–402. [5] Abe K, Akata S, Ohkubo Y, et al. Venous hemangioma of the mediastinum. Eur Radiol 2001;11:73–5. [6] Ishii K, Maeda K, Hashihira M, et al. MRI of mediastinal cavernous hemangioma. Pediatr Radiol 1990;20:556–7. [7] Kivrak AS, Koc O, Emlik D, Kiresi D, Odev K, Kalkan E. Differential diagnosis of dumbbell lesions associated with spinal neural foraminal widening: imaging features. Eur J Radiol 2009;71:29–41. [8] Feng J, Xu YK, Li L, et al. MRI diagnosis and preoperative evaluation for pure epidural cavernous hemangiomas. Neuroradiology 2009;51:741–7. [9] Shin JH, Lee HK, Rhim SC, Park SH, Choi CG, Suh DC. Spinal epidural cavernous hemangioma: MR findings. J Comput Assist Tomogr 2001;25:257–61.