1. MedPix Medical Image Database COW - Case of the Week Case Contributor: Brittany Ritchie Affiliation: National Capital Consortium

2. MedPix No: 12635 - History Pt Demographics: Age = 38 y.o. Gender = woman 38 y/o woman to evaluate liver lesion. Downloaded by (-1)

3. MedPix No: 12635 - EXAM & LABS Normal AST, ALT, Alk Phos, and Total Bilirubin.

4. Hemangioma of Liver Non-contrast axial CT image of the liver demonstrating a large hypoattenuating lesion in the peripheral subcapsular right lobe of the liver. Downloaded by (-1)

5. Liver Hemangioma During the arterial phase of contrast enhancement there is peripheral puddling of contrast (nodular enhancement). Downloaded by (-1)

6. Hepatic Hemangioma Dynamic enhanced images in portal venous phase demonstrating shows progressive discontinuous peripheral puddling of contrast enhancement. Downloaded by (-1)

7. Hemangioma Contrast enhanced axial CT image of the liver in portal venous phase demonstrating a large hypodense lesion in the right lobe of the liver with progressive discontinuous peripheral puddling of contrast enhancement. Downloaded by (-1)

8. Hemangioma Contrast enhanced axial CT image of the liver in portal venous phase demonstrating a large hypodense lesion in the right lobe of the liver with progressive discontinuous peripheral puddling of contrast enhancement. Downloaded by (-1)

9. Hemangioma of the liver Delayed images from the dynamic contrast enhanced axial CT shows *fill=in* of the lesion. Downloaded by (-1)

10. FINDINGS Discontinuous peripheral pooling of contrast enhancement in the arterial phase with progressive filling seen in the portal venous phase and prolonged enhancement of the lesion in delayed images on a three phase enhanced liver CT.

11. DIFFERENTIAL DIAGNOSIS What is your Differential Diagnosis? DDX of hypodense liver lesion: - Cavernous hemangioma - Metastatic disease - HCC - Focal Nodular Hyperplasia - Hepatic cyst - Fibrolamellar Carcinoma - Lymphoma - Hepatic Adenoma -

12. Diagnosis: Liver Hemangioma Dx Confirmed by: Imaging is diagnostic. No further confirmation required.

13. DISCUSSION NOTE: These are dynamic enhanced images that confirm benign hemangioma. The discontinuous peripheral pooling of contrast enhancement in the arterial phase - followed by progressive filling seen in the portal venous phase - with prolonged enhancement of the lesion on the delayed images - is classic for hemangioma.