Multimodal Management of an Aggressive Vertebral Hemangioma in a Child with Neurological Deficit: A Case Report with 5-Year Follow-Up.
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INTRODUCTION: Aggressive vertebral hemangiomas (AVHs) are rare benign vascular lesions that can exhibit locally destructive behavior and cause epidural extension, spinal cord compression, and neurological deterioration. Pediatric AVHs are particularly uncommon, and there is no established consensus on the optimal treatment strategy. To our knowledge, this is one of the few reported pediatric cases of a neurologically symptomatic aggressive thoracolumbar vertebral hemangioma managed with a multimodal strategy and followed for 5 years. This case is important because it demonstrates that effective neurological recovery and durable local control can be achieved without radical en bloc resection. CASE REPORT: A 12-year-old girl presented with progressive lower limb sensory disturbance, followed by bilateral weakness, gait imbalance, and night pain. Neurological examination revealed an ataxic high-stepping gait, bilateral lower limb weakness, bilateral foot drop, dermatomal sensory loss, brisk reflexes, clonus, and extensor plantar responses (Nurick grade 4). Imaging revealed an aggressive D12 vertebral hemangioma with characteristic corduroy and polka-dot appearances, cortical involvement, epidural extension, and significant spinal cord compression. Angiography revealed a hypervascular lesion predominantly supplied by the bilateral T12 posterior intercostal arteries. Superselective embolization was performed while preserving the anterior spinal artery. The patient subsequently underwent D12 vertebroplasty, laminectomy, bilateral transpedicular decompression, and D10-L2 posterior spinal fusion. Histopathological and immunohistochemical analyses confirmed the diagnosis of vertebral hemangioma. Adjuvant external beam radiotherapy was administered at 4000 cGy in 22 fractions. Neurological function progressively improved, with complete recovery within 3 months. At the 5-year follow-up, she remained neurologically normal, with no radiological evidence of recurrence. CONCLUSION: Pediatric AVH can cause rapid and severe neurological deterioration, requiring prompt multidisciplinary management. In this case, pre-operative embolization, vertebroplasty, decompression, stabilization, and adjuvant radiotherapy provided durable neurological recovery and disease control. This Case report highlights a potentially effective multimodal alternative to morbid radical resection in selected pediatric patients.