NAME- SISAY ABRHA IDNO- UGR/7241/14 DEPT- MRT Atypical hepatic hemangioma Atypical liver hemangioma is a variant of hepatic hemangioma with atypical imaging finding features and it can be confused with other pathologies like liver metastases, HCC and so on. Hemangiomas typically appear as hyperechoic, well defined lesions, or hypoechoic masses with hyperechoic periphery. However, when the features of the lesion are atypical at conventional ultrasound (US), further investigation is required. Contrast-enhanced ultrasound (CEUS) has been proven to be a reliable method for the characterization of the focal liver lesions, it is a sensitive and very specific method for the diagnosis of hemangiomas. Ultrasound appearance of atypical hepatic hemangioma Atypical appearance of hemangioma most commonly results with increased size, often demonstrating a variety of echo patterns ranging from hyperechoic, isoechoic, to hypoechoic and appearing heterogeneous and lobular. These atypical characteristics may lead to misdiagnosis as the appearance can closely mimic malignant neoplasms, such as HCC. Other atypical appearances that may present with hepatic hemangiomas that can sometimes make a definitive diagnosis challenging include echogenic border and calcifications. One of the more common atypical appearances of a hepatic hemangioma is an echogenic border. Hepatic hemangiomas may also present with the atypical appearance of calcifications. This is quite rare in hepatic hemangiomas. Atypical pattern of CEUS for hemangioma included rapid homogeneous hyperenhancement at the arterial phase and hypo-enhancement at the portal/late phase and peripheral nodular enhancement at the arterial phase and lack of enhancement in the center at the late phase. The atypical pattern of hemangioma makes the differentiated diagnosis quite difficult from liver metastases, especially in patients with a previous history of malignant tumor. (A) Ultrasound revealed an isoechoic mass in the left liver. (B) and (C) CEUS showed a central enhancing foci in the arterial phase and followed by a centrifugal enhancemen Subtypes of atypical hepatic hemangioma Subtypes of atypical appearance of hepatic hemangiomas are listed as follow: Giant hepatic hemangioma- may contain areas of central necrosis/liquefaction, hemorrhage, peripheral calcification, fibrosis, and thrombosis, resulting in heterogeneous appearance and incomplete enhancement, even on very delayed imaging. Flash filling hepatic hemangioma: make up to 16% of all hepatic hemangiomas. On ultrasound, most are hyperechoic - same as the typical hemangiomas. During CEUS these lesions show rapid, homogeneous hyperenhancement followed by hyper/ isoenhancement relative to the adjacent liver due to the retention of contrast until the late phase without washout. Calcified hepatic hemangioma Hyalinised/sclerosed hepatic hemangioma- are a rare variant of hepatic hemangioma. Because of their unusual imaging features, they cannot be reliably differentiated from a malignant tumor without a biopsy. Liver capsular retraction is a common feature of these lesions. other unusual imaging patterns o hepatic hemangioma with capsular retraction o hepatic hemangioma with surrounding regional nodular hyperplasia o hepatic hemangioma with fatty infiltration o pedunculated hepatic hemangioma o cystic hepatic hemangioma: rare o fluid-fluid level containing hepatic hemangioma: rare Flash filling hepatic hemangioma Atypical hemangioma due to hepatic steatosis References https://radiopaedia.org/articles/hepatic-haemangioma-3?lang=us https://radiopaedia.org/cases/flash-filling-hepatic-haemangioma-3 https://www.ncbi.nlm.nih.gov/pmc/articles https://journals.sagepub.com/doi/10.1177/8756479317701965?icid=int.sj-fulltext.similar-articles https://radiopaedia.org/cases/hepatic-haemangioma-atypical-due-to-hepatic-steatosis-
