Diagnosis and surgical decision-making in hepatic hemangioma: From venous malformation overlap to artificial intelligence-assisted multimodality imaging

Table 3 Common mimics that should not be prematurely labeled as hepatic hemangioma

Mimic	Typical ultrasound/CEUS pattern	Typical CT/MRI pattern	Clue arguing against classic HH
Focal nodular hyperplasia	May be iso- or mildly hyperechoic; spoke-wheel vascularity can be present	Homogeneous arterial enhancement; often iso/hyperintense on hepatobiliary phase	Presence of functioning hepatocytes and hepatobiliary phase uptake argues against HH
Hepatocellular carcinoma	Variable; often not classically hyperechoic in cirrhosis	Arterial phase hyperenhancement with washout/capsule; diffusion restriction more common	Cirrhotic background, washout, growth, and capsule should override a hemangioma default assumption
Hypervascular metastasis	Often multiple; CEUS may show rim or targetoid enhancement	Ring-like or targetoid arterial enhancement, lower T2 signal, restricted diffusion, no progressive blood-pool matching	Known malignancy, multiplicity, interval growth, and ring enhancement make HH less likely

HH: Hepatic hemangioma; CT: Computed tomography; MRI: Magnetic resonance imaging; CEUS: Contrast-enhanced ultrasound.