Calvarial intraosseous common venous malformation (hemangioma) diagnosed on technetium-99m labeled RBC scintigraphy: a case report and review of the literature

BACKGROUND: Common venous malformations ("hemangiomas") are slow-growing, non-aggressive tumors consisting of small and large caliber vascular channels which can be found throughout the body, including within the musculoskeletal system. In cases where these masses do not present with the typical hallmark X-Ray, CT, or MRI findings, Technetium-99 m labeled Red Blood Cell (RBC) scintigraphy may be performed to confirm the diagnosis. METHODS: A retrospective chart review was performed of a single patient with an indeterminate lesion of the calvarium. Relevant clinical history and imaging findings were reviewed. Current literature regarding the use of technetium-99 m labeled RBC scintigraphy in the diagnosis of intraosseous hemangiomas was also reviewed. CASE DISCUSSION: A 25-year-old female initially presented to a neurologist in 2016 for new onset of seizures and intermittent panic attacks, at which time a non-contrast MRI Brain was obtained, revealing a T2 hyperintense and mildly T1 hyperintense mass within the occipital bone, which was suspected to represent an intraosseous hemangioma. She underwent a repeat non-contrast MRI Brain examination 8 years later for headaches, which found an increase in size of the calvarial lesion from 1.6 cm to 2.4 cm. While this lesion was still suspected to represent an intraosseous hemangioma, Technetium-99 m labeled RBC scintigraphy was performed as a confirmatory examination, which revealed normal initial blood flow but abnormal pooling of tagged RBCs within the lesion, thus compatible with a calvarial intraosseous hemangioma. CONCLUSION: Technetium-99 m labeled RBC scintigraphy can be an effective problem-solving tool in the diagnosis of intraosseous hemangiomas, and may be considered as a confirmatory examination or when results of conventional imaging techniques are felt to be indeterminate, and thus avoiding histologic correlation.