Introduction to Orbital Vascular Lesions

Orbital cavernous venous malformation (CVM) represents a common slow-flow vascular anomaly of the orbit. However, clinicians rarely encounter cases where a CVM develops a secondary high-flow arteriovenous fistula (AVF). This case study highlights a 55-year-old female presenting with a pulsatile left upper eyelid mass. Furthermore, ophthalmic examination revealed a palpable thrill, which suggests a high-flow component. Imaging indicated a complex lesion, requiring sophisticated diagnostic techniques for definitive characterization.

Diagnosing Complex Orbital Cavernous Venous Malformation Cases

Consequently, the medical team performed diagnostic cerebral angiography to confirm the presence of an AVF. This procedure identified a composite lesion consisting of a CVM and a secondary fistula. To manage this rare orbital cavernous venous malformation, the specialists chose a multi-stage intervention. Specifically, they utilized transvenous coil and N-butyl cyanoacrylate (NBCA) glue embolization. Additionally, the team performed transarterial NBCA embolization to reduce vascularity before surgery. After successful embolization, they performed a surgical excision of the eyelid mass. Histopathology confirmed the diagnosis of a complex combined vascular malformation. Therefore, the patient remained asymptomatic without any recurrence at the one-year follow-up.

Clinical Implications and Multidisciplinary Care

This case demonstrates the necessity of high-resolution imaging in suspicious vascular lesions. Moreover, it underscores that CVMs may not always follow a slow-flow clinical course. When high-flow signs like bruits or thrills appear, clinicians must consider secondary complications. A multidisciplinary approach involving ophthalmologists, radiologists, and surgeons ensures the safest outcome for such complex cases. Ultimately, preoperative embolization reduces the risk of intraoperative hemorrhage, facilitating complete surgical resection.

Frequently Asked Questions

Why is diagnostic cerebral angiography necessary for complex orbital lesions?

Angiography remains the gold standard for distinguishing between low-flow malformations and high-flow fistulas, which is critical for planning safe interventions and avoiding surgical complications.

What distinguishes a cavernous venous malformation from an arteriovenous fistula?

A cavernous venous malformation is typically a slow-flow, well-circumscribed lesion. In contrast, an arteriovenous fistula involves high-pressure direct communication between arteries and veins, often causing pulsatile symptoms.

How does preoperative embolization improve surgical outcomes?

Embolization blocks the blood supply to high-flow lesions, significantly reducing the risk of life-threatening bleeding during subsequent surgical excision of the mass.

Disclaimer: This content is for informational and educational purposes only. It does not constitute medical advice or establish a doctor-patient relationship. Always seek the advice of a qualified healthcare provider regarding any medical condition. Refer to the latest local and national guidelines for clinical practice.

References

Sukon N et al. Cavernous venous malformation complicated by a secondary spontaneous arteriovenous fistula of the eyelid. Orbit. 2026 May 04. doi: 10.1080/01676830.2026.2666869. PMID: 42077185.

Wu CY, Kahana A. Combined Embolization and Resection of Orbital Arteriovenous Malformation. Ophthalmic Plast Reconstr Surg. 2017;33(3S):S144-S146.

Calandriello L, et al. Cavernous venous malformation (cavernous hemangioma) of the orbit: current concepts and a review of the literature. Surv Ophthalmol. 2017;62(4):393-403.