Cavernous hemangioma of the intracranial optic pathways: CT and MRI

Optochiasmatic Cavernomas: Updated systematic review and proposal of a novel classification with surgical approaches

Cavernomas are histologically benign vascular malformations found at different sites in the brain. A rare site for such cavernomas, however, is the anterior optic pathway, comprising the optic nerve, chiasma, and optic tract-called optochiasmatic cavernomas (OCC). These lesions usually present with sudden onset or progressive vision loss, headache, and features mimicking pituitary apoplexy. In this paper, we describe a case of OCC operated at our center. We carry out an updated review of literature depicting cases of OCC, their clinical presentation, management, and postoperative complications. We also propose a novel classification system based on lesion location and further analyze these cavernoma types with respect to the surgical approach used and visual outcome. A 30-year-old lady had presented with a 3-week history of progressive bilateral vision loss and headache. Based on imaging, she was suspected to have a cavernous angioma of the chiasma and left optic tract. Due to progressive vision deterioration, the lesion was surgically excised using pterional craniotomy. Postoperatively, her visual symptoms improved, but she developed diabetes insipidus. Clinical and radiological follow-up has been done for 18 months after surgery. A total of 81 cases have been described in the literature, including the present case. Chiasmal apoplexy is the most common presentation. Surgical excision is the standard of care. Our analysis based on lesion location shows the most appropriate surgical approach to be used for each cavernoma type. Visual outcome correlates with the preoperative visual status. Visual outcome is good in patients presenting with acute chiasmal apoplexy, and when complete surgical excision is performed. The endonasal endoscopic approach was found to provide the best visual outcome. In addition to preoperative visual status, complete surgical excision predicts favorable visual outcomes in OCC. Our proposed classification system guides the appropriate surgical approach required for a particular location of the cavernoma.

Diagnosis and treatment status of suprasellar optic pathway cavernous malformations

Cerebral cavernous malformations constitute a subtype of cerebral vascular malformation typically located in the cerebral cortex. However, their occurrence in the suprasellar optic pathway is relatively rare. There is some uncertainty surrounding the clinical diagnostic methods and optimal treatment strategies specific to suprasellar optic pathway cavernous malformations. In this narrative review, we retrospectively analyzed relevant literature related to suprasellar visual pathway cavernous malformations. We conducted a study involving 90 patients who were postoperatively diagnosed with cavernous malformations, including the 16-year-old male patient mentioned in this article. We have summarized crucial clinical data, including the patient age distribution, sex ratio, lesion locations, primary symptoms, and surgical approaches. The comprehensive analysis of this clinical information underscores the critical importance of timely intervention in relieving symptoms and improving neurological deficits in affected patients. These findings provide valuable guidance and insight for clinical practitioners and researchers dealing with this specific medical condition.

Cavernous Malformation of the Optic Nerve and Chiasm: Prompt Suspicion and Surgery Matter

BACKGROUND

Cavernous malformations (CMs) of the optic nerve and chiasm are extremely rare, accounting for less than 1% of all intracranial CMs. Acute, subacute, or progressive visual loss from CM may occur with or without hemorrhage. Prompt surgical excision of the CM offers the best hope to improve or stabilize vision. Given its rarity, optic nerve and chiasm CMs may not be readily suspected. We provide 3 cases of optic nerve and chiasm CM, highlighting key neuroimaging features and the importance of expedited intervention.

METHODS

Case records of the neuro-ophthalmology clinics of the Bascom Palmer Eye Institute and the University of Colorado, and literature review of reported cases of optic CM.

