Optimizing imaging in orbital vascular anomalies: a review on matching modality to pathology for effective diagnosis and treatment planning

Introduction: Orbital vascular anomalies (OVAs) encompass a heterogeneous group of lesions requiring precise imaging to guide diagnosis and treatment. Multiple imaging modalities offer distinct strengths and limitations, with the choice guided by the balance between spatial and temporal resolution. This review aligns imaging modalities with specific OVM subtypes to optimize diagnostic accuracy and procedural planning, while highlighting advanced and evolving imaging techniques that may further enhance clinical decision-making. Methods: A narrative review was conducted on studies describing imaging characteristics, diagnostic performance, and clinical utility in OVAs, supplemented with imaging from patients presenting with a wide range of lesions. All patient data were collected and reviewed in compliance with HIPAA regulations and international ethical standards. Results: Although ultrasound provides dynamic assessment of vascular flow and superficial morphology, its role is limited in modern practice due to poor spatial resolution and depth penetration. CT offers superior spatial resolution for osseous and calcified lesions, while MRI provides excellent soft tissue characterization and evaluation of complex low-flow malformations. MR and CT angiography deliver detailed vascular mapping critical for pre-embolization planning, yet their static nature limits evaluation of dynamic changes. Dynamic techniques, such as Time-Resolved Imaging of Contrast KineticS (TRICKS) MRI angiography and dynamic CT angiography, enable real-time assessment of flow and venous distensibility, improving procedural planning. Conventional digital subtraction angiography remains the standard for complex lesions in critical locations, combining high-temporal-resolution diagnosis with therapeutic intervention. Given the heterogeneity of OVAs, a multimodal approach is often necessary to address diagnostic, planning, and treatment needs comprehensively. Conclusion: Optimal imaging of OVAs requires tailoring modality selection to lesion type and clinical context. Incorporating advanced and emerging imaging approaches into clinical practice may further improve diagnostic precision, procedural planning, and patient outcomes.