Optochiasmatic cavernous angioma: unexpected diagnosis. Case report

Cavernous Malformation From Cranial Nerves: A Systematic Review With a Novel Classification and Patient-Level Analysis

BACKGROUND AND OBJECTIVES

Cavernous malformations (CMs) occurring in the cranial nerve (CN) are extremely rare, and there is currently no comprehensive review on CN CMs, leading to a lack of sufficient understanding of CN CMs. We aimed to systematically review all published CN CM cases; summarize the epidemiology, clinical manifestations, treatment, and prognosis of CN CMs; and identify factors influencing the prognosis of CN CMs.

METHODS

This systematic review identified all cases potentially diagnosed with CN CM through a systematic search of PubMed, SCOPUS, Web of Science, and Cochrane databases. This represents the most comprehensive systematic review to date. We classified CN CMs based on their anatomic origins. Patient characteristics, disease manifestations, treatment approaches, and prognosis were summarized descriptively. Further analysis was conducted to identify factors influencing the prognosis of CN CMs.

RESULTS

The final analysis included 108 articles (127 individual patient cases). The optic nerve (49/128, 38.3%) is the most commonly affected nerve. Notably, CN CMs can be categorized into 3 types: Intraneural, Perineural, and Extraneural. Preoperative nerve function status and novel classification were associated with the prognosis of CN CMs (P = .001; P < .001). The postoperative neurological deterioration rate for the Intraneural type was 19/37 (51.4%); for the Extraneural type, it was 13/69 (18.8%); and for the Perineural type, it was 1/22 (4.5%) (P < .001).

CONCLUSION

We reviewed all the published CN CMs to date, offering a comprehensive description of CN CMs for the first time and identifying prognostic factors. The classification of CN CMs proposed in this study could serve as guidance for the selection of intraoperative treatment regimens. The findings of this systematic review are expected to provide a foundation for clinical decision-making in this crucial rare disease and lay the groundwork for developing relevant clinical guidelines.

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.

Optochiasmatic cavernoma: Surgical treatment and outcomes

OBJECTIVE

Optochiasmatic cavernoma is an extremely rare cerebral lesion. They account for approximately 1% of all cavernomas of the central nervous system. Reports on this pathology are limited. Abrupt visual deterioration is a common symptom of the disease. Treatment strategy and visual outcomes after different treatment approaches remain a subject for discussion.

METHODS

Patients operated in a period 2005-2021 were analyzed in this study. All patients preoperatively underwent computed tomography (CT) scan, CT-angiography, and magnetic resonance imaging (MRI). Visual function of the patients was assessed pre-op, post-op and at the follow-up. Duration of visual dysfunction was noted as well. Surgical details were also extracted from medical notes. All patients were followed up, and control MRI was performed one month after operation. We assessed surgical series of optochiasmatic cavernomas published for last 10 years. Further comparative analysis with our data was performed.

RESULTS

Five patients were included into this study. There were four men and one woman. Mean age comprised 33.8 years (range 20-48 years). Most patients were admitted to our hospital due to visual disturbances (80%). Visual function improved in four patients. Visual function was unchanged in one patient, lacking visual disturbancies pre-op. Complication developed in one patient.

CONCLUSIONS

Optochiasmatic cavernomas are encountered extremely rare. Despite the use of contemporary diagnostic options, differential diagnosis remains challenging. Full diagnostic work-up is mandatory. After the diagnosis is made, surgical treatment should be considered first. Total microsurgical or endoscopic transsphenoidal removal of the optochiasmatic cavernoma is a relatively safe and effective treatment method facilitating improvement of visual function.

III cranial nerve cavernous malformation: A case report and review of the literature

Background:

Cavernous malformations generally occur in brain parenchyma but rarely these lesions arise from cranial nerves (CNs).

Case Description:

This paper described a case of a woman presented with III CN dysfunction due to the presence of a right III CN cavernoma. Surgical treatment with nerve sparing gross total resection was performed. A 3-month follow-up was documented.

Conclusion:

Only few cases of CNs cavernomas have been described in the literature. These lesions have been described to show a more aggressive behavior compared to intraparenchymal cavernomas, especially in symptomatic patients. Differential diagnosis and surgical treatment could be challenging, especially trying to preserve nerve integrity and function.

Cavernous Hemangioma of the Chiasm and Left Optic Nerve

Cavernous malformations (CMs) of the optic nerves, chiasm, and optic tract are very rare. This report describes a 26-year-old man who presented with recurring headaches, loss of vision in his left eye, and elevated blood pressure. After being diagnosed with glioma of the chiasm, he was referred to our department. Magnetic resonance imaging revealed signs of a mass lesion of the left chiasmal area, a finding confirmed after transcranial biopsy. In February 2015, he underwent gross total resection of the cavernous angioma of the chiasm and the left optic nerve. Three months later, the patient's vision returned to normal. The absence of a typical clinical picture and the lack of radiological visualization can hinder pathologic diagnosis. Total microsurgical resection is the optimal treatment strategy for patients with CMs of the chiasm and optic nerve because it usually results in improved vision and long-term benefits. The results in this patient demonstrate the importance of rapid diagnosis and gross total surgical resection of CMs of the chiasm and left optic nerve.

[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.

Transnasal endoscopic removal of a retrochiasmatic cavernoma: A case report and review of literature

Background:

Cavernomas arising in the region of the optic apparatus are extremely rare, accounting for <1% of all the central nervous system cavernomas. Most patients are affected by acute visual disturbances related to hemorrhagic events. A prompt resection of the lesion together with a decompression of the optic apparatus may lead to a functional improvement. Almost all patients reported in literature were treated by means of a craniotomy, whereas only few papers described the use of a transnasal approach.