RESULTS

A 49-year-old woman reported acute progressive painless vision loss in the right eye. MRI showed a suprasellar mass with heterogeneity in signal involving the right prechiasmatic optic nerve. Surgical excision of the CM 5 days after onset of visual loss improved vision from 20/300 to 20/30. A 29-year-old woman with acute painless blurred vision in the right eye had anterior chiasmal junctional visual field defects corresponding to a heterogeneously minimally enhancing mass with blood products enlarging the optic chiasm and proximal right optic nerve. Surgical excision of the CM 8 weeks after onset of visual loss improved vision from 20/40 to 20/15 with improved visual fields. A 33-year-old woman with a history of familial multiple CMs, diagnosed at age 18, reported new-onset severe headache followed by blurred vision. MRI showed a hemorrhagic lesion of the optic chiasm and right optic tract. She was 20/20 in each eye with a reported left superior homonymous hemianopia. No intervention was recommended. Vision of the right eye worsened to 20/400 2 months later. The patient was followed over 13 years, and the MRI and visual function remained unchanged. Literature review yielded 87 optic CM cases occurring across gender and nearly all ages with visual loss and headache as the most common presenting symptoms. Optic chiasm is the most common site of involvement (79%). Nearly 95% of reported CM cases were treated with surgery with 81% with improved vision and 1% with worsened vision.

CONCLUSION

MRI features are critical to the diagnosis of optic nerve and chiasm CM and may mimic other lesions. A high index of suspicion by the neuro-ophthalmologist and neuroradiologist leads to early recognition and intervention. Given optic CM displaces and does not infiltrate neural tissue, expedited surgical resection by a neurosurgeon after consideration of other diagnostic possibilities improves visual function in most cases.

An isolated cavernous malformation of the sixth cranial nerve: A case report and review of literature

Background

Isolated cavernous malformation (CM) of the abducens nerve has not been reported in the literature. Herein, the authors address the clinical importance of these lesions and review the reported cases of CM from 2014 to 2020.

Case Description

A 21-year-old man presented with binocular diplopia and headache from 2 months before his admission. The neurological examination revealed right-sided abducens nerve palsy. The brain MRI revealed an extra-axial pontomedullary lesion suggestive of a CM. The lesion was surgically removed. During the operation, the abducens nerve was resected considering the lesion could not be separated from the nerve and an anastomosis was performed using an interposition nerve graft and fibrin glue. Pathological examination of the resected lesion revealed that it was originated from within the nerve. The patient's condition improved in postoperative follow-ups.

Conclusion

Surgical resection of the cranial nerves CMs is appropriate when progressive neurological deficits are present. If the lesion is originated from within the nerve, we suggest resection of the involved nerve and performing anastomosis. Novel MRI sequences might help surgeons to be prepared for such cases and fibrin glue can serve as an appropriate tool to perform anastomosis when end-to-end sutures are impossible to perform.

[Cavernous malformation of the optic nerve: clinical case and literature review]

INTRODUCTION

Cavernous malformation (cm) of the optic nerve is a rare condition It is clinically presented by the so-called chiasmal apoplexy. Microsurgical removal of cavernous malformation is the method of choice.

MATERIAL AND METHODS

Authors present a clinical case of the removal of cavernous malformation of the left optic nerve.

RESULTS

The presented case demonstrates the successful removal of the CM of the left optic nerve from the lateral supraorbital access. In the postoperative period, visual disorders did not worsen. Control MRI of the brain showed total removal of cavernoma.

CONCLUSION

Presented clinical case demonstrates the radical removal of CM of the optic nerve. Early and correct diagnosis makes it possible to adequately treat the patient and preserve his/her visual functions.

Postoperative Management of Anterior Visual Pathway Cavernoma, a Unique Perspective: Case Report

Cavernous malformations (CMs) are low-flow vascular lesions with an incidence of 0.1% to 0.7% in the general population. Less than 1% are found in the anterior visual pathway. The most common presenting symptoms are visual disturbances due to hemorrhage and the current standard of treatment is gross total resection.

