Cavernous hemangioma of the optic chiasm: a surgical review

Abstract

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.

Keywords: Cavernoma; apoplexy; cavernous hemangioma; optic chiasm.

Figure 1

(A) T1-weighted sagittal and (B) T1-weighted sagittal post gadolinium images of the pituitary fossa, and (C) T2-weighted axial image of the brain. There is a hypothalamic/posterior chiasmal lesion that measures 1.4 cm in maximum axial dimension. It returns heterogeneous T2-weighted signal characterized by hyperintensity and areas of peripheral and punctate central hypointensity. Nodular areas of T1-weighted hyperintensity are demonstrated with minimal gadolinium enhancement. Craniopharyngioma was felt to be most likely, with partially thrombosed aneurysm, cavernoma, hemorrhagic glioma, and dermoid also being considered.

Figure 2

(A) T1-weighted coronal and (B) T1-weighted sagittal post gadolinium images of the pituitary fossa, and (C) T2-weighted axial image of the brain (one section inferior to Fig. 1). There is no change to the hypothalamic/posterior chiasmal lesion relative to Fig. 1. There is a new area of signal abnormality more anteriorly. This returns T2-weighted hyperintensity with peripheral T2-weighted hypointensity and patchy central T1-weighted hyperintensity. This expands the optic chiasm and prechiasmal optic nerves without associated gadolinium enhancement. Features are consistent with hemorrhagic degradation products.

Figure 3

Histology from the lesion reveals a cavernous hemangioma composed of numerous distended blood-filled channels (hematoxylin and eosin stain, magnification not available).