Superior and inferior ophthalmic veins thrombosis with cavernous sinus meningioma.

Ophthalmic vein thrombosis is an extremely rare entity. We present a case of middle-aged female who presented with proptosis. Contrast-enhanced computed tomography and magnetic resonance imaging showed cavernous sinus meningioma with ipsilateral superior and inferior vein thrombosis. A brief review of the vascular involvement of the meningioma and ophthalmic vein thrombosis is presented along with the case.

INTRODUCTION

The vascular involvement by meningioma is either due to encasement of a vessel or by direct extension of the tumor. Cavernous sinus meningioma with superior and inferior ophthalmic vein thrombosis is not described in the English peer review literature based on our Pubmed search. Thrombosis of the ophthalmic vein is associated with orbital congestion with tumors being a relatively rare cause.1 Magnetic resonance imaging (MRI) and computed tomography (CT) are standard radiographic studies that play important role in delineating the vascular involvement of the tumors.

CASE REPORT

A 45-year-old female presented with gradual proptosis of the left eye for duration of 3 months without any visual complaints or redness of the eye. There was no history of headache or fever. The patient was complaining of aggravation of the proptosis for previous month before presentation. A vague history of redness, pain, and blurring of vision three months prior to presentation with subsequent onset of proptosis was elicited during examination. On examination, the patient was afebrile and hemodynamically stable. Proptosis of the left eye was not associated to pulsation of the globe. The visual acuity was normal bilaterally. The laboratory workup of the patient was normal. Contrast-enhanced MRI of the brain and orbit [Figures 1–3] revealed an extra-axial, homogenously enhancing left parasellar mass in the cavernous sinus. There was left-sided proptosis with dilated and thrombosed superior and inferior ophthalmic veins with hyperintense signal and mild peripheral enhancement on T1-weighted and T2-weighted images. Based on the radiographic studies, the patient was diagnosed with left cavernous sinus meningioma with superior and inferior ophthalmic vein thrombosis. The patient underwent open craniotomy with excision of the tumor and thrombus. The cavernous sinus meningioma with ophthalmic vein thrombosis was confirmed histopathologically [Figure 4].

Figure 1

Coronal T1-weighted (T1WI) and T2-weighted (T2WI) images showing dilated left-sided superior (large white arrow) and inferior (small white arrow) ophthalmic veins with intraluminal T1WI hyperintense and T2WI hypointense signals

Figure 3

Contrast-enhanced T1-weighted sagittal magnetic resonance imaging study showing left cavernous sinus meningioma (black arrow) with dilated and thrombosed superior (large white arrow) and inferior (small white arrow) ophthalmic veins

Figure 4

Micrograph showing meningioma with prominent whorls. (a) low magnifi cation (×20) and (b) under high magnifi cation (×40), hematoxylin-eosin stain

Contrast-enhanced T1-weighted axial magnetic resonance imaging study showing left cavernous sinus meningioma (black arrow) with thrombosed superior (large white arrow) and inferior (small white arrow) ophthalmic veins

DISCUSSION

Meningioma is the most common intracranial extra-axial tumor and the most common nonglial primary brain tumor. Meningioma generally occurs in the fourth to sixth decades with greater a frequency in females. Sellar meningioma constitutes between 5 and 10% of all meningiomas. Juxta and suprasellar meningioma can arise from the cavernous sinus dura, tuberculum, dorsum, or diaphragm sella.2 Cavernous sinus meningioma can extend posteriorly to involve the tentorium. Meningioma may invade bone, muscle, dura, or the dural sinuses and may cause thrombosis of dural sinuses. The mechanism of dural venous sinus thrombosis by meningioma is by direct involvement of the tumor. Vascular encasement is common with cavernous sinus meningioma, which constrict the lumen of the encased vessel. MRI is superior to CT in demonstrating sinus involvement or venous thrombosis. MRI shows venous sinus invasion by the tumor as partial or complete obliteration of the sinus flow void with a soft tissue mass. On T1- and T2-weighted images, the intensity of the tissue within the venous sinus is usually similar to that of adjacent tumor. Cavernous sinus involvement is distinct in the coronal or axial planes. It is very difficult to distinguish complete from near-total venous sinus obliteration. MR angiography or other MR flow techniques may help demonstrate cases of partial obstruction.

Superior ophthalmic vein thrombosis (SOVT) is usually found in cases of orbital congestion such as orbital cellulitis, idiopathic orbital inflammation, vascular malformation, and thyroid-related orbitopathy.34 Infection, trauma, and tumor account for approximately 10% cases of cerebral venous thrombosis. CT shows SOVT as a dilated tubular structure inferior to the superior rectus and levator complex. MRI is the imaging modality of choice for confirming SOVT as it shows all stages of thrombus formation. Contrast-enhanced MRI with fat suppression in axial and coronal planes is useful for confirmation. Parmar et al.5 reported that diffusion-weighted MR may be helpful in the cavernous sinus and SOVT by showing restricted diffusion, in addition to correlation of clinical signs and findings of conventional imaging. Orbital color Doppler imaging also allows noninvasive confirmation of SOVT. To our knowledge, thrombosis of inferior ophthalmic vein is not reported in the literature. Our case was very unusual in that there was thrombosis of both superior and inferior ophthalmic veins.