The authors report a case of a 42-year-old male with visual disturbance and findings on T1-weighted magnetic resonance imaging (MRI) suggesting CM of the right optic nerve and right optic chiasm. The patient underwent right pterional craniotomy for gross total resection of the lesion. One year postoperatively, the patient demonstrated improvement in visual deficits with no signs of recurrence on MRI. Thirty-two months postresection, MRI showed a small slightly lobulated area of T1 hyperintense material within the postoperative cavity along the right aspect of the optic chiasm. MRI at 39 months postresection showed previously seen small amounts of T1 hyperintensity in the central and right aspect of the optic chiasm, with significantly decreased conspicuity. These findings suggest a trace amount of recurrence in the 32-month postoperative imaging despite overall stable visual field testing.

There is a paucity of literature concerning the retreatment of resected CM in the anterior visual pathway. The authors suggest serial imaging as an integral component of CM management. Although repeated visual field testing and clinical follow-up are important aspects of CM management, they are no substitute for the gold standard of MRI.

Cavernous Malformation of the Hypoglossal Nerve: Case Report and Review of the Literature

Objective:

To describe a patient who presented with a hypoglossal nerve palsy caused by a cavernous malformation, review the literature on cavernous malformations associated with cranial nerves and the differential diagnosis of hypoglossal palsy.

Results:

Partial resection of the lesion was achieved and the diagnosis of cavernous malformation proven histologically.

Conclusions:

Involvement of a cranial nerve by a cavernous malformation is very uncommon and the facial nerve is the example most frequently reported. This case report adds another possible site for this rare occurrence.

Incidental optochiasmatic cavernoma: Case report of an unusual finding on 3 Tesla MRI

Cavernoma is a vascular hamartoma, which represents 10-20% of all central nervous system vascular malformations. The majority (80%) of them are supratentorial, while involvement of the cranial nerves and the optic pathways is extremely rare. The main clinical presentation of optochiasmatic cavernomas consists of chiasmatic apoplexy, which is a neurosurgical emergency. Here, we report a case in which the finding was incidentally detected in a 49-year-old man. We describe the imaging characteristics of the lesion in such a rare location, highlighting the role of magnetic resonance imaging (MRI) (specifically 3 Tesla) in the management of asymptomatic patients.

Angiographically occult vascular malformation of the intracranial accessory nerve: case report

Angiographically occult cerebral vascular malformations (AOVMs) are usually found in the supratentorial brain parenchyma. Uncommonly, AOVMs can be found within the cavernous sinus or basal cisterns and can be associated with cranial nerves. AOVMs involving the intracranial segment of the spinal accessory nerve have not been described. A 46-year-old female patient presented with a history of episodic frontal headaches and episodes of nausea and dizziness, as well as gait instability progressing over 6 months prior to evaluation. Imaging revealed a well-circumscribed 3-cm extraaxial T1-weighted isointense and T2-weighted hyperintense contrast-enhancing mass centered in the region of the right lateral cerebellomedullary cistern. The patient underwent resection of the lesion. Although the intraoperative appearance was suggestive of a cavernous malformation, some histological findings were atypical, leading to the final diagnosis of vascular malformation, not otherwise specified. The patient's postoperative course was uneventful with complete resolution of symptoms. To the authors' knowledge, this is the first report of an AOVM involving the intracranial portion of the accessory nerve. For any AOVM located within the cerebellomedullary cistern or one suspected of involving a cranial nerve, the authors recommend including immunohistochemistry with primary antibody to neurofilament in the histopathology workup.

Cavernous malformations isolated from cranial nerves: Unexpected diagnosis?

OBJECTIVES

Cranial nerves (CN) cavernous malformations (CMs) are lesions that are isolated from the CNs. The authors present three cases of CN CMs, for which MR was demonstrated to be critical for management, and surgical resection produced good outcomes for the patients. Surgical removal is the recommended course of action to restore or preserve neurological function and to eliminate the risk of future haemorrhage. However, the anatomical location and the complexity of nearby neural structures can make these lesions difficult to access and remove. In this study, the authors review the literature of reported cases of CN CMs to analyse the clinical and radiographic presentations, surgical approaches and neurological outcomes.

