Presentation
No history provided.
Patient Data
A large lobulated mass arises from the cavernous sinus, with a larger component extending into the middle cranial fossa displacing the temporal lobe. The cavernous ICA is displaced laterally but not narrowed. It invaginates into the mass rather than true encasement. The mass is of intermediate to low T1 signal and vividly high T2 signal.
Unfortunately, no contrast was administered (unsure as to why - scan is from another institution).
The patient went on to have craniotomy for resection/biopsy but this had to be abandoned due to hemorrhage. At this point, the patient was transferred to another institution for further management.
Evidence of prior right pterional craniotomy with small subdural fluid collection and thickening of the dura.
Large extra-axial mass is evident, involving the right cavernous sinus and extending medially into the pituitary fossa and a large rounded component bulging laterally into the right middle cranial fossa. Pituitary tissue appears separate from the lesion. Overall dimensions are 35mm AP, 45 mm transverse and 40 mm SI, not significantly changed from previously.
There is marked crowding of structures at the orbital apex and mild right proptosis is evident.
Moderate compression of the right side of the optic chiasm, which is compressed against the right hypothalamic region. The mass has increased T2 signal and enhances reasonably homogeneously post administration of contrast. The cavernous segment of the right internal carotid artery appears encased in narrow and there is displaced inferolaterally by the mass, the right M1 segment is displaced anterior to the mass. The mass has raised cerebral blood volume and increased lactate. Evidence of prior infarction/hemorrhage in the right striatocapsular region.
From a right groin approach ( 5 F sheath), bilateral CCA, ICA and ECA angiography was performed.
Distortion of the supraclinoid right ICA remains evident ( narrowing now approximately 20-30%).
The tumor receives its blood supply from right ICA and MCA branches, with no significant ECA supply. No significant supply from the left ICA or ECA.
Incidental note is made of a sessile 2.3mm right ICA bifurcation aneurysm.
The patient went on to have another craniotomy with successful resection.
Histology
MICROSCOPIC DESCRIPTION:
Paraffin sections show an intensely vascular lesion in which there is a complex, haphazard arrangement of enlarged thin-walled vascular channels within fibrous and regionally myxoid connective tissue. The vascular channels are lined by unremarkable endothelial cells. No stromal cells are identified. Immunohistochemistry shows strong staining for CD34 in endothelial cell lining the vascular channels.
There is patchy weak staining for S-100 protein and CD10 in a small number of spindle cells in connective tissue. No staining for inhibin, progesterone receptor (PgR) or neuron specific enolase (NSE) is seen. The features are of a cavernous hemangioma. No evidence of tumor is seen.
FINAL DIAGNOSIS:
Cavernous hemangioma.
Case Discussion
Cavernous hemangiomas of the cavernous sinus are uncommon, and often not thought of resulting in incorrect pre-operative diagnosis. They do however have a relatively characteristic appearance with very high T2 and low T1 signal and gradual puddling contrast enhancement. Familiarity with the entity allows pre-operative diagnosis to be made, and the surgeon can be prepared for bleeding.
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