A 26-year-old man was admitted for recurrent headaches, loss of vision in his left eye, and elevated blood pressure. His loss of sight had been gradual, manifesting for over six months before hospitalization. He also exhibited episodes of inadequate behavior with some aggression. The patient was conscious at admission, and no other meningeal or focal neurological symptoms were found. The patient consented to publication of his protected health information.\nHis right and left eyes had logarithm of the minimum angle of resolution visual acuities of 1.0 and 0.2, respectively. T1-weighted magnetic resonance imaging (MRI) showed a hyperintense signal mass lesion occupying his chiasm and left ON (Figure ). These findings led to a diagnosis of high-grade glioma of the chiasm and left ON, or CM.\nSurgery was performed with the patient in the supine position, with his head slightly elevated and turned to the right side about 30 degrees. A left frontolateral craniotomy was performed to optimize the approach to the chiasm and left ON. Fenestration of the basal cistern and aspiration of cerebrospinal fluid yielded a relaxed brain with satisfactory gravity retraction. The left optic canal was unroofed, and several blood clots at different stages of resorption were evacuated through the longitudinal dissection of the ON. Minimal coagulation currents were applied to occlude the feeding vessels with their sharp sections. Resection was estimated to be gross total (Video ).\nThere were no surgical complications, and MRI performed six months later showed no signs of CM recurrence (Figure ). The patient was discharged after seven days, and his vision returned to normal three months later. He is still in touch with us and has reported no signs of visual deterioration or recurrent bleeding.\nThe microscopic structure of the resected CM with heterochromous thromboses is shown in Figure .
A 27-year-old gentleman, presented with 3 months history of blurring of vision associated with headache. There was no history of loss of consciousness, seizures, or weakness in limbs. Visual examination showed acuity of 6/6 bilaterally with left temporal field defect.\nMRI of brain, T1W, T2 axial, contrast and multiplanar sequences were performed which showed evidence of lobulated mixed signal intensity lesion seen in the optic chiasm, measuring 18 × 11 mm. Multiple hemorrhagic foci of varying sizes were seen within the lesion. No obvious enhancement was seen after IV contrast material injection. On the right side, the lesion was extending anteriorly up to the optic canal and superiorly abutting the hypothalamus. The features were suggestive of CM of the optic chiasm [Figures and ].\nThe lesion was removed neuro-endoscopically through the trans-nasal trans-sphenoidal route. After reaching the sella, dura opened and the pituitary gland was displaced. Under-surface of chiasm was visualized. The lesion was seen on the surface with brownish discoloration. A small incision was made and the lesion could be removed. Post–operatively, there was a transient worsening left temporal field defect. The histopathological examination and features are consistent with organizing hematoma.