PATIENTS AND METHODS

A MEDLINE/Pub Med search was performed and revealed 86 cases of CN CMs. The authors report three additional cases in this study for a total of 89 cases. CMs affecting the optic nerve (CN II), oculomotor nerve (CN III), facial/vestibule-cochlear nerves (CN VII, CN VIII) have been described. The records of three patients were reviewed with respect to the lesion locations, symptoms, surgical approaches and therapeutic considerations. Clinical and radiological follow-up results are reported. Three patients (2 females, 1 male; age range 21-37 year) presented with three CN lesions. One lesion involved CN III, one lesion involved CN VII-CN VIII, and one involved CN II. The patient with the CN III lesion had a one-month history of mild right ptosis and diplopia. The patient with the CN VII-CN VIII lesion exhibited acute hearing loss and on the left and left facial paresis. The patient with the opticchiasmatic lesion presented with acute visual deterioration on the right and a left temporal field deficit in the left eye. Pterional and orbitozygomatic craniotomies were performed for the CN III lesion and the CN II lesion, and retrosigmoid craniotomy was performed for the cerebello-pontine angle lesion.

RESULTS

All patients experienced symptom improvement after surgery. On MR follow-up, recurrence was excluded in all patients.

CONCLUSIONS

CN CMs present with specific symptoms and require complex surgical techniques for resection. These lesions are frequently symptomatic, because of the complexity of the origin tissue. Symptomatic CN CMs should be resected microsurgically and completely when possible to prevent further losses of nerve function, improve function, avoid recurrence, and to eliminate the risk of future haemorrhages. The authors discuss the therapeutic options and the radiological features of these infrequent localisation of CMs. Specifically, the authors focus on the role of magnetic resonance imaging in the identification of these rare lesions.

Cranial nerve cavernous malformations causing trigeminal neuralgia and chiasmal apoplexy: Report of 2 cases and review of the literature

BACKGROUND

Cavernous malformations (CMs) confined to the cranial nerves (CN) are extremely rare lesions.

CASE DESCRIPTION

The authors report 2 cases of CMs, one involving the trigeminal nerve presenting with a 3 years history of a refractory right trigeminal neuralgia that was microsurgically resected by a retromastoid approach with resolution of the neuralgia; and another CM involving the chiasma with an abrupt onset of vision loss with acute intralesional bleeding that was removed through a right pterional approach with vision improvement.

CONCLUSION

Surgical resection is recommended in the context of progressive significant neurological deficit, emergency decompression as a result of recent hemorrhage for symptomatic relief or increase in size on serial magnetic resonance imaging (MRI).

Uncommon cavernous malformation of the optic chiasm: a case report

Cavernous malformation (CM) is a vascular malformation disorder characterized by a berry-like mass of expanded blood vessels. CM, originating from the optic chiasm. usually leads to chiasma syndrome presenting with bitemporal hemianopsia. We report a 28-year-old male presenting with left homonymous hemianopsia. Magnetic resonance imaging (MRI) revealed an occupied lesion located in the right side of the optic chiasm, and a clinical diagnosis of chiasmal CM was made. Microsurgical excision was performed via anterolateral pterional craniotomy. The patient showed good recovery with slight improvement of the visual field deficits after the operation. No CM recurrence was discovered during the follow-up MRI scans.

Cavernous hemangioma of the optic chiasm: a surgical review

OBJECTIVES

To report a new case of cavernous hemangioma of the optic chiasm and to review all previously published cases with regard to presentation, surgical treatment, and outcomes.

DESIGN

Case report and literature review.

MAIN OUTCOME MEASURES

Cases identified though PubMed and published literature. Presentation states of patients in terms of visual loss and pituitary function. Surgical approaches, operations performed, and outcomes of the surgery.

RESULTS

thirty-nine previously reported cases were studied with the present case. All 40 patients presented with visual failure. Where documented, there was an 20% pituitary dysfunction rate. A total of 32 craniotomies were reported. Seventy-eight percent of patients underwent decompression including hematoma evacuation and partial or complete removal of the cavernoma, with improvement in visual function in 87% of these patients. The patients undergoing only biopsy showed stable visual function in 50% with further deterioration in 50%.

