Clinical history: 13 year old girl with a back mass.
MRI shows enhancing serpiginous vessels in the subcutanous fat, extending into muscle, consistent with a vascular malformation. Classification of the vascular malformation is important, because it affects treatment.
Vascular malformations are named after the types of abnormal vessels that they contain (arteries, veins, or lymphatics). In this case, there is no non-enhancing fluid filled component to suggest lymphangioma. There are no arterial flow voids, enlarged feeding artery, or enlarged draining vein to suggest an arteriovenous malformation. There is no soft tissue component to suggest hemangioma. This lesion consists of abnormal veins, and is consistent with a venous malformation (formerly called cavernous hemangioma). Phleboliths are pathognomonic for venous malformations. There is a possible phlebolith here.
Venous malformations and lymphangiomas can be treated using percutaneous sclerotherapy. (In contrast, soft tissue AVMs -- which are rare -- are typically treated by carefully embolizing the feeding artery using ethanol.)
First, we injected contrast directly into the venous malformation. This showed the venous drainage of the lesion.
Next, we used forceps to press on and occlude the venous drainage from the venous malformation, and injected sclerosant directly into the lesion. In this case, we used a sclerosing foam made from sodium tetradecyl (a detergent) and ethiodol.