Valsalva-manoeuvre or prone belly position for computed tomography (CT) scan when an orbita varix is suspected: a single-case study. Poster No.: C-0512 Congress: ECR 2012 Type: Authors: Keywords: DOI: Scientific Exhibit J. Bekker, H. Tanghe, A. Moelker; Rotterdam/NL Neuroradiology brain, Eyes, Vascular, CT, Diagnostic procedure, Varices 10.1594/ecr2012/C-0512 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 6
Purpose Timing is difficult especially when a CT-scan is combined with the valsalva-manoeuvre to raise intra-orbital pressure. Our purpose was to test the hypothesis that a prone belly position is better for the diagnosis of an orbital varix, and we performed a review of the literature. Methods and Materials A Valsalva-manoeuvre and a prone belly position were performed when an intraconal lesion was detected on a CT-scan with contrast. A literature search was performed in Pubmed. Results A sharply demarcated intense enhanced lesion, occurring in the distal portions of the superior ophthalmic vein, was detected with maximal diameters of 6x5 mm (Figure 1 and Figure 2) lateral from the medial rectus muscle in the right orbit and medial to the right eyeball, a so called intraconal orbital lesion. First a Valsalva-manoeuvre together with a CT-scan with contrast was performed which failed; the diameters did not change and the ophthalmic veins were not dilated. Secondly a CT-scan was performed in prone position and the diameters changed to 10x8 mm (Figure 3), diagnostic for an orbital varix. The orbital varix is a congenital venous malformation and the incidence is low. It usually occurs in the superior ophthalmic vein and less likely in the inferior ophthalmic vein. In exceptional cases such as exophthalmus, intermitted proptosis, retrobulbar pain or an episode of bleeding an excision is performed by the ophthalmic surgeon. Another symptom is enophthalmus caused by orbital fat-atrophy and volume loss of the varix. Manoeuvres such as coughing increase intra-orbital pressure causing the intermitted symptoms. Apart from a CT-scan an ophthalmic ultrasonography should be considered as a useful and patient friendly alternative with realtime images. Ultrasound shows a hypoechoic lesion with a low flow on Doppler, compatible with other venous varices. MR is also a method of choice in which flow in the varix presents as a low signal intensity detected on spin echo sequences and a variable signal intensity with blood products. Similar to a CT-scan with contrast there is intense enhancement of the orbital varix. The main differential diagnosis is a cavernous hemangioma. In most cases an expectative policy is followed [1-3]. Page 2 of 6
Images for this section: Fig. 1: Axial image of the orbita showing a well defined intraconal orbital lesion of 6x5mm. Page 3 of 6
Fig. 2: Coronal image of the orbita showing a well defined intraconal orbital lesion of 6x5mm. Page 4 of 6
Fig. 3: Coronal image in prone position with increased diameters of the intraconal lesion to 10x8mm. Page 5 of 6
Conclusion A CT-scan in prone belly position might be a better option in comparison to the Valsalvamanoeuvre to raise intra-orbital pressure when an orbital varix is suspected. A raised intra-orbital pressure exists when ophthalmic veins are dilated. It is easier for a patient to perform because timing is difficult. Literature review; a variety of symptoms is associated with an orbital varix. Treatment is usually expectative. References 1) Hamedani M, Pournaras JA, Goldblum D. Diagnosis and management of enophthalmos. Surv Ophthalmol. 2007 Sept-Oct;52(5):457-73. 2) Grossman RI, Yousem DM. The Requisites. Neuroradiology, second edition: 498-499. 3) Radiologyassistent.com. Personal Information Corresponding author: J. Bekker, MD. Resident. Department of Radiology, Erasmus Medical Center, Rotterdam, the Netherlands. E-mail: j.bekker@erasmusmc.nl Page 6 of 6