CONCLUSIONS

We conclude that this rare condition can be managed with good outcomes in terms of visual improvement, provided a high index of suspicion is maintained and the goals of surgery for emergency patients are maintained to include chiasmal decompression. Although complete resection of the lesion is frequently possible, it should not be the primary aim of surgery.

Successful resection of the recurrence of a cavernous malformation of the optic chiasm

The case of a 33-year-old female who suffered from a recurrence of an intrachiasmatic cavernous malformation is presented. She had already undergone surgery in 1991 and 2001 and was admitted to our hospital with reduced vision in the right eye. After MRI, and diagnosis of recurrence of the cavernoma, a neurosurgical operation was performed using the pterional approach. The intraoperative situation was documented with micro photographs. The postoperative course was uneventful. The female described a minimal improvement of her vision. No postoperative complications were observed. To our knowledge, microsurgically complete extirpation of a recurrence of an intrachiasmatic cavernoma has not yet been reported in the literature.

Cavernous Hemangioma of the Abducens Nerve: Clinical Implication of Duplicated Variants: Case Report

BACKGROUND AND IMPORTANCE:

A cavernous hemangioma arising from the abducens nerve has not been previously reported in the literature. Based on the surgical experience with this case, the authors discuss the clinical importance and resectability potential of a duplicated abducens nerve.

CLINICAL PRESENTATION:

A 54-year-old woman presented with a recurrence of diplopia that had occurred 3 years before this admission and had spontaneously resolved without any specific treatment. On admission, there were no specific neurological deficits. Magnetic resonance imaging revealed a cone-shaped mass on the right anterior cerebellopontine angle with hemorrhagic change. Surgical resection via a standard right lateral suboccipital approach was performed. A cystic mass was found emerging from the entry zone of the Dorello canal and encircling the larger branch of the duplicate abducens nerve. Because there was no demarcation between the mass and origin branch, both were removed en bloc. Pathology revealed the presence of a cavernous hemangioma mixed with nerve tissue. Despite preserving a small branch of the duplicate abducens nerve, the patient had permanent right abducens palsy.

CONCLUSION:

A cavernous hemangioma arising from the abducens nerve should be suspected as a possible diagnosis for a cystic mass on the anterior cerebellopontine angle. Although duplication of the abducens nerve has not been clearly confirmed on clinical grounds, sacrificing the larger branch during surgery may lead to permanent abducens palsy, as in our case.

Cavernous Malformation of the Trochlear Nerve: Case Report and Review of the Literature on Cranial Nerve Cavernomas

BACKGROUND AND IMPORTANCE:

Cavernous malformations (CMs) arising intrinsically to the cisternal segment of the trochlear nerve are extremely rare. This case of a trochlear nerve cavernous angioma is the third to be reported in the neurosurgical literature and the first to be resected by a middle fossa approach.

CLINICAL PRESENTATION:

The authors present a case of a 31-year-old woman with progressive left-sided headache and left hemisensory symptoms, whose magnetic resonance imaging showed a solid enhancing tumor in the left ambient cistern at the level of the midbrain-pontine junction causing significant brainstem compression. Intraoperatively, a left trochlear nerve cavernous angioma circumferentially enveloping the nerve was visualized. The angioma was microsurgically resected by a middle fossa approach under frameless stereotactic guidance. Gross total resection of the intrinsic trochlear nerve lesion was achieved, although the trochlear nerve could not be preserved intact.

CONCLUSION:

CMs should be considered in a possible differential diagnosis of cisternal trochlear nerve tumors. Surgical resection remains the standard of care, and is indicated for relief of compressive symptoms and prevention of future bleeds. Postoperative diplopia often persists; however, resolution of diplopia reported in the literature can be attributed to either regeneration after direct surgical repair of the sacrificed nerve or a spontaneous adaptation over time.

