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The Not So Incidental Finding: A Cavernous Hemangioma

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Title: The Not So Incidental Finding: A Cavernous Hemangioma
Authors: Christopher D. Conrady, MD, PhD, Jun Guan, MD, H. Christian Davidson, MD, and Bhupendra Patel, MD
Date: 09/28/2015
Keywords/Main Subjects: Cavernous hemangioma; Orbit; Orbital mass; Proptosis

Secondary CORE Category: Orbit, Eyelids and lacrimal System / Orbital Neoplasms and Malformations / Vascular Tumors, Malformations, and Fistulas
Diagnosis/Differential Diagnosis: cavernous hemangioma
Description: Thirty-one-year-old female with past medical history significant for a traumatic brain injury, von Willebrand disease, and migraines, that presented to an outside ophthalmologist with recurrent headaches and “sparkles within her vision.”. She was noted to have a normal exam, including dilated fundus exam, with one exception, mild disk edema of the left optic nerve. Humphrey visual fields were normal. The patient was referred for imaging due to a change in headaches and associated visual symptoms not typical of prior migraines. MRI of the orbits identified a well-circumscribed mass within the left orbit abutting the globe (Figure 1).
The patient was referred to the oculoplastics service at the Moran for further evaluation and treatment due to concern of optic nerve compression with edema on exam. She was found to 20/15 vision, pupils were equal and reactive without relative afferent defect, extraocular motility full, and color vision was normal OU. However, there was noticeable periorbital asymmetry with increased fullness of the left lateral orbit compared to right and left-sided proptosis of 1.5 mm.
Due to concern of optic nerve changes, the patient underwent an anterior orbitotomy with complete resection of the orbital mass without complications. Histopathological specimens were consistent with an orbital cavernous hemangioma with a pseudocapsule and large vascular spaces lined with endothelium (Figure 2). The patient made a quick and full recovery with a resolution of symptoms.
Images:

Conrady_20295_Figure_1_Moran_CORE_20295

Figure 1: Well-circumscribed left orbital mass on MRI of the orbits.  (a) Axial MRI of the orbits with contrast with large, well-circumscribed, enhancing lesion of the left orbit.  (b)  Time course of enhancement showing fill-in of lesion.  Radiographic findings are typical for cavernous hemangioma.

Conrady_20295_Figure_2_Moran_CORE_20295

Figure 2: Cavernous hemangioma on histopathology.  (a) Gross surgical specimen of the cavernous hemangioma.  H&E staining was then performed for further evaluation with (b) 20x, (c) 40x, and (d) 100x images.  Pseudocapsule and vascular spaces lined with endothelium are noted.

Summary of Case:

  1. Consider cavernous hemangiomas in both men and women with painless, unilateral proptosis in the 3rd to 5th decade of life.
  1. Use imaging to help aide in diagnosis as carvernous hemangiomas are well-circumscribed intraconal masses of which 90% can be diagnosed pre-operatively.
  2. Multiple emerging ways to access orbital tumors that decrease post-operative morbidity.
  3. Hormones (i.e. pregnancy and menopause) may influence size of lesion but no known factors predictive of growth.
  4. Presenting symptoms: Eyeball protrusion (90%), visual impairment (65%), double vision (20%), local Pain (18%), headache (12%), eyelid fullness/swelling (5%).
  5. For more details on the case, please see associated PowerPoint Presentation.

 

Format: PowerPoint presentation

References:

  1. Di Tomasso et al., Progesterone receptor expression in orbital cavernous hemangioma. Virchows Arch. 2000.
  1. Fries and Char, Bilateral orbital cavernous hemangioma.  Br. J. Ophtho.  1988.
  2. Goldberg et al., Orbital Tumors Excision without bony marginotomy under local and general anesthesia.  J. Ophtho.  2014.
  3. Hsu and Hsu, Cavernous Hemangioma of the Orbit: 42 patients.  J. Exp and Clinc Med, 2011.
  4. Jayaram et al., Potential correlation between menopausal status and the clinical course of orbital cavernous hemagniomas.  Optho Plast Recon Surg.  2015.
  5. Paluzzi et al., “Round-the-Clock” Surgical Access to the Orbit.  J. Neurol Surg, 2015
  6. Som and Curtin., Head and neck imaging. Mosby. ISBN: 0323009425

 

Faculty Approval by: Dr. Bhupendra Patel, MD

Identifier: Moran_CORE_20295

Christopher D. Conrady, ©2015. For further information regarding the rights to this collection, please visit: http://morancore.utah.edu/terms-of-use/

Disclosure: The authors have no financial conflicts of interest.