Cavernous hemangioma extending to extracranial, intracranial, and orbital regions

Extra-Axial Cavernous Angioma: A Case Report and Review of the Literature

Cavernous angiomas (CAs) are benign vascular malformations predominantly seen in the brain parenchyma and therefore referred to as intra-axial. Extra-axial dural-based cavernous angiomas, on the other hand, are rare vascular lesions found outside of the brain parenchyma. They occur in the middle fossa and may be easily misdiagnosed as meningiomas due to their extra-axial location. In addition, CAs that are located outside the middle fossa, such as in the convexity, have a better prognosis since they are more surgically accessible. Surgical resection is the main treatment of choice in CAs. However, other options, such as embolization and radiotherapy, may also be considered therapeutic choices or additive treatment options. The pathogenesis of CA and the involvement of other factors (genetics or environmental factors) are still unknown and require further investigation. We are presenting a young man who presented for evaluation of seizure-like events without any family history of neurologic conditions. The physical examination was unremarkable except for a slightly antalgic gait. Imaging studies showed an extra-axial left tentorial mass suggestive of a meningioma, hemangiopericytoma, or other extra-axial lesions. The lesion was resected where its vascular nature was mentioned initially, and the histology proved the diagnosis of cavernous angioma. Here we give an overview of the known pathogenesis, causes, clinical features, and diagnostic and therapeutic options in CA. Better knowledge about CA, its causes, clinical features, and treatment options would help clinicians in early diagnosis and patient management.

Multiple nodular dural cavernous angiomas occluding superior sagittal sinus and destructing calvarium: Case report and literature review

Dural cavernous angiomas (CAs) outside the middle cranial fossa are uncommon vascular lesions that generally present with benign clinical course compared to those within the middle cranial fossa. Aggressive invasion of these lesions is less common and mainly involves the skull. Dura sinus invasion and diffused nodular growth are exceedingly rare. We presented a case of a 33-year-old male with multiple nodular CAs growing in a sheet-like pattern along the falx cerebri and convexity dura, which occluded the superior sagittal sinus, destructed calvarium and were associated with an isolated skull CA on the right forehead. Both dura sinus and convexity skull were extensively invaded by these multiple dural CAs without obvious mass effect, suggesting an aggressive infiltration pattern. Invasive dural CAs have been predominantly observed in patients <40 year-old and might be along the extra-axial vasculature. Therefore, cavernous angiomas should be considered in the diagnosis of dura-based invasive lesions and a closer follow-up might be recommended for young patients with dural CAs adjacent to dura sinus or skull.

Venous Malformation (Cavernous Hemangioma) of the Supraorbital Nerve

Cavernous hemangiomas are not true vascular tumors, but rather are slow-flow venous malformations (VMs). They are present at birth as nonproliferating vascular birthmarks composed of anomalous ectatic venous channels. VMs have often been incorrectly called cavernous hemangiomas and cavernous angiomas. These terms have for a long time lead to confusion with the more common proliferating or true hemangioma of infancy. VM has been reported to arise at all sites including skin and subcutaneous layers of the head and neck, face, extremities, liver, gastrointestinal tract, and even the thymus. Although VMs are common intraocular tumors and are involved within intracranial, extraaxial cranial nerves within the cavernous sinus has been sporadically reported, and less often in the supraorbital nerve, an extraocular and extracranial division of the trigeminal nerve has not been reported. The authors present an extremely rare occurrence of VM involving the supraorbital nerve in an 80-year-old female.

Mixed Lymphangioma and Cavernous Hemangioma Within the Ulnar Nerve: A Case Report

BACKGROUND

Lymphangiomas are benign lymphatic vessel hamartomas typically found in the skin or subcutaneous tissue of the head and neck. Although mostly seen in a congenital context, acquired forms have been reported. By contrast, cavernous hemangiomas are benign hamartomas of endothelial origin. They can arise anywhere in the body, but are typically described as arising from the central nervous system.

METHODS

We report the case of a young patient who developed a mixed lymphangioma and cavernous hemangioma within the ulnar nerve. The tumor was removed during an intrafascicular dissection with preservation of all major fascicles.

RESULTS

Postoperatively, the patient retained intrinsic motor function and full sensation returned. This is the first published case of this type of mixed tumor occurring in a peripheral nerve.

CONCLUSIONS

It could not be ascertained whether trauma was the mechanism by which a lymphangioma developed within the peripheral nerve, as has been proposed. Although this is plausible, alternative mechanisms should be considered.

