When a baby's eye begins to push forward
In the first weeks of life, a baby's face should be growing, not changing shape in alarming ways. But at 55 days old, this infant girl's left eye began visibly bulging outward — a condition called proptosis — and it was getting worse week by week.
It was the kind of finding that stops parents and pediatricians alike. Something was pushing the eye from behind.
What the scans showed — and what they didn't
Magnetic resonance imaging (MRI) revealed two distinct masses: one wrapped around the optic nerve inside the left orbit (the bony socket of the eye), and a second mass near the parasellar region — an area deep at the base of the skull, near where critical blood vessels and nerves cluster around the pituitary gland.
The imaging characteristics were concerning. The tumors looked, on the scan, very much like a meningioma — a type of tumor that can behave aggressively, particularly when it encases a nerve.
But the infant had no skin lesions. No telltale red birthmarks that often accompany the most common type of these tumors. Nothing on the outside to hint at what might be happening within.
The diagnosis that changes everything
Infantile hemangiomas (IHs) are the most common benign (non-cancerous) tumors of infancy. Most are visible on the skin as raised, red, or strawberry-like patches. They grow in the first year of life and then slowly shrink on their own.
But occasionally, hemangiomas grow inside the body — behind the eye, inside the skull, along internal organs — without any visible skin involvement. When that happens, they can be nearly impossible to diagnose without tissue.
Having two simultaneous deep hemangiomas — one orbital, one intracranial — with no external signs is exceptionally rare. The medical literature contains very few documented cases.
When surgery is both the question and the answer
The medical team faced a difficult situation. The imaging couldn't definitively distinguish between a hemangioma and something more dangerous. The infant was showing symptoms — the eye was already being displaced, and the mass near the brain base posed risk to surrounding structures.
A multidisciplinary team made the decision to operate — removing both lesions in a single surgery using a pterional approach (an entry through the side of the skull near the temple). The goal was twofold: relieve the pressure on the optic nerve and nearby brain structures, and obtain tissue to finally know what they were dealing with.
This kind of complex surgical decision in a 55-day-old infant requires a highly specialized team at a center experienced in pediatric neurosurgery.
Histopathological examination — looking at the tissue under a microscope — confirmed the diagnosis of cellular infantile hemangioma. Positive staining for two markers, GLUT-1 and CD31, is characteristic of IH and helped distinguish it from other vascular tumors or malignancies.
The infant recovered without complications. The proptosis resolved completely. No neurological deficits were observed. Follow-up imaging confirmed that both tumors had been fully removed.
Why this case matters beyond one baby
Infantile hemangiomas without skin involvement are easy to miss — or to misdiagnose as something more dangerous. This case adds to a small but growing body of evidence that deep IHs should be included in the differential diagnosis (the list of possibilities doctors consider) for any infant presenting with orbital masses or unexplained intracranial lesions, even without characteristic skin findings.
For clinicians caring for infants with unusual imaging findings, this case reinforces that hemangioma should remain on the radar — and that surgery can be both diagnostic and curative when other methods fall short.
What this means for parents
If your infant or young child develops progressive eye bulging, decreased vision, unexplained neurological symptoms, or visible swelling around the eye, seek evaluation promptly. These symptoms are not always serious, but they warrant immediate assessment by a pediatrician and, if indicated, a specialist in pediatric ophthalmology or neurology.
For most infantile hemangiomas — particularly the common surface variety — surgery is not needed, and many respond well to medications like propranolol. Internal hemangiomas are different, and management must be individualized.
The limits of a single case report
A case report represents a sample size of one. It documents what happened in this particular infant but cannot guide general treatment decisions on its own. The approach taken here — single-stage surgical resection — was appropriate given the specific clinical situation, but it is not a template that applies to all similar presentations.
What comes next
The authors call for greater awareness among radiologists, neonatologists, and pediatric neurosurgeons that internal IHs can mimic other lesions on imaging. Broader awareness and more documented cases will help the field develop clearer diagnostic criteria and management guidelines for this rare presentation — so that future infants benefit from faster, more confident diagnosis and care.
