What is the recommended management for a newborn with a sacral hemangioma?

Management of Newborn Sacral Hemangioma

Newborns with sacral hemangiomas require urgent evaluation by a hemangioma specialist to screen for underlying spinal dysraphism and structural anomalies (LUMBAR syndrome), with MRI imaging of the spine indicated for segmental lumbosacral lesions, followed by oral propranolol 2 mg/kg/day divided into three doses if the lesion is high-risk for ulceration or disfigurement. 1

Risk Stratification for Sacral Location

Sacral hemangiomas fall into a high-risk category that demands immediate attention:

• Segmental lumbosacral hemangiomas carry significant risk of underlying structural anomalies, particularly spinal dysraphism (myelopathy), which is the most common extracutaneous anomaly associated with this location 1
• Perineal and perianal hemangiomas have increased risk of ulceration, especially when segmental in distribution 1, 2
• These lesions may be associated with LUMBAR syndrome (lower body hemangioma, urogenital anomalies, ulceration, myelopathy, bony deformities, anorectal malformations, arterial anomalies, and renal anomalies) 1

Immediate Evaluation Steps

Specialist Referral

• Facilitate evaluation by a hemangioma specialist as soon as possible after identifying a sacral hemangioma as high-risk 1
• The time frame "as soon as possible" is intentionally emphasized because the window for optimal intervention is narrow—ideally by 1 month of age, when early IH growth accelerates between 5-7 weeks 1
• Office staff should be educated to give young infants with high-risk IHs priority appointments 1
• Telemedicine consultation can assist with triage if in-person evaluation cannot be arranged promptly 1

Imaging Evaluation

• MRI with contrast is indicated for lumbosacral lesions to evaluate for potential spinal involvement and structural anomalies 3, 4
• Ultrasonography with Doppler is the initial imaging modality when the diagnosis of IH is uncertain, as it requires no sedation and no radiation exposure 1, 3
• MRI is specifically reserved for deep structures and lumbosacral lesions with potential spinal involvement 3, 4

Treatment Algorithm

For High-Risk Sacral Hemangiomas Requiring Intervention

First-Line Pharmacologic Therapy:

• Oral propranolol 2 mg/kg/day divided into three doses is the first-line treatment for infantile hemangiomas requiring intervention 3, 4
• Propranolol should be started in a clinical setting with cardiovascular monitoring every hour for the first 2 hours 3
• Early pharmacotherapy with propranolol may prevent ulceration in perineal hemangiomas 4
• Treatment should be initiated during the proliferative phase for best therapeutic effect, ideally leading to complete or near-complete regression within 6 months 5, 2

Special Initiation Considerations for Newborns:

• Initiate propranolol as an inpatient in infants under 8 weeks of age, postconceptional age under 48 weeks, or presence of cardiac/respiratory risk factors 3
• This is particularly relevant for newborns with sacral hemangiomas who will often be under 8 weeks at presentation 3

Combination Therapy Option:

• Topical timolol 0.5% gel-forming solution may be added to systemic propranolol for combination therapy, particularly for superficial components 4, 5
• One case report demonstrated satisfactory outcomes using combination systemic propranolol and topical timolol for lumbo-sacral infantile hemangioma 5

For Low-Risk Small Sacral Lesions

• Small lesions on the torso that are not segmental are lower risk, less likely to be disfiguring, and typically do not require active intervention 1
• Observation with regular monitoring to assess growth and potential complications is appropriate for non-problematic lesions 3, 4

Additional Evaluations Required

• Screen for structural anomalies including spinal dysraphism, urogenital anomalies, anorectal malformations, and renal anomalies in all segmental lumbosacral hemangiomas 1, 3
• If multiple cutaneous hemangiomas are present (≥5), screen for hepatic involvement with ultrasonography 3, 4
• Thyroid hormone screening is necessary if multifocal or significantly diffuse hemangiomas are present, as the tumor may inactivate thyroid hormone 3, 4

Critical Pitfalls to Avoid

• Do not adopt a "wait-and-see" approach for segmental lumbosacral hemangiomas—this can result in missed opportunities to prevent adverse outcomes including permanent disfigurement from ulceration and delayed diagnosis of spinal anomalies 1
• Do not delay imaging evaluation—structural anomalies require early identification, and the proliferative phase (peak growth 5-7 weeks) occurs rapidly 1
• Do not confuse infantile hemangiomas with vertebral hemangiomas—the latter are distinct entities that do not involute spontaneously and do not respond to propranolol 3
• Do not start propranolol without cardiovascular monitoring in the outpatient setting for newborns, as infants under 8 weeks require inpatient initiation 3

Surgical Considerations

• Surgical resection should generally be delayed until after infancy to allow for natural involution and better outcomes 3, 4
• Resection during infancy carries higher risk of anesthetic morbidity, blood loss, and iatrogenic injury 3, 4
• Optimal timing for surgical intervention, if needed, is before 4 years of age, as most hemangiomas do not improve significantly after this age 3, 4