Gamma Knife radiosurgery for hemangioma of the cavernous sinus

OBJECTIVE Cavernous sinus hemangiomas (CSHs) are rare vascular tumors. A direct microsurgical approach usually results in massive hemorrhage and incomplete tumor resection. Although stereotactic radiosurgery (SRS) has emerged as a therapeutic alternative to microsurgery, outcome studies are few. Authors of the present study evaluated the role of SRS for CSH. METHODS An international multicenter study was conducted to review outcome data in 31 patients with CSH. Eleven patients had initial microsurgery before SRS, and the other 20 patients (64.5%) underwent Gamma Knife SRS as the primary management for their CSH. Median age at the time of radiosurgery was 47 years, and 77.4% of patients had cranial nerve dysfunction before SRS. Patients received a median tumor margin dose of 12.6 Gy (range 12-19 Gy) at a median isodose of 55%. RESULTS Tumor regression was confirmed by imaging in all 31 patients, and all patients had greater than 50% reduction in tumor volume at 6 months post-SRS. No patient had delayed tumor growth, new cranial neuropathy, visual function deterioration, adverse radiation effects, or hypopituitarism after SRS. Twenty-four patients had presented with cranial nerve disorders before SRS, and 6 (25%) of them had gradual improvement. Four (66.7%) of the 6 patients with orbital symptoms had symptomatic relief at the last follow-up. CONCLUSIONS Stereotactic radiosurgery was effective in reducing the volume of CSH and attaining long-term tumor control in all patients at a median of 40 months. The authors' experience suggests that SRS is a reasonable primary and adjuvant treatment modality for patients in whom a CSH is diagnosed.

A new classification and clinical results of Gamma Knife radiosurgery for cavernous sinus hemangiomas: a report of 53 cases

BACKGROUND

Cavernous sinus hemangiomas (CaSHs) are rare vascular lesions in the cavernous sinus(CS). Gamma Knife radiosurgery (GKS) provides a treatment modality alternative to microsurgery. This study was conducted to describe a new classification of CaSHs based on their magnetic resonance (MR) imaging findings and determine the efficacy and safety of GKS in a large series of CaSH patients.

METHODS

From April 2007 to November 2012, 53 patients harboring CaSHs were treated using Leksell Gamma Knife model C (before April 2012) or Perfexion (from May 2012 ) at the Gamma Knife Center of Huashan Hospital. Of the 53 patients, 15 with definitive histopathologic diagnoses after surgery, 38 were diagnosed based on their MR imaging findings. There were 15 male and 38 female patients with a mean age of 52 (range, 25-76) years old. The characteristics of MR images of CaSHs were their extremely high homogeneous intensity on T2-weighted and FLAIR images: as bright as cerebrospinal fluid signal. According to the relationship between the carotid line and their location, CaSHs were classified into three types: the intrasellar, parasellar and mixed type. The mean volume of the tumors was 13.2 ± 8.2 cm(3) (range, 1-41 cm(3)). A mean marginal dose of 13.3 Gy (range, 8-15 Gy) was directed to the 49%-64% isodose line (mean 53%).

RESULTS

Of the 53 tumors, 6 (11%) were classified as intrasellar type. Eight (15%) were parasellar type and the other 39 cases(74%) mixed type. The mean radiological and clinical follow-up time of this study was 24 (range, 2-67 months) and 34 months (range, 2-73 months), respectively. The tumor control rate was 100%. The mean tumor volume reduction was 79.5% (range, 16.5%-100%) compared with the pre-GKS volume. Six months after GKS, MR imaging revealed an average of 60.2% tumor volume reduction (range, 16.5%-89.2%). Twenty-nine cases (55%) showed a >80% tumor volume decrease. Neurologically, only two of these patients showed clinical deterioration, and 33 patients demonstrated an obvious improvement in ocular or endocrine disorders. At last follow-up, there were no more complications related to GKS, and none of the tumors progressed.

CONCLUSIONS

Our study showed that GKS is a useful and safe therapeutic method for CaSHs as both a primary and adjuvant treatment. The new classification of CaSHs may help predict their clinical course during tumor development and treatment response after GKS. Further studies with long-term follow-up and larger numbers of cases are necessary to optimize the treatment conditions and verify the benefit of this treatment.

Co-occurrence of a cerebral cavernous malformation and an orbital cavernous hemangioma in a patient with seizures and visual symptoms: Rare crossroads for vascular malformations

Background:

Cerebral cavernous malformations (CCMs) are angiographically occult vascular malformations of the central nervous system. As a result of hemorrhage and mass effect, patients may present with focal neurologic deficits, seizures, and other symptoms necessitating treatment. Once symptomatic, most often from hemorrhage, CCMs are treated with microsurgical resection. Orbital cavernous hemangiomas (OCHs) are similar but distinct vascular malformations that present within the orbital cavity. Even though CCMs and OCHs are both marked by dilated endothelial-lined vascular channels, they are infrequently seen in the same patient.

Case Description:

We provide a brief overview of the two related pathologies in the context of a patient presenting to our care with concomitant lesions, which were both resected in full without complication.

Conclusion:

This is the first known report that describes a case of concomitant CCM and OCH and explores the origins of two pathologies that are rarely encountered together in neurosurgical practice. Recognition of disparate symptomatologies is important for properly managing these patients.