Cavernous malformations of the optic pathway and hypothalamus: analysis of 65 cases in the literature

Object

Cavernous malformations (CMs) of the optic pathway and hypothalamus (OPH) are extremely rare. Patients with these lesions typically present with chiasmal apoplexy, characterized by sudden visual loss, acute headaches, retroorbital pain, and nausea. Surgical removal is the recommended treatment to restore or preserve vision and to eliminate the risk of future hemorrhage. However, the anatomical location and eloquence of nearby neural structures can make these lesions difficult to access and remove. In this study, the authors review the literature for reported cases of OPH CMs to analyze clinical and radiographic presentations as well as surgical approaches and neurological outcomes.

Methods

A MEDLINE/PubMed search was performed, revealing 64 cases of OPH CMs. The authors report an additional case in the study, making a total of 65 cases. Each case was analyzed for clinical presentation, lesion location, radiographic features, treatment method, and visual outcome.

Results

In 65 patients with OPH CMs, the optic chiasm was affected in 54 cases, the optic nerve(s) in 35, the optic tract in 13, and the hypothalamus in 5. Loss of visual field and acuity was the most common presenting symptom (98%), followed by headache (60%). The onset of symptoms was acute in 58% of patients, subacute in 15%, and chronic progressive in 26%. Computed tomography scans revealed hyperdense suprasellar lesions, with calcification visible in 56% of cases. Magnetic resonance imaging typically demonstrated a heterogeneous lesion with mixed signal intensities suggestive of blood of different ages. The lesion was often surrounded by a peripheral rim of hypointensity on T2-weighted images in 60% of cases. Minimal or no enhancement occurred after the administration of gadolinium. Hemorrhage was reported in 82% of cases. Most patients were surgically treated (97%) using gross-total resection (60%), subtotal resection (6%), biopsy procedure alone (6%), biopsy procedure with decompression (23%), and biopsy procedure followed by radiation (2%). Those patients who underwent gross-total resection had the highest rate of visual improvement (85%). Two patients were treated conservatively, resulting in complete blindness in 1 patient and spontaneous recovery of vision in the other patient.

Conclusions

Cavernous malformations of the OPH are rare and challenging lesions. Gross-total resection of these lesions is associated with favorable visual outcomes. Emergent surgery is warranted in patients presenting with chiasmal apoplexy to prevent permanent damage to the visual pathway.

Cavernous malformation of the optic chiasm: case report

We report a 14-year-old boy with cavernous malformation of the optic chiasm. He had a 2-year history of gradually worsening visual disturbance. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a suprasellar mass, findings compatible with craniopharyngioma. The mass was biopsied and histological examination confirmed cavernous malformation. On the second day after the biopsy, he suffered chiasmal apoplexy due to intratumoural haemorrhage, lost visual acuity and developed a field cut. Cavernous malformations arising from the optic nerve and chiasm are extremely rare; only 29 cases have been reported to date. Most patients manifested acute visual acuity and visual field disturbances. Although MRI findings of cavernous malformations in the brain parenchyma have been reported, MRI findings on the optic nerve and chiasm may not be completely diagnostic. Of the 29 documented patients, 16 underwent total resection of the lesion without exacerbation of their preoperative symptoms; in some cases, resection was complicated by risk of damage to the surrounding neural tissue. As patients may suffer intratumoural haemorrhage after biopsy or partial removal of the lesion, the advisability of surgical treatment of cavernous malformations of the optic nerve and chiasm must be considered carefully.

Imagerie des cavernomes du système nerveux central

MRI is the best radiological technique to explore cavernomas, vascular malformations affecting the entire central nervous system. The presence of blood degradation products produces a specific aspect which enables excellent contrast resolution. Certain diagnosis can be established with MRI which can also be used to follow growth and modifications, particularly in familial forms. In the emergency setting, the first exam is often a CT-scan for patients presenting acute neurological sign(s) and/or with a clinical suspicion of hemorrhagic stroke. Angiography is generally not contributive because cavernomas are occult vascular malformations. Nevertheless, this exam is often necessary when an associated vascular abnormality is suspected, particularly a developmental venous abnormality.

