Hemorrhage in Congenital Hemangioma: A Rare but Serious Complication

Meryem Sassi I^1*, Hamza Naouli², Samir El Youbi Hamid Jiber², Abdellatif Bouarhroum²

Feb 26, 2025

Abstract

We report the case of a 16-year-old male admitted to the emergency department in hemorrhagic shock due to severe bleeding from a cutaneous hemangioma. The patient was stabilized with resuscitation measures. A detailed clinical examination and imaging assessment, including Doppler ultrasound and emergency arteriography, revealed a Rapidly Involuting Congenital Hemangioma (RICH) located on the left knee. Given the vascular anatomy and high-flow characteristics of the lesion, partial embolization was performed to control the bleeding. The patient’s recovery was favorable, with complete ulceration healing observed within one month.

Case Presentation

A 16-year-old male was admitted to the emergency department in a state of hemorrhagic shock caused by profuse bleeding from a cutaneous hemangioma (Figure A). Initial management involved resuscitation with intravenous fluids and blood transfusions to stabilize hemodynamics. Physical examination revealed a well-defined, bluish-colored tumor with a telangiectatic surface at the level of the left knee. The lesion was non-pulsatile, measuring 9 × 8 cm, with a central ulceration and crust detachment, actively bleeding at the time of admission (Figure B). A Doppler ultrasound was performed, revealing a heterogeneous, well-vascularized tissue mass with rapid arterial flow, highly suggestive of a RICH. To further evaluate the vascular supply, an emergency arteriography was conducted via the left femoral artery, demonstrating two distinct vascular territories within the hemangioma (Figure C):

Upper territory (subcutaneous, anterior aspect of the lower third of the thigh): Supplied by a large branch of the deep femoral artery and three muscular branches from the trunk of the superficial femoral artery.

Lower territory (subcutaneous, anterior aspect of the upper third of the leg): Supplied by arterial branches from the lower third of the superficial femoral artery, an articular branch from the popliteal artery, and a recurrent branch from the anterior tibial artery.

Venous drainage was observed along the superficial femoral vein. Given the risk of continued hemorrhage due to high vascular flow, a decision was made to perform partial embolization, aimed at reducing hemodynamic pressure within the venous drainage system and achieving hemostasis (Figure D). The intervention was successful, with no further bleeding episodes. The patient was monitored closely, and within one month, the ulceration completely healed. The patient reported no functional limitations, and follow-up imaging confirmed progressive involution of the lesion.

Discussion

Capillary Hemangiomas (HCs) are rare congenital vascular tumors that lack postnatal growth and have no gender predominance. Unlike Infantile Hemangiomas (IH), which proliferate after birth, HCs are fully developed in utero. Most cases have a favorable prognosis, and severe hemorrhagic

Complications are uncommon due to the predominantly superficial vascular architecture. One predictive factor for hemorrhagic risk is the presence of a Rapidly Involuting Congenital Hemangioma (RICH) with an ulcerated, crusted surface located on the limbs, particularly the thigh. These lesions often have high-flow arterial supply, predisposing them to significant bleeding. In such cases, early imaging—Doppler ultrasound, magnetic resonance imaging, or angiography—is critical for assessing vascular involvement and guiding management. Urgent intervention is necessary for hemorrhagic RICHs, and vascular embolization remains a preferred treatment strategy. In our patient, partial embolization effectively controlled the bleeding while allowing the lesion to continue its natural involution.

Conclusion

This case highlights the importance of early recognition and intervention in ulcerated RICHs presenting with hemorrhage. Doppler ultrasound and arteriography play crucial roles in the diagnostic and therapeutic approach. Vascular embolization is an effective and minimally invasive technique for managing life-threatening bleeding from congenital vascular lesions[1].

References

• 1. Hémorragie dans l’hémangiome congénital: complication rare mais grave R. Chaabouni, F. Frikha, E. Bahloul, K. Sellami, M. Amouri, H. Turki. Annales de dermatologie et de venerologie volume 146, Issue 12, Suplement, December 2019, pages A190-A191.