Cavernous malformation of the optic chiasm : 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.

Acute management of ruptured cavernous malformation of the optic nerve: illustrative case

BACKGROUND

A cavernous malformation of the optic nerve (CMON) is a rare condition that often presents with an abrupt decline in vision. Acute management of ruptured optic nerve cavernous malformations is generally surgical, although the timing of surgery is controversial.

OBSERVATIONS

A 47-year-old female experienced the sudden loss of vision in her left eye. Examination showed that this eye was nearly blind, and her right eye had a temporal field defect. Neuroimaging showed hemorrhage in her left optic nerve and optic chiasm. She was taken to the operating room on an emergent basis where the optic canal was decompressed, the hemorrhage was evacuated, and a vascular malformation with features of a cavernoma was removed from the optic nerve. Over the next 2 days, the vision in her right eye significantly recovered.

LESSONS

CMONs remain rare, and it is unlikely that enough cases can be gathered to form a larger trial to compare the role and timing of surgery. On the basis of our experience with this case, the authors recommend that acute CMON-related hematomas should be treated as a surgical emergency and managed with acute optic nerve decompression, hematoma evacuation, and cavernoma resection to improve chances of vision recovery and prevent further vision loss.

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.

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.

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.

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.

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 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.