Aggressive thoracic vertebral hemangioma managed with preoperative embolization and surgical decompression: A case report

A 24-year-old male presented with a 3-month history of progressive spastic paraparesis (Frankel grade B) secondary to a T9 aggressive vertebral hemangioma (AVH) with epidural extension and spinal cord compression, displaying the characteristic polka-dot and corduroy signs on computed tomography. Spinal digital subtraction angiography confirmed marked hypervascularity predominantly supplied by the right T9 intercostal artery. Selective injection of the left T9 intercostal artery opacified an ipsilateral posterior spinal artery, contraindicating embolization on that side. Preoperative embolization was therefore limited to the right-sided feeders, using calibrated microspheres (Hydropearls 400 µm, Terumo, Tokyo, Japan) for distal occlusion followed by coil deployment for proximal hemostasis. Subsequent T9 laminectomy with posterior instrumentation and fusion resulted in low intraoperative blood loss (400 mL) with no complications. Histopathological examination confirmed a benign vascular proliferation consistent with vertebral hemangioma, with no signs of malignancy. Neurological status improved to Frankel grade D. This case illustrates that meticulous angiographic evaluation and selective unilateral embolization can achieve safe and effective hemostasis in compressive AVH when radiculomedullary arteries are identified.