Histoire naturelle des cavernomes du système nerveux central

We present a critical review of the literature on the central nervous system cavernomas in order to highlight their natural history and to define the most appropriate management of these rare lesions. The prevalence is now estimated from 0.3 to 0.7% in the general population without any significant difference by gender; 25% of cases are pediatric. Two forms of the disease can be described: sporadic forms in 80% of cases, characterized by isolated or rare lesions and familial dominant autosomic forms characterized by multiple and evolutive lesions. The incidence is not well known, the consultation of the French PMSI database suggests that 50 to 100 cases are operated on each year (1 to 2 per million). Cavernomas are dynamic lesions: growing in many cases, seldom remaining quiescent and disappearing in rare cases. The anatomical evolution is more pejorative in familial forms. "De novo" cases are now well known, either in familial or sporadic forms and after radiotherapy. Many lesions are totally asymptomatic, but the frequency of symptomatic forms is debated in the literature from 3 to 90%... The hemorrhagic risk is evaluated from 0,5 to 3% each year, depending on the localization, and the risk of rebleeding is more important but not well known. The epileptic risk is correlated to the localization, more frequent for temporal and frontal lesions from 4,5 to 11% each year, but these data are controversial. The natural history depends on the topography: hemispheric, deep-seated, brain stem, cerebellum or intramedullary and in pediatric situations. Each situation will be treated in this report.

[Results of surgical treatment]

In this chapter we report the results of the main papers of the international literature, but it is difficult to make an objective synopsis because only the best results are published and failure and complications remain confidential. Few papers describe "general complications" as thrombo phlebitis, wound infection, cardio respiratory insufficiency... which are probably as frequent as for all intracranial or spinal surgical procedures. The postoperative neurological status depends essentially on the location of the lesion. In non eloquent area, the postoperative neurological status is almost always excellent. But in a hemispheric functional area, basal ganglia and brain stem it is frequent to observe neurological sequellae; in the better series of the literature, 80% of the patients achieve a good outcome equivalent to or better than before the operation, but 20% are worsened. It is important to remember this fact before discussing the surgical indication. The risk of hemorrhage disappears after total surgical resection; and it is one of the benefits of the treatment, but this objective can be reached only when the lesion is unique. The risk persists in multiple forms and "de novo" cavernomas are always possible especially in familial forms. The main benefit is the treatment of epilepsy for seizure control. In case of good concordance between the location of the cavernoma and the clinical and electrical data, lesionectomy alone or lesionectomy with resection of the perilesional hemosiderin ring provide good results. In the event of severe epilepsy without good concordance between the site of the cavernoma and symptoms, the surgical approach may be functional and outcome less satisfactory.

Optochiasmatic cavernous angioma: unexpected diagnosis. Case report

A 15-year-old boy presented with an extremely rare optochiasmatic cavernous angioma. He was admitted to a special hospital with the complaint of blurred vision persisting for 1 month. Magnetic resonance imaging and biopsy of the lesion were inconclusive. He was admitted to our neurosurgical clinic after worsening of the visual symptoms 9 months later. Repeat magnetic resonance imaging showed optochiasmatic cavernous angioma which had doubled in size. The lesion was removed completely without any problem. Postoperatively his visual complaints remained stable, but had improved after 1 year. Optochiasmatic cavernous malformation should be treated by surgical excision, whereas biopsy is useless and may result in enlargement.

