Synovial hemangioma of the suprapatellar bursa Poster No.: P-0040 Congress: ESSR 2013 Type: Authors: Keywords: DOI: Scientific Exhibit A. YESILDAG, S. Keskin, H. Kalkan, S. Kucuksen, U. Kerimoglu; Konya/TR Musculoskeletal joint, MR, Education, Hemangioma 10.1594/essr2013/P-0040 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.essr.org Page 1 of 9
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: Page 2 of 9
Fig. 1: Hypoechoic soft tissue lesion (arrows) in the suprapatellar bursa under the ouadriceps muscle (Q) is seen. Page 3 of 9
Fig. 2: Color doppler imaging demonstrates the venous flows. Page 4 of 9
Fig. 3: T2 weighted fat saturated image demonstrates hyperintense tubular lesion including thin septa. The lesion was filling the suprapatellar bursa. Page 5 of 9
Fig. 4: T1(W)fat saturated image obtained after administration of the contrast material demonstrates the heterogenous enhancement. Page 6 of 9
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 Page 7 of 9
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- Page 8 of 9
old boy: a case report. Journal of Medical Case Reports 2010, 4:105 Personal Information Page 9 of 9