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 42-year-old woman presented with a 6-day history of severe headache and a 3-day history of blurred vision. She had visual field defect in the confrontation test with no other neurological deficits. Ophthalmologic evaluation revealed central scotoma on both eyes () with normal visual acuity. Funduscopic examination showed intact optic discs with no abnormalities. A computed tomography scan showed a 1.3 cm high density ovoid lesion in the right suprasellar area (). Magnetic resonance (MR) imaging showed that the lesion was hypointense in the T2-weighed and T2* gradient-echo (GRE) images and isointense in the T1-weighted images with no vascular abnormalities (). Transfemoral cerebral angiography did not reveal any vascular abnormalities. On the presumptive diagnosis of a hemorrhagic mass such as thrombosed aneurysm, meningioma or CM, craniotomy was performed via a right supraorbital keyhole approach to relieve the mass effect. Once the frontal lobes were retracted, a mulberry-shaped lesion was present at the junction of the right optic nerve and optic chiasm with no connection to the anterior cerebral artery (). The mass was completely removed with no damage to the optic apparatus Histologic analysis confirmed a diagnosis of CM (). The patient made an uneventful recovery after surgery. One year after surgery, the patient's visual symptoms remained unchanged.