Classification and ultrasound findings of vascular anomalies in pediatric age: the essential

Fig. 5
Infantile hemangioma. Spectral analysis shows arterial flow 
with low resistance and high velocities
Fig. 6
Rapidly involuting congenital hemangioma (RICH) in 2-day-
old boy (same case as of Fig. 
8
). Newborn with congenital vascular 
tumor in the occipital region. Biopsy confirmed the diagnosis

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Journal of Ultrasound (2019) 22:13–25 
1 3
hemangioma
(RICH) and in 
non
-
involuting congenital 
hemangioma
(NICH). The RICH shows regression by 
about 14 months, unlike infantile hemangioma whose 
regression is slower and can even occur over several years 
[
22
].
On the contrary, the NICH does not show involution and 
tends to grow with the child [
23
, 
26
, 
27
]. This behavior is 
very similar to the natural history of vascular malformations.
More recently, a third category has been hypothesized 
called 
partially involutive congenital hemangioma
(PICH) 
[
12
], as it is easy to imagine these lesions showing a first 
involutive phase, similar to the RICH, but at some point the 
involution stops and these lesions assume the same behavior 
of the NICH [
9
, 
28
].
Congenital hemangioma is much less common than infan-
tile hemangioma. It is generally solitary and occurs with 
more frequency at the level of the head and limbs near the 
joints [
29
].
Sometimes it is not possible, on the basis of clinical his-
tory alone and of the instrumental finding, to make a differ-
ential diagnosis between infantile hemangioma and congeni-
tal hemangioma. If a diagnosis is necessary, it is possible 
to distinguish the two lesions on the basis of immunohisto-
chemistry with the GLUT 1 research (the infant hemangioma 
is positive for GLUT 1, while the congenital hemangioma 
is negative for GLUT 1). The ultrasound and color Doppler 
findings can be very similar to what is found in infantile 
hemangioma; however, it is possible to identify some ele-
ments more often present in the congenital form [
7
, 
12
, 
24
, 
26
, 
27
, 
30
, 
31
].
Congenital hemangioma B-mode ultrasound is more 
inhomogeneous than infantile hemangioma. It is often possi-
ble to identify vascular structures of relatively high diameter 
that well distinguishable in the lesion (Fig. 
7
) in comparison 
to the infantile hemangioma whose vascular structures are of 
smaller caliber and difficult to distinguish in grayscale. The 
calcifications are not common but when present they aid in 
distinguishing the congenital hemangioma from the infantile 
hemangioma, where the calcifications are very rare (Fig. 
8
).
The color Doppler vascular density is very high for 
congenital hemangioma, similar to that of infantile 
hemangioma, with arterial flows at high velocities and 
low resistance (Fig. 
9
). However, the venous vascular sig-
nal is more frequently seen as compared to the infantile 
form. In some cases, the venous flow tends to be pre-
dominant and often corresponds to the larger vessels seen 
at the B-mode that represent dysplastic veins that cross 
the lesion transversely. Moreover, it is possible to detect 
the presence of arteriovenous MicroShunt with turbulent 
flow on the spectral examination, particularly frequent 
Fig. 7
Rapidly involuting congenital hemangioma (RICH) in 
1-month-old boy. Sonogram shows heterogeneous subcutaneous mass 
that contains large visible vessel (arrow)
Fig. 8
Rapidly involuting congenital hemangioma (RICH) in 2-day-
old boy. Sonogram shows heterogeneous subcutaneous mass with 
intralesional calcification (arrow) and large visible vessel (arrowhead)
Fig. 9
Rapidly involuting congenital hemangioma (RICH) in 
1-month-old boy. Color Doppler shows high vascular density, and 
spectral analysis shows the presence of low resistance arterial flow

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Journal of Ultrasound (2019) 22:13–25
1 3
in the NICH. Finally, the possible presence of thrombi 
in the larger venous vessels has been described, and this 
characteristic is never present in infantile hemangioma.