Cavernous haemangiomas of the anterior visual pathways. Short review on occasion of an exceptional case

The anterior optic pathways are rarely affected by vascular malformations. In a meticulous literature review, 42 published cases of patients with vascular malformations within optic nerves, chiasma and/or optic tract were found, 30 of them being diagnosed as cavernous haemangiomas. All of them suffered from visual disturbances; in 38.1% previous symptoms had occurred. Surgical treatment resulted in major improvement in most patients. We include a further patient with a cavernous haemangioma of the optic chiasma and left optic tract who presented with an acute defect of the right visual field and severe retro-orbital pain. We succeeded in total excision of the malformation via a neuronavigationally guided approach. In the postoperative course, vision of our patient improved immediately and was found to be completely normal three months after the surgical intervention. Considering our patient and the published cases in the literature, we are of the opinion that microsurgical excision is a safe and efficient treatment for these rare pathologies.

Pituicytoma presenting with spontaneous hemorrhage

Pituicytomas are rare tumors. Previously reported pituicytomas all presented with signs and symptoms relating to mass effect or endocrinological dysfunction. We report a 47 year old man who presented with sudden, severe headache and was found to have a hemorrhagic suprasellar mass with hemorrhage into the third ventricle. A mass arising from the pituitary stalk was found at surgery, and thorough pathological analysis revealed a pituicytoma. Pituicytoma should be considered in the differential diagnosis of a hemorrhagic suprasellar mass.

Surgical management of cavernous malformations involving the cranial nerves

OBJECTIVE

To analyze the indications and techniques pertinent to the treatment of cranial nerve (CN) cavernous malformations (CMs).

METHODS

CN CMs are lesions isolated to the CNs. CMs affecting the optic nerve (CN II), oculomotor nerve (CN III), facial/vestibulocochlear complex (CN VII and CN VIII), and hypoglossal nerve (CN XII) have been described. The records for six patients were reviewed with respect to lesion location, symptoms, surgical approach, and therapeutic considerations. This is the largest series of CMs isolated to CNs reported to date.

RESULTS

Three female patients and three male patients (age range, 28-76 yr; mean age, 41 yr) presented with six CN lesions; four lesions involved the optic chiasm and two involved CN VII and CN VIII. The patients with chiasmatic lesions presented with acute visual deterioration. Both patients with CN VII/CN VIII lesions exhibited acute hearing loss. The level of deterioration suggested CM hemorrhage. Orbitozygomatic craniotomies were performed for chiasmatic lesions, and retrosigmoid craniotomies were performed for cerebellopontine angle lesions. All patients experienced symptom improvement after surgery. One chiasmatic lesion recurred after 2 years and required resection.

CONCLUSION

CN CMs present with site-specific symptoms and require complex surgical techniques for resection. These lesions are frequently symptomatic, because of the eloquence of the tissue of origin. Therefore, all CN CMs should be resected. Subtotal resection uniformly results in disease and symptom recurrence. CN CMs can be resected safely, with preservation of CN function.

Chiasmal apoplexy due to hemorrhage from a pituitary adenoma into the optic chiasm: case report

OBJECTIVE AND IMPORTANCE

Chiasmal apoplexy, defined as hemorrhage into the optic chiasm, generally is caused by an intrachiasmal vascular malformation. We report the first case of chiasmal apoplexy due to hemorrhage from a pituitary macroadenoma into the optic chiasm.

CLINICAL PRESENTATION

A 52-year-old man presented with headache, sudden and severe deterioration of visual acuity in the left eye, and a bitemporal visual field deficit. Magnetic resonance imaging revealed a large intra- and suprasellar homogeneously enhancing mass, which elevated a markedly thickened optic chiasm. After emergent transsphenoidal resection of the pituitary adenoma, vision did not improve.

INTERVENTION

A pterional craniotomy was subsequently performed, during which a hematoma was found and evacuated from within the substance of the left optic nerve and chiasm. The hematoma cavity was found to communicate with the sella through a defect in the diaphragm. Vision improved dramatically after the operation.

CONCLUSION

Chiasmal apoplexy resulting from pituitary adenoma should be distinguished from pituitary apoplexy, particularly because it requires a different surgical treatment. Clinical and radiographic features that may help distinguish the two are discussed.