Download Synovial hemangioma of the suprapatellar bursa

Synovial hemangioma of the suprapatellar bursa
Poster No.:
P-0040
Congress:
ESSR 2013
Type:
Scientific Exhibit
Authors:
A. YESILDAG, S. Keskin, H. Kalkan, S. Kucuksen, U. Kerimoglu;
Konya/TR
Keywords:
Musculoskeletal joint, MR, Education, Hemangioma
DOI:
10.1594/essr2013/P-0040
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Purpose
To discuss the imaging findings of a synovial hemangioma located in suprapatellar bursa
Methods and Materials
A 17 years-old male presented with recurrent swollen, painful knee for 3 years. Gray
scale and color doppler ultrasound (Toshiba Aplio 80, Japanese, Tokyo) proceeded
by magnetic resonance imaging (MRI, Siemens, Avanto, Erlangen, Germany) were
performed. Routine knee sequence including proton density imaging in 3 orthogonal
planes, coronal T2 weighted (W) image with fat saturation were obtained. Intravenous
contrast material (10 cc) was also performed. To visualize the extension of the lesion and
relation between the knee joint and the bones MRI was preferred.
Results
Laboratory tests were all within normal limits. On gray scale ultrasound hypoechoic soft
tissue lesion containing tubular structures (Figure 1) were seen. These tubular structures
demonstrated compression-decompression so to rule out vascular origin color doppler
was activated. On color doppler spectral imaging demonstrated venous flow (Figure 2).
The soft tissue lesion was filling the suprapatellar bursa. MRI demonstrated that the
lesion was extending to the surrounding muscles on the medial and posterior aspect
of the knee joint. The lesion was hyperintense related to the muscles and including
hypointense nodular foci representing fat on T2 W fat saturated images (Figure 3). On
contrast enhanced images the lesion demonstrated heterogenous linear enhancement
(Figure 4). No bone involvement is seen.
Images for this section:
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Fig. 1: Hypoechoic soft tissue lesion (arrows) in the suprapatellar bursa under the
ouadriceps muscle (Q) is seen.
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Fig. 2: Color doppler imaging demonstrates the venous flows.
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Fig. 3: T2 weighted fat saturated image demonstrates hyperintense tubular lesion
including thin septa. The lesion was filling the suprapatellar bursa.
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Fig. 4: T1(W)fat saturated image obtained after administration of the contrast material
demonstrates the heterogenous enhancement.
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Conclusion
Synovial hemangioma is a rare, benign tumour of joints first described by Bouchut in
1856. In 97% of cases, it is located in the knee just like in our patient, but it also has been
reported in other joints including the elbow, ankle and wrist (1). Usually, patients present
with decreased range of motion and locking and complain about pain and swelling of
knee caused by repetetive episodes of hemarthrosis.
According to the anatomical location, articular hemangioma is differentiated into synovial,
juxta-articular or intermediate. The synovial type is located within the joint capsule. Juxtaarticular hemangiomas are outside of the joint, but connected with the capsule, the
intermediate type can be found intra-articular or extra-articular. Our case represents
synovial type hemangioma since it islocated in the joint (2).
Plain film may demonstrate the increased soft tissue density representing the effusion or
the mass. Phleboliths, periosteal thickening, advanced maturation of the epiphysis, and
arthritic changes are also occasionally noted on plain radiographs (3). None was seen
in our case.
Ultrasound imaging is helpful in the differentiation of cystic lesion from solid one. Color
doppler also may reveal the vascular origin of the lesion. To the best of our knowledge
there is no article about the ultrasound findings and diagosis of synovial hemangioma in
the litherature. Our case was evaluated firstly by ultrasound and color doppler imaging
was diagnostic.
Computed tomography may demonstrate the soft tissue lesion but it is not specific and
may underestimate the size of the lesion because it is not able to distinguish between the
lesion and the muscle(4) also be helpful in the diagnosis. With contrast material, vascular
lesion and association with the bone is revealed.
MRI is the most effective modality in the evaluation of the soft tissue lesions related
to the high contrast resolution. On T1- weighted (W) images the synovial hemangioma
demonstrates low or intermediate signal intensity but high signal intensity may also be
seen because of the fat or blood ingredients. On T2-weighted images high signal intensity
is shown caused by the stagnant blood in vascular spaces (5,6). Also on fat suppression
images thin, serpentine low-intensity septa may be seen as in our case.
The differential diagnosis should include mainly PVNS, synovial sarcoma, arthropathies
(rheumatoid arthritis, juvenile chronic arthritis, hemophilic arthropathy, synovial
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osteochondromatosis or lipoma aborescens) usually being distinguished clinically or after
MRI interpretation (7).
In cases with repeated knee pain and hemoarthrosis, we think that it is necessary
to include the hemangioma in the differential diagnosis (particularly in children) and
it is important to diagnose hemangioma as early as possible. We want to emphasize
that especially color doppler ultrasound in addition to gray scale imaging may also be
diagnostic for soft tissue lesions.
References
1. Llauger J, et al. Synovial hemangioma of the knee: MRI findings in
two cases. Skeletal Radiol 1995, 24:579-581.
2. Holzapfel BM, et al. Synovial hemangioma of the knee joint with
cystic invasion of the femur: a case report and review of the
literature. Arch Orthop Trauma Surg 2009,129:143-148
3. Moon NF, et al. Synovial hemangioma of the knee joint. Clin Orthop
1973; 90: 181.
4. Yuh WTC, et al. Hemangiomas of skeletal muscle: MR findings in five
patients. AJR Am J Roentgenol 1987, 149:765-768.
5. Gougeon F, et al. Synovial haemangioma of the knee: a frequently
misdiagnosed lesion. Skeletal Radiol 1995, 24:257-261.
6. Narvaez JA, et al. MR imaging of synovial tumors and tumor-like
lesions. Eur Radiol 2011, 11:2549-2560.
7. Vakil-Adli, et al. Synovial hemangioma of the knee joint in a12-year-
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old boy: a case report. Journal of Medical Case Reports 2010, 4:105
Personal Information
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