Case Description:

We report the case of a 53-year-old woman with a hemorrhagic, cavernous malformation of the optic chiasm region and we discuss the technical nuances of the endoscopic transnasal approach we employed. We also review literature for patients with cavernomas treated with a transsphenoidal approach. In our case, the patient underwent the gross-total resection of the lesion through a fully endoscopic transnasal route and the visual disturbances improved immediately after the operation. The ventral access allowed an adequate exposure of the chiasm/anterior circulation complex, thus avoiding an excessive dissection and retraction of neurovascular structures. Moreover, with the aid of angled scopes, we were able to identify the frail vascular supply of the chiasm by employing the suprachiasmatic corridor as well as the infrachiasmatic one. We stress the need for a careful reconstruction of the skull base to avoid a postoperative cerebrospinal fluid leak.

Conclusions:

With the evolution and spreading of the neuroendoscopic techniques, in selected cases, we advocate the use of the transnasal route for the removal of cavernomas arising in the region of the anterior optic pathways.

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.

Optic chiasmal cavernous angioma: A rare suprasellar vascular malformation

Background:

Suprasellar cavernous malformation in the optic pathway is not commonly encountered. To date, there are only few reports present in the literature.

Case Description:

The authors report a rare case of suprasellar optic pathway cavernous malformation in a 33-year-old female who presented with progressive visual loss. Her imaging revealed a large heterogeneous, hyperintense, hemorrhagic right suprasellar extra-axial complex cystic structure, causing mass effect on the adjacent hypothalamus and third ventricle displacing these structures. Gross total resection of the lesion was achieved utilizing a right frontal craniotomy approach. Histopathological examination confirmed the diagnosis of suprasellar chiasmal cavernous malformation.

Conclusion:

Although visual pathway cavernous malformation is a rare event, it should be included in the differential diagnosis of lesions occurring suprasellarly in the visual pathway and hypothalamus.

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.

Cavernous malformation of the optic chiasm: An uncommon location

BACKGROUND

Cavernous malformations (CMs) of the optic chiasm are rare lesions often presenting with acute chiasmal syndrome or a progressive visual loss. The case of a 48-year-old female with an intrachiasmatic CM is presented.

CASE DESCRIPTION

The patient presented with an insidious history of progressive visual loss. Magnetic resonance imaging (MRI) showed a CM in the suprasellar region. The patient was operated via a right pterional approach with a complete lesion removal. The postoperative course was uneventful. Early postoperative ophthalmological examination revealed minimal improvement of the vision in the left eye.

CONCLUSION

The clinical, neuroradiological, and intraoperative findings are presented, along with a review of the literature.

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).

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.

Optochiasmatic cavernous angioma with rapid progression after biopsy despite radiation therapy

We present a rare case of optochiasmatic cavernous angioma (CA) that progressed despite radiation therapy. A 31-year-old female patient presented with sudden loss of left visual acuity and right homonymous hemianopsia. Magnetic resonance imaging (MRI) revealed a suprasellar mass and findings compatible with a craniopharyngioma or an optic glioma with bleeding. An open biopsy was conducted using the transcranial approach, and histological examination revealed gliosis. During the one-year follow-up period, imaging suggested intratumoral bleeding and the mass continued to grow. We recommended re-operation, but the patient refused due to fear of surgery. Consequently, the patient received fractionated radiation therapy (3,000 cGy) to the parasellar area. Despite the radiotherapy, the mass continued to grow for the following 6 years. The final MRI before definitive treatment revealed a multilobulated, multistage hematoma with calcification in the parasellar area, extending into the third ventricle and midbrain. The patient ultimately underwent reoperation due to the growth of the tumor. The mass was completely removed with transcranial surgery, and the pathologic findings indicated a cavernous angioma (CA) without evidence of glioma. As shown in our case, patients may suffer intratumoral hemorrhage after biopsy and radiotherapy. This case places the value of biopsy and radiotherapy for a remnant lesion into question. It also shows that reaching the correct diagnosis is critical, and complete surgical removal is the treatment of choice.

Cavernous malformation of the cisternal trigeminal nerve

Intradural extraaxial cavernous malformations (CM) are very rare. We report a case of CM originating from the cisternal portion of trigeminal nerve in a 20-year old male. Surgery produced favourable outcome in this case.

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.

Spinal accessory nerve cavernous malformation

We present the first reported case of a spinal accessory nerve cavernous malformation. A 54-year-old Caucasian male presented with a several-year history of progressive, vague bilateral upper and lower extremity paresthesias and pain. MRI of the spine revealed a heterogenously enhancing mass in the dorsal aspect of the spinal canal at the level of the atlas with mild spinal cord compression. The lesion was resected and upon gross and histologic examination it was a cavernous malformation embedded within a branch of the spinal accessory nerve. Post-operatively, the patient had no complications and some improvement in his symptoms. To our knowledge, this is the first report of a patient with a spinal accessory nerve cavernous malformation, and this should be considered in the differential of lesions in the craniocervical region.

Right Third Nerve Palsy Caused by Extra-Axial Cavernoma in a Patient with Multiple Intracranial Cavernomas

We report an unusual case of a 54-year-old man with third nerve palsy caused by an extra-axial cavernoma in relation to the cisternal portion of the oculomotor nerve. In addition to this lesion, the patient had multiple intracranial cavernomas. Interestingly, an initial MRI without T2* gradient sequence missed the multiple cavernomas. A subsequent MRI done after one month showed an increase in size with fluid level within the extra-axial cavernoma.