Hemangiomas: 
Infantile hemangiomas: 

• Present between 2 weeks and 2 months of life, rapid proliferation during first 9 months, gradual involution until 3.5 years
• Treatment: 
• Observation: total involution of hemangiomas occur in 50% by age 5, 70% by age 7 and 90% by age 9 
• Propranolol 
• Mechanism of action: blocks noradrenaline action on VEGF production 
• Adverse effects of propranolol: lethargy, hypotension, hypoglycemia, bradycardia
• Steroids: either oral steroids or intralesional steroids can arrest or slow growth of hemangiomas in the proliferative phase but will not impact involution 
• Laser: pulse dye Nd:YAG lasers are used for treating ulcerative lesions and for removing residual color from involuted hemangiomas 
• Surgery: 
• Usually reserved for older children after involution if there is still excess tissue 
• Special circumstances: surgery is performed in the proliferative phase if critical structures are threatened including visual obstruction, nasolaryngeal obstruction, or auditory canal obstruction 
• Special Circumstances: 
• Parotid tumor infantile hemangiomas frequently are wrapped in facial nerve and difficult to completely resect –> observe 
• Liver is the most common extracutaneous site
• Complications: 
• Bleeding: usually self limited 
• Ulceration: most common, but only occuring in <5% of patients 

Congenital Hemangiomas: 

• Definition: rare form of hemangioma that is present at birth
• Classification: 
• RICH (rapidly involuting congenital hemangioma) – rapidly involutes after birth 
• NICH (non-involuting congenital hemangioma) – stable over time, and often has a white grey rim
• Stains negative for GLUT-1

Kaposiform hemangioendothelioma: 

• Definition: hemangiomas or diffuse hemangiomatosis that is locally aggressive but not metastasize 
• Association: Kasabach-merritt syndrome  – profound thrombocytopenia due to platelets being trapped and destroyed within the hemangioma 
• Treat with chemotherapy and resection (vincrystine)

Syndromes Associated with Hemangiomas: 

• Mafucci syndrome: endochondromatosis associated with multiple cutaneous hemangiomas 
• Von hippel-lindau disease: hemangiomas of the retina, hemangioblastoma of the cerebellum, commonly associated with cysts of the pancreas, livers, adrenals and kidneys 
• PHACE syndrome: large facial hemangiomas associated with Posterior fossa malformations, Hemangiomas, Arterial anomalies, Coarctation of the aorta, Eye anomalies 

Other Vascular Malformations: 

• Port Wine Stain:
• Definition: capillary malformation most commonly seen on the face in the trigeminal nerve distribution 
• Treatment:
• Laser: use pulse dye laser and or Nd:YAG 
• Pharmacologic: imiquimod 
• Associated syndromes: 
• Sturge Webber: large facial port wine stain and leptomeningeal venous malformation and metal retardation 
• Klippel-Trenaunay Syndrome: extremity port wine stain overlying a deeper venous and lymphatic malformation. Associated with limb length discrepancy
• Parkes Weber: similar to Klippel Tranaunay Syndrom but with the presence of AV fistulas 

• Venous Malformation: 
• Presentation: blue or purple lesion that swell in the dependent position. These are often hormone sensitive and can grow during puberty and pregnancy 
• Treatment: 
• Sclerotherapy
• Laser if superficial or involving the skin 
• Surgical excision 

• AVM 
• Presentation: pulsatile high-flow lesion
• Diagnosis: MRI and angiography 
• Progression: can progress to an ulcerated, bleeding lesion that can lead to decompensated heart failure or destructive coagulopathy 
• Treatment: embolization and surgical resection with WLE because recurrence rates are high 

• Lymphatic Malformation: 
• Definition: formation of lymphatic vessels slow flow lesion. Most common on neck and axilla
• Treatment: 
• Sclerosis 
• Surgery 
• Complications: 
• Frequent infections requiring abx