Acute visual deterioration and headaches in a patient with suprasellar lesion: Answer

Abstract

•Cavernous malformation should be a differential diagnosis of suprasellar lesions.•Management of asymptomatic optic apparatus cavernous malformation is still debatable.•The relative risk of visual deterioration after repetitive hemorrhage may be higher than the risk of surgical removal. D. Optic tract cavernoma The patient underwent surgery through a left pterional craniotomy, and the intraoperative findings revealed a cavernoma in the left optic chiasm extending forward into the left optic nerve and posteriorly to the optic tract. (Fig. 3). Cavernous malformation (CM) is a common intracranial vascular lesion and accounts for 10 – 15% [1Tan T. Tee J.W. Trost N. McKelvie P. Wang Y.Y. Anterior visual pathway cavernous malformations.J Clin Neurosci. 2015; 22: 258-267Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 2Moriarity J.L. Clatterbuck R.E. Rigamonti D. The natural history of cavernous malformations.Neurosurg Clin N Am. 1999; 10: 411-417Abstract Full Text PDF PubMed Google Scholar] of the cases. The most common location is supratentorial (80%), brainstem (15%), and spinal cord (5%). Optic nerve CMs are very rare, with only 70 cases reported in the literature [3Voznyak O. Lytvynenko A. Maydannyk O. Kalenska O. Hryniv N. Cavernous Hemangioma of the Chiasm and Left Optic Nerve.Cureus. 2020; 12e8068PubMed Google Scholar, 4Hempelmann R.G. Mater E. Schröder F. Schön R. Complete resection of a cavernous haemangioma of the optic nerve, the chiasm, and the optic tract.Acta Neurochir (Wien). 2007; 149: 699-703Crossref PubMed Scopus (30) Google Scholar, 5Mano Y. Kumabe T. Saito R. Watanabe M. Tominaga T. Cavernous malformation of the optic pathway mimicking optic glioma: a case report.Childs Nerv Syst. 2014; 30: 1753-1758Crossref PubMed Scopus (7) Google Scholar, 6Hassler W. Zentner J. Wilhelm H. Cavernous angiomas of the anterior visual pathways.J Clin Neuroophthalmol. 1989; 9: 160-164PubMed Google Scholar]. The relative risk of hemorrhage from asymptomatic supratentorial cavernomas is 0.7 to 3.1% per year [[7]Liu J.K. Lu Y. Raslan A.M. Gultekin S.H. Delashaw J.B. Cavernous malformations of the optic pathway and hypothalamus: analysis of 65 cases in the literature.Neurosurg Focus. 2010; 29: E17https://doi.org/10.3171/2010.5.FOCUS10129Crossref PubMed Scopus (45) Google Scholar] Management of asymptomatic CM within the optic apparatus is problematic and requires consideration of the relative risk of hemorrhage with devastating visual loss consequences against those of surgery. In contrast, the risk increases in patients with previous hemorrhages up to 3.8% to 22.9% [[7]Liu J.K. Lu Y. Raslan A.M. Gultekin S.H. Delashaw J.B. Cavernous malformations of the optic pathway and hypothalamus: analysis of 65 cases in the literature.Neurosurg Focus. 2010; 29: E17https://doi.org/10.3171/2010.5.FOCUS10129Crossref PubMed Scopus (45) Google Scholar]. Since a small hemorrhage from a cavernoma located in the anterior optic apparatus could have catastrophic consequences, we recommend resection of the lesion in cases with radiological or clinical evidence of hemorrhage [[8]Crocker M. DeSouza R. King A. Connor S. Thomas N. Cavernous hemangioma of the optic chiasm: a surgical review.Skull Base. 2008; 18: 201-212Crossref PubMed Scopus (20) Google Scholar], as subsequent hemorrhage risk with visual loss is increased (Fig. 1, Fig. 2).Fig. 2A) Axial T1-weighted gadolinium-enhanced MRI, and B) axial T2-weighted MRI showing a left side non-enhancing hypointense suprasellar lesion, in a 62-year-old woman.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig. 3A) Intraoperative image of the left optic tract cavernoma removal (blue arrow) through a left pterional craniotomy, compressing the left optic nerve (red arrow) B) Intraoperative image after removal of the cavernoma, showing the left optic tract (blue star) and the optic chiasm (blue arrow head).View Large Image Figure ViewerDownload Hi-res image Download (PPT) The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Acute visual deterioration and headaches in a patient with suprasellar lesion: QuestionJournal of Clinical NeuroscienceVol. 86PreviewA 62-year-old woman presented with a history of headaches for two weeks and sudden loss of vision in her left eye. Neurological examination revealed right eye acuity 6/6, left eye 6/9.5, left eye relative afferent pupillary defect (RAPD), red desaturation reduced in the same eye, confrontation visual fields showed non-congruent right homonymous hemianopia. Fundoscopy did not show any sign of papilledema or chronic optic atrophy (Fig. 1). There was no other focal neurological deficit [1–8]. Full-Text PDF