Answer for BIR CoW 03 Oct 2021
Choroidal hemangioma
Findings
T1 hyperintense / T2 isointense lesion noted in the superior aspect of right orbit predominantly involving the choroidal layer. The lesion shows avid enhancement on contrast. Patchy enhancement noted in retrobulbar portion of right optic nerve. Impression: Features suggestive of Right choroidal hemangioma.
Discussion
These congenital vascular hamartomas typically manifest in middle-aged or elderly people (age range, 7–58 years) . The solitary or circumscribed choroidal hemangioma is a benign vascular neoplasm that is confined to the choroid, has distinct margins, and is typically located posterior to the equator of the globe .In contrast, the diffuse hemangiomas that occur in Sturge-Weber syndrome not only involve the choroid but also may involve the ciliary body, iris, and, occasionally, nonuveal tissues including the episclera, conjunctiva, and limbus. Both types of choroidal hemangiomas are stable lesions with little or no tendency to enlarge. The clinical appearance of the circumscribed choroidal hemangioma is that of a smoothly elevated, slightly dome-shaped, reddish-orange choroidal mass that blends with the surrounding choroid. At times, these lesions can barely be distinguished from the choroidal background. Choroidal hemangiomas are classified histologically as capillary, cavernous, or mixed. Asymptomatic circumscribed choroidal hemangiomas do not require treatment unless retinal detachment occurs. In cases of retinal detachment, the most widely accepted form of treatment is laser photocoagulation. CT is useful for diagnosis, but MR imaging is considered to provide depiction superior to that of CT .At CT, circumscribed choroidal hemangiomas in the absence of retinal detachment appear as ill-defined masses that exhibit intense enhancement after the administration of contrast material. At MR imaging, the lesions are more clearly depicted: Most have a lenticular shape with a maximal diameter of 3–11 mm (average, 7.5 mm) and signal that is hyperintense to that of vitreous on T1-weighted images, although some lesions may appear isointense to vitreous. On T2-weighted fast spin-echo images, the signal is typically hyperintense, usually appearing isointense to that of vitreous. The lesions enhance intensely after the administration of contrast material .Clinically, a circumscribed choroidal hemangioma may be confused with a uveal melanoma; however, the isointensity of the signal in a choroidal hemangioma to that of vitreous fluid on T2-weighted fast spin-echo MR images is an important imaging feature that permits differentiation between the two lesions. Diagnostic specificity of 93% and sensitivity of 96% with unenhanced MR imaging have been reported .The additional use of contrast-enhanced dynamic MR imaging resulted in reported sensitivity of 100% and specificity of 88% for differentiation between the two lesions.
References:
MullikenJB, Glowacki J. Hemangiomas and vascular malformations in infants and children: a classification based on endothelial characteristics. Plast Reconstr Surg1982; 69: 412–422. ForbesG. Vascular lesions in the orbit. Neuroimaging Clin N Am1996; 6: 113–122. Medline, Google Scholar RootmanJ. Vascular malformations of the orbit: hemodynamic concepts. Orbit2003; 22: 103–120. Crossref, Medline, Google Scholar BilaniukLT. Vascular lesions of the orbit in children. Neuroimaging Clin N Am2005; 15: 107–120. Crossref, Medline, Google Scholar
Findings
T1 hyperintense / T2 isointense lesion noted in the superior aspect of right orbit predominantly involving the choroidal layer. The lesion shows avid enhancement on contrast. Patchy enhancement noted in retrobulbar portion of right optic nerve. Impression: Features suggestive of Right choroidal hemangioma.
Discussion
These congenital vascular hamartomas typically manifest in middle-aged or elderly people (age range, 7–58 years) . The solitary or circumscribed choroidal hemangioma is a benign vascular neoplasm that is confined to the choroid, has distinct margins, and is typically located posterior to the equator of the globe .In contrast, the diffuse hemangiomas that occur in Sturge-Weber syndrome not only involve the choroid but also may involve the ciliary body, iris, and, occasionally, nonuveal tissues including the episclera, conjunctiva, and limbus. Both types of choroidal hemangiomas are stable lesions with little or no tendency to enlarge. The clinical appearance of the circumscribed choroidal hemangioma is that of a smoothly elevated, slightly dome-shaped, reddish-orange choroidal mass that blends with the surrounding choroid. At times, these lesions can barely be distinguished from the choroidal background. Choroidal hemangiomas are classified histologically as capillary, cavernous, or mixed. Asymptomatic circumscribed choroidal hemangiomas do not require treatment unless retinal detachment occurs. In cases of retinal detachment, the most widely accepted form of treatment is laser photocoagulation. CT is useful for diagnosis, but MR imaging is considered to provide depiction superior to that of CT .At CT, circumscribed choroidal hemangiomas in the absence of retinal detachment appear as ill-defined masses that exhibit intense enhancement after the administration of contrast material. At MR imaging, the lesions are more clearly depicted: Most have a lenticular shape with a maximal diameter of 3–11 mm (average, 7.5 mm) and signal that is hyperintense to that of vitreous on T1-weighted images, although some lesions may appear isointense to vitreous. On T2-weighted fast spin-echo images, the signal is typically hyperintense, usually appearing isointense to that of vitreous. The lesions enhance intensely after the administration of contrast material .Clinically, a circumscribed choroidal hemangioma may be confused with a uveal melanoma; however, the isointensity of the signal in a choroidal hemangioma to that of vitreous fluid on T2-weighted fast spin-echo MR images is an important imaging feature that permits differentiation between the two lesions. Diagnostic specificity of 93% and sensitivity of 96% with unenhanced MR imaging have been reported .The additional use of contrast-enhanced dynamic MR imaging resulted in reported sensitivity of 100% and specificity of 88% for differentiation between the two lesions.
References:
MullikenJB, Glowacki J. Hemangiomas and vascular malformations in infants and children: a classification based on endothelial characteristics. Plast Reconstr Surg1982; 69: 412–422. ForbesG. Vascular lesions in the orbit. Neuroimaging Clin N Am1996; 6: 113–122. Medline, Google Scholar RootmanJ. Vascular malformations of the orbit: hemodynamic concepts. Orbit2003; 22: 103–120. Crossref, Medline, Google Scholar BilaniukLT. Vascular lesions of the orbit in children. Neuroimaging Clin N Am2005; 15: 107–120. Crossref, Medline, Google Scholar
Note:
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!