Hepatic Hemangioma: Pitfalls & Mimics, Part I

In this video lecture, we discuss tips and tricks to diagnose everybody’s favorite hepatic tumor on CT, MRI and ultrasound.

Key points include:

Hemangioma is the most common benign hepatic tumor, and it is more common in females.
These tumors are usually asymptomatic and typically require no treatment, but can rarely cause pain, rupture if large, or cause Kasabach-Merritt syndrome.
On nonenhanced CT, hemangiomas will be hypodense to liver parenchyma and homogeneously isodense to the blood pool.
There are three major enhancement patterns for typical hemangiomas, and all patterns will show persistent delayed enhancement without contrast washout.
Peripheral, nodular, interrupted enhancement with gradual centripetal progression to uniform enhancement is the most common pattern.
Smaller lesions (less than 1-2 cm) can have immediate uniform enhancement and appear flash-filling.
Larger hemangiomas may have a central scar that does not enhance.
MRI is highly specific in the diagnosis of hemangioma.
On MRI, hemangiomas will appear T1 hypointense and T2 hyperintense to liver parenchyma, or (perhaps more importantly) T1 isointense to the blood pool and T2 hyperintense to the spleen.
Hemangiomas usually do not show restricted diffusion.
If present, the central scar of hemangioma will appear T1 hypointense and T2 hyperintense on MRI.
Additional liver masses that may have a central scar include focal nodular hyperplasia, fibrolamellar hepatocellular carcinoma, cholangiocarcinoma, and hepatocellular carcinoma.
On ultrasound, hemangiomas are usually uniformly echogenic.
40% of hemangiomas can have a “reverse target” appearance with an echogenic periphery and hypoechoic center.
Hemangiomas usually have no color Doppler flow on ultrasound, but they may occasionally exhibit mild flow.

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