A case report of multiple aggressive vertebral hemangiomas: a rare mimic of metastatic malignancy

Background: A rare subset of vertebral haemangiomas presents aggressively, characterized by significant osseous expansion and extraosseous extension. Particularly in the case of multiple lesions, they present a diagnostic challenge due to the radiological similarity to malignant lesions. We present a case of multiple osseous haemangiomas including three in the vertebrae causing cord compression and radiculopathy, successfully treated via both endovascular and surgical means. Case Description: A 55-year-old female presented with radicular lower back pain. She had a past medical history of type 2 diabetes, hypercholesterolemia, and hypertension, for which she took perindopril and semaglutide. Computed tomography (CT) and magnetic resonance imaging (MRI) of the spine demonstrated multi-level vertebral body lytic lesions with cord compression at the T12 vertebral level. The patient underwent a T11 to L1 posterior decompression and instrumented fixation, then further endovascular angioembolization of an L5 vertebral lesion that was causing radiculopathy and progressive canal stenosis. Histopathology found the lesion to be a haemangioma. At 1-month follow-up, the patient's pain had largely resolved and had improving right sided L5 distribution paraesthesia. Conclusions: Cases of multiple aggressive vertebral haemangiomas often present a diagnostic dilemma due to their similarity to malignancy. In cases of multifocal dissemination of haemangiomatous lesions, the extremely rare condition cystic angiomatosis should be considered as a differential. Surgical treatment is indicated in lesions causing myelopathy, and endovascular embolization can be considered either as primary therapy for the lesion or pre-operatively to reduce bleeding risk.