What is the typical appearance of a hemangioma on ultrasound?

Ultrasound Appearance of Hemangiomas

On ultrasound, hemangiomas typically present as well-defined, hyperechoic (bright) lesions with peripheral nodular enhancement in the arterial phase and progressive centripetal filling on contrast-enhanced studies. 1

Characteristic Ultrasound Features

B-mode (Conventional) Ultrasound:

• Most common pattern (70-80%): Well-defined, uniformly hyperechoic lesion with rounded margins 2, 1
• Less common patterns:
  • Complex pattern with mixed echogenicity (seen in larger hemangiomas) 2
  • Cystic or anechoic appearance with distal enhancement (mimicking cysts) 2

Contrast-Enhanced Ultrasound (CEUS):

• Arterial phase: Peripheral nodular enhancement (key diagnostic feature) 3, 1
• Portal venous phase: Progressive centripetal filling ("filling-in" pattern) 3
• Late phase: Complete or near-complete filling with contrast retention 3
• Sensitivity: 80-90% for correct characterization of hemangiomas 1

Size-Based Variations

• Small hemangiomas (<3 cm):

  • Usually uniformly hyperechoic 2
  • May show rapid filling on CEUS (high-flow variants) 3

• Medium hemangiomas (3-10 cm):

  • May show more heterogeneous echogenicity 3
  • Classic peripheral nodular enhancement pattern more evident 1

• Giant hemangiomas (>10 cm):

  • Often have complex or mixed echo patterns 4
  • May show incomplete late filling due to internal scarring or hemorrhagic regions 3

Diagnostic Pitfalls and Caveats

• High-flow hemangiomas can show rapid enhancement that may be confused with hepatocellular carcinoma or focal nodular hyperplasia if the nodular pattern and centripetal direction are not recognized 3

• Atypical features can be found in both small (15-40 mm) and large (>4 cm) hemangiomas 3

• Incomplete filling in late phase, especially in larger hemangiomas, due to focal scarring or hemorrhagic regions 3

• Diagnostic accuracy: CEUS correctly characterizes 80-90% of hemangiomas, but MRI may be complementary in uncertain cases 1

When to Consider Additional Imaging

• When the ultrasound appearance is atypical or uncertain, especially in:

  • Patients with underlying malignancy
  • Patients with liver cirrhosis
  • Lesions showing growth over time 5

• The American College of Radiology recommends ultrasound as the initial imaging modality when the diagnosis is uncertain, avoiding unnecessary radiation exposure and sedation 3

Clinical Relevance

• Most hemangiomas (especially those <5 cm) remain stable in size and echo pattern over time 4
• Only hemangiomas >5 cm typically cause symptoms 4
• Prolonged follow-up of small and medium-sized hemangiomas with typical appearance is generally not warranted 4

Understanding the characteristic ultrasound appearance of hemangiomas is essential for accurate diagnosis and to avoid unnecessary invasive procedures like biopsy, which carries a risk of bleeding in these highly vascular lesions 1.