A 52-year-old male was admitted with a paroxysmal headache in the right parietal region accompanied by visual disturbance in the right eye for over 2 months. Both symptoms mostly occurred in the morning and could be partially relieved with ibuprofen. He had a 2-year history of diabetes mellitus type 2 well controlled with metformin and repaglinide. He was afebrile and neurological examination was unremarkable. CT scan showed a mass in sphenoid sinus and cavernous sinus with bone destruction (Fig. a). MRI showed a 20 × 25 mm circular intrasellar mass with hyperintensity T1WI and T2WI, heterogeneously gadolinium-enhancement, and adjacent meningeal enhancement. The lesion extended bilaterally into the cavernous sinus and formed a 12 × 11 mm mass (Fig. b–d). The patient underwent a trans-sphenoidal mass excision and debridement. The lesion was solid and cystic with yellow-brown fluid and a gray wax-like solid component. A biopsy was performed immediately and histopathologic examination revealed Aspergillus species (Fig. e). Post-operative physical and neurological examination showed obvious improvement of headache and visual disturbance. Post-operative images indicated the resection of the mass (Fig. f). Examination after a follow-up of 20 months showed no clinical symptoms.
A 50-year-old female was admitted with a paroxysmal boring pain in the left parietal and left frontal region for 9 months, accompanied by progressive vomiting and decreasing of visual acuity and proptosis in the left eye. Headache could be relieved by diclofenac sodium. Two months prior to presentation, her headache worsened extending to the whole left side of the face, accompanied by numbness. No light perception or reflex was detected in the left eye. Horizontal movement was limited in the left eye. Pre-operative CT showed a 29 × 20 mm isodense lesion with heterogeneously enhancement in the region of the left cavernous sinus, left orbital apex, left optic nerve canal, and sphenoid sinus. Bone destruction could be seen in the left wall of the sphenoid sinus. The optic nerve could not be distinguished from the lesion (Fig. a). MRI showed a 21 × 26 mm patchy lesion that was isointense on T1WI and hyperintense on T2WI in the left cavernous sinus region (Fig. b, c). Enhanced-MRI showed noticeable enhancement of the lesion. The lesion was closely related to the dura mater and extended to the sphenoid sinus and optic apex, partly surrounding the left internal carotid artery (Fig. d). MRA suggested stenosis in the cavernous segment of the left internal carotid artery and A1 segment of the left anterior cerebral artery. The patient underwent partial mass excision via a pterional craniotomy due to its close attachment to the ophthalmic branch and maxillary branch of the trigeminal nerve. The lesion was partly fibrotic and partly a milk-white viscous substance. A biopsy was performed immediately and histopathologic examination revealed Aspergillus species (Fig. e). The patient was administered voriconazole after surgery. Post-operative images indicated the resection of the mass (Fig. f). Examination after a follow-up of 15 months showed a complete resolution of the headache. Her vision of the left eye was not regained.