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| LETTER TO EDITOR |
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| Year : 2013 | Volume
: 61
| Issue : 4 | Page : 442-443 |
Cavernous sinus but not intrasellar cavernous hemangioma
Bao-Yuan Zhou, Bo-Wen Cai, Yan-Hui Liu, Ying-Jun Fan
Department of Neurosurgery, West China Hospital, Chengdu City, Sichuan Province, China
| Date of Submission | 10-Jun-2013 |
| Date of Decision | 14-Jun-2013 |
| Date of Acceptance | 21-Jul-2013 |
| Date of Web Publication | 4-Sep-2013 |
Correspondence Address:
Bo-Wen Cai
Department of Neurosurgery, West China Hospital, Chengdu City, Sichuan Province
China
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.117603
How to cite this article:
Zhou BY, Cai BW, Liu YH, Fan YJ. Cavernous sinus but not intrasellar cavernous hemangioma. Neurol India 2013;61:442-3 |
Sir,
Intrasellar cavernous hemangiomas are extremely rare and the origin of the lesion is uncertain and the optimal treatment is controversial. We present a rare case of intrasellar cavernous hemangioma.
A 33-year-old female patient presented with dizziness, blurred vision of 2 months duration. Magnetic resonance imaging (MRI) revealed intrasellar and suprasellar lesion surrounding left internal carotid artery, with hyperintense in T2-weighted images, isointense in T1-weighted images, obviously homogeneous enhancement on gadolinium-enhanced T1-weighted images [Figure 1]a-c. The lesion volume was 9.55 ml (24 mm × 19 mm × 40 mm) (the formula used to compute volumes was the standard volume of an ellipsoid, as follows: V = 1/6 pi a × b × c, where a, b and c are the three diameters [1] ). Computerized visual-field examination showed bilateral vision field defect. The endocrinological studies revealed hyperprolactinemia (prolactin 119.90 ng/ml). Relevant medication history, which affects prolactin levels, was denied. A non-functional pituitary adenoma was diagnosed pre-operatively. Direct trans-nasal transsphenoidal approach surgery was performed under the microscope. Needle puncture revealed highly vasculized mass. The dura over the sella was opened and a firm, fibrous vascular mass was encountered. Lesion was too tenacious to scrape and an attempt to tear the lesion was made but to no avail. There was profuse bleeding during the surgical procedure. A biopsy was performed to avoid disrupting the saddle diaphragm. Pathologic analysis of a frozen specimen revealed a tendency of angiogenic tumor. Histological studies revealed grossly large dilated blood vessels, intermingled with micro-hemorrhage. Immunohistochemical techniques reveal a CD34(+), supporting the diagnosis of cavernous hemangioma [Figure 2]. There were no post-operative complications. Patient was treated by gamma knife with margin doses of 12 Gy and isodose curves 50% [Figure 3]. At 6 months after surgery and gamma knife, MRI showed a lesion shrink to 0.87 ml (11 mm × 9 mm × 17 mm). The part involving the sella turcica disappeared and the left cavernous sinus was still involved [Figure 1]d and e. | Figure 1: (a‑c) Pre‑operative magnetic resonance imaging showing (a) hyperintense in T2‑weighted images, (b) isointense in T1‑weighted images, (c) obviously homogeneous enhancement on gadolinium‑enhanced T1‑weighted images. (d and e) 6 months after surgery and gamma knife, magnetic resonance imaging showing lesion shrink
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 | Figure 2: Histological examinations (H and E, ×100). Immunohistochemical techniques reveal a CD34‑positive, denoting existence of endothelial cells of blood vessels
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The term of "intrasellar cavernous hemangiomas" was used to refer to cavernous hemangiomas mainly or soundly involving the intrasellar in the cases ever reported. The authors believe it is a type of cavernous sinus hemangiomas growing into the sella. [2] Cavernous sinus hemangiomas may originate from components of the cavernous sinus itself or from the surrounding tissues. [3] There are two patterns of growths, when cavernous hemangiomas grow within the dural sinuses: Exophytic extension and endophytic growth. They can grow within the cavernous sinus with a medial extension into the sella, a lateral extension into the middle cranial fossa and an anterior extension into the superior orbital fissure. Intrasellar cavernous hemangiomas are extremely rare and there are eight cases reported. [4],[5] The authors present a very rare case of an intrasellar cavernous hemangioma with invading left cavernous sinus. At 6 months after the gamma knife treatment, the part involving the sella turcica disappeared and the left cavernous sinus was still involved. In fact, it is more appropriate to consider it as a cavernous sinus lesion involving the sellar region.
Intrasellar cavernous hemangiomas are highly euangiotic lesions, often resulting in massive hemorrhage while excision. Puncture before resection may provide more information and thus reduce the bleeding risk. One should be wary of the possibility of cavernous hemangiomas, once a blood supplied abundant, tenacious lesions was contoured during operation. Intraoperative pathological findings of a frozen specimen are essential for surgical strategy. Even for an experienced neurosurgeon, total resection is difficult and dangerous. A partial resection or biopsy can be performed to avoid unmanageable bleeding, once a hemangioma is identified.
Gamma knife proved to be effective for hemangiomas of the cavernous sinus and orbit by some reports while avoiding the potentially serious complications associated with surgery. [6],[7] The present patient underwent gamma knife post-operatively without short-term complications. After 6 months of the gamma knife treatment, the lesion volume shrank from 9.55 ml markedly to 0.87 ml. Gamma knife with margin doses of 12 Gy and isodose curves 50% is reasonable.
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[Figure 1], [Figure 2], [Figure 3]
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