Distinguishing of vertebral haemangioma in sacral vertebrae by CT ore MRI in some cases is very difficult.
MRI - T1/T2/STIR will detect fat rich as well as fat poor hemangioma.
Also in my opinion MRI is surely the best imaging technique for this aim; CT surely doesn't help, whereas PET might be considered only in the suspicion of a malignant lesion at MRI.
Actually, vertebral hemangiomas can be diagnosed on CT. However, since MRI of the spine has become so much more common than CT of the spine, you are more likely to see a vertebral hemangioma on an MRI. On an MRI, its a combination of a T1-hyperintense and T2-hyperintense lesion, because it contains both fat and slow-flowing blood (essentially fluid). Atypical hemangiomas may not have enough fat to demonstrate T1 hyperintensity, and may need follow-up MRI, or limited CT. PET would be reserved for rare cases, such as an atypical hemangioma that appears to change slightly between scans, or a hemangioma in a patient with neoplasm, but no other spine lesion, such that the definitive diagnosis would change management.
Not sure about the exact nature of the question. Why are you looking for a sacral hemangiomas ? MR is sensitive for demonstrating hemangiomas, but fat islands and metastatic melanomas may be bright on T1 images.
To distinguish a fat or non fat containing hemangioma, be sure to include fat suppressing sequences on mri exam..typically short tau inversion recovery. Susceptibility weighed are useful too...regards.
I would also recommend Tc-99m RBC scintigraphy which is reported to show the vertebral hemangiomata in several case reports
I also consider that MRI technique is the best imaging method to distinguish Haemangioma in cases for typically Haemangioma. In cases of atypically haemangioma is very difficult to conclude for presence of haemangioma and to exclude malignant process. Bone Tc-99 RBC scintigraphy also is insufficient for determination of haemangioma, but will exclude primary and secondary malignant deposites in bones. In this cases I consider that biopsy under CT control is necessary to make definitive diagnosis.
MRI would be ideal for a typical haemangioma which would be bright on T1/T2. CT may show it as well, with trabecular thickening and a "polka dot" appearance, but it won't be as definite. I have not used PET for this purpose.
Based on my experience I believe MRI is best method to start with, and if MRI shows hyperintense signal on T2 and hypointense signal on T1, we can add CT scan
18-FDG PET-CT scan often shows uptake by atypical hemangioma of vertebrae and is non-specific. MDP Bone Scan with SPECT-CT is also non-specific, more frequently showing a hot spot due to associated micro-fractures and reactive bone formation, but may appear as cold focus too. RBC-Blood pool scan is rarely conclusive in atypical hemangioma, though it is a good tool is diagnosing other hemangioma. MRI is the best, though occasionally quite confusing with variable patterns. CT scan is most of the time inconclusive.
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