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Orbital and Cranial Extension of an Intraosseous Cavernous Hemangioma

Bentivegna, Rocio M.D.; Espinoza, Gabriela M. M.D.

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Ophthalmic Plastic and Reconstructive Surgery: May/June 2020 - Volume 36 - Issue 3 - p e82
doi: 10.1097/IOP.0000000000001440
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A 68-year-old woman presented with a 1-year history of diplopia, discomfort, and pressure around her left orbit and forehead. She noted gradual painless left eye proptosis during the last 4 years. On examination, there was a 4-mm downward displacement of the left globe with 6 mm of relative proptosis (Fig. A). Her ocular exam was normal other than exotropia and limited upgaze. Magnetic resonance imaging (Fig. B,C) showed an expansive mass in the left frontal skull extending into the orbit, displacing the globe and the frontal lobe. Computed tomography revealed a well-circumscribed lesion with a honeycombed appearance (Fig. D). Fine needle aspiration was performed at time of presentation through a palpable orbital rim bony defect to facilitate timely diagnosis and treatment. The aspiration confirmed the vascular nature of the lesion, and cytology report was negative for malignancy. During subsequent stereotactic craniotomy surgery, the authors encountered a vascular intraosseous lesion with adherence to dura mater and brittle bone at the orbital rim (Fig. E). Loss of the orbital roof and superior orbital rim due to lesion invasion was also observed. Tissue sample confirmed the diagnosis of intraosseous cavernous hemangioma. Intraosseous cavernous hemangiomas involving the orbital bones with intracranial extension are exceedingly uncommon with only five previously reported cases. These lesions originate from the vessels in the diploic space and typically erode the outer table of the calvarium with rare involvement of the inner table. Surgical excision is the most common therapeutic treatment of this benign lesion.

Intraosseous orbital hemangioma. A, Clinical photograph demonstrating the left orbital asymmetry. B, MRI scan orbits, coronal section, reveal high signal on T2-weighted image. C, MRI scan orbits, sagittal section, reveal displacement of the orbital contents. D, CT scan orbits, axial section, reveal typical honeycombed appearance created by the pattern of bone trabeculation. E, Surgical specimen of the calvarium with dural adhesion and bone spicules visible.
© 2020 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.