Keywords

1 Epidemiology and Clinical Presentation

  • Cavernous sinus cavernous hemangiomas (CSCHs) are distinct from cavernous malformations (angiomas) [1].

  • CSCHs are benign vascular tumors, not true vascular malformations; they frequently present with headaches and cranial nerve paresis [1, 2].

  • Cavernous angiomas, on the other hand, are true vascular malformations that may be located anywhere in the brain. (See Chap. 61.)

  • CSCHs comprise 2–3 % of cavernous sinus tumors.

  • The mean age of patients with CSCHs is 43 years; there is female predilection [3].

  • CSCHs occasionally may extend medially into the sella turcica and mimic pituitary adenomas [4–9].

  • CSCHs represent 0.07 % of lesions treated in major transsphenoidal series [10].

  • In rare cases, cavernous hemangiomas may arise in the sphenoid sinus, potentially resulting in visual deficits and headaches [11].

2 Imaging Features

  • On MRI, CSCHs often show hypointensity or isointensity on T1-weighted imaging and hyperintensity on T2-weighted imaging (Fig. 33.1). Avid contrast enhancement is common in CSCHs [12, 13].

  • On dynamic-enhancement MRI, CSCHs typically demonstrate heterogeneous contrast enhancement with initial enhancement [3].

  • In angiographic studies, one third of CSCHs are occult; a blush in the cavernous sinus can be seen for the other two thirds [1].

Fig. 33.1
figure 1

Cavernous sinus cavernous hemangioma. (a) Axial T2-weighted MRI showing a rounded, hyperintense lesion in the left parasellar region and cavernous sinus. (b) Axial T1-weighted MRI shows the same lesion that is isointense to gray matter. (c, d) Axial and coronal contrast-enhanced T1-weighted MRI shows avid contrast enhancement of the left cavernous sinus hemangioma (adapted from Tannouri et al with permission, Neuroradiology. 2001;43:317–320)

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3 Histopathology

  • CSCHs are frequently lined by a pseudocapsule. Vascular channels are commonly seen, with intratumoral hemorrhage and calcification being rare findings in CSCHs (Fig. 33.2).

  • CSCHs can be classified as one of two subtypes [14]:

    • Type A CSCHs are characterized by adjacent thin-walled, sinusoidal vessels with little intervening connective tissue. These CSCHs are associated with a high degree of intraoperative bleeding.

    • Type B CSCHs are characterized by more interconnective tissue and fewer sinusoidal vessels. These CSCHs are easier to resect surgically because they are associated with less bleeding.

Fig. 33.2
figure 2

Masson trichrome stain showing a cavernous hemangioma with compact, sclerotic vessels and little interstitium (adapted from Tannouri et al with permission, Neuroradiology. 2001;43:317–320)

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4 Clinical and Surgical Management

  • When necessary, surgical resection of a symptomatic cavernous sinus cavernous hemangioma may be performed via an endonasal endoscopic approach or craniotomy [4].

  • The extradural temporopolar approach to the cavernous sinus is often utilized when open craniotomy is recommended [15].

  • Injection of fibrin glue has been successfully used to control intraoperative bleeding during resection of CSCHs [16].

  • Although recurrence rates are low following surgical resection via craniotomy, the incidence of cranial nerve paresis is rather high [2].

  • As a less invasive alternative, stereotactic radiosurgery has been successfully and safely used to treat CSCHs. Tumor volume is decreased in up to 80 % of cases. The typical treatment dose is 13–14 Gy [12, 17, 18].