Numbness matters: a clinical review of trigeminal neuropathy

AIM

Trigeminal neuropathies are a group of clinical disorders that involve injury to primary first-order neurons within the trigeminal nerve. We review the spectrum of etiologies underlying both painful and non-painful trigeminal neuropathies, with attention to particularly dangerous processes that may elude the clinician in the absence of a meticulous evaluation. Complications and management issues specific to patients with trigeminal neuropathy are discussed.

METHODS

Retrospective literature review.

RESULTS

Facial or intraoral numbness, the hallmark of trigeminal neuropathy, may represent the earliest symptomology of malignancy or autoimmune connective tissue disease as sensory neurons are destroyed. Such numbness, especially if progressive, necessitates periodic evaluation and vigilance even years after presentation if no diagnosis can be made.

CONCLUSIONS

In the routine evaluation of patients with facial pain, the clinician will inevitably be confronted with secondary pathology of the trigeminal nerves and nuclei. The appearance of numbness, even when pain continues to be the most pressing complaint, necessitates clinical assessment of the integrity of all aspects of the trigeminal pathways, which may also include neurophysiologic, radiographic, and laboratory evaluation.

Gamma knife surgery for cavernous hemangiomas in the cavernous sinus

BACKGROUND

Cavernous hemangioma in the cavernous sinus (CS) is a rare vascular tumor. Direct microsurgical approach usually results in massive hemorrhage. Radiosurgery has emerged as a treatment alternative to microsurgery.

OBJECTIVE

To further investigate the role of Gamma Knife surgery (GKS) in treating CS hemangiomas.

METHODS

This was a retrospective analysis of 7 patients with CS hemangiomas treated by GKS between 1993 and 2008. Data from 84 CS meningiomas treated during the same period were also analyzed for comparison. The patients underwent follow-up magnetic resonance imaging at 6-month intervals. Data on clinical and imaging changes after radiosurgery were analyzed.

RESULTS

Six months after GKS, magnetic resonance imaging revealed an average of 72% tumor volume reduction (range, 56%-83%). After 1 year, tumor volume decreased 80% (range, 69%-90%) compared with the pre-GKS volume. Three patients had > 5 years of follow-up, which showed the tumor volume further decreased by 90% of the original size. The average tumor volume reduction was 82%. In contrast, tumor volume reduction of the 84 cavernous sinus meningiomas after GKS was only 29% (P < .001 by Mann-Whitney U test). Before treatment, 6 patients had various degrees of ophthalmoplegia. After GKS, 5 improved markedly within 6 months. Two patients who suffered from poor vision improved after radiosurgery.

CONCLUSION

GKS is an effective and safe treatment modality for CS hemangiomas with long-term treatment effect. Considering the high risks involved in microsurgery, GKS may serve as the primary treatment choice for CS hemangiomas.

Removal of cavernous malformation of the Meckel's cave by extradural pterional approach using Heros muscle dissection technique

BACKGROUND

We report on a patient with trigeminal neuralgia caused by an extraaxial cavernous malformation (CM) located within Meckel's cave. The lesion was removed via a pterional extradural approach with a modified temporalis muscle dissection technique, which was first described by Heros and Lee. Cadaveric dissections were performed to demonstrate the wider exposure gained by this approach.

METHODS

A 56-year-old man presented with a history of episodic shocklike, right-sided facial pain for 10 years. Neurologic examination revealed diminished sensation in the mandibular division of the right trigeminal nerve. Magnetic resonance imaging showed an ipsilateral enhancing lesion in Meckel's cave.

RESULTS

After placement of a lumbar drain, a right extradural pterional approach was undertaken. By reflecting the temporalis muscle posterolaterally, the craniotomy was extended so that the line of sight was level with the floor of the middle fossa. This allowed access to the lesion without needing to remove the zygoma. The lesion was resected with microsurgical technique. The patient's pain improved significantly after resection, and histopathologic examination confirmed the diagnosis of CM.

CONCLUSIONS

Extraaxial middle fossa CMs arising solely from Meckel's cave are rare. These lesions are safely and simply approached by posteriorly deflecting the temporalis muscle during a pterional craniotomy, avoiding excessive elevation of the anterior temporal lobe or further bony removal.

Cavernous Hemangioma of the Cavernous Sinus, Skin, and Retina: Hemodynamic Changes after Treatment: Case Report

OBJECTIVE

There are several reports concerning cavernous hemangiomas of the skin and central nervous system. Additional retinal involvement has also been reported.

CLINICAL PRESENTATION

The authors report a 69-year-old woman with a giant extra-axial cavernous hemangioma of the right cavernous sinus involving the supra- and parasellar region, retina, and skin.

INTERVENTION

Shrinkage of its cutaneous part lead to subsequent increase of the volume of the intracranial part. Owing to compression of the optic and the oculomotor nerves, oculomotor disturbances, ptosis, and visual impairment to 0.2 occurred. Via a pterional approach microsurgical removal of the tumor except for a remnant of the intracavernous part was performed.

CONCLUSION

Hemodynamic connection between cutaneous, retinal, and intracranial hemangiomas should be considered.