A 53-year-old woman was admitted to our institution complaining of a mild fever, severe headache, and progressive visual loss that had started 4 days before. On admission, the general condition of the patient and the results of the gross neurological examination were unremarkable. Goldmann perimetry testing showed bitemporal hemianopsia. Her visual acuity was 20/400 in the right and 20/200 in the left eye. A computed tomography scan showed a hyperdense, hemorrhagic mass measuring approximately 2.5 cm in diameter in the suprasellar region []. A magnetic resonance (MR) imaging scan [ and ] better outlined the mass: it affected both the pituitary stalk and the hypothalamus while reaching cranially the left Monro foramen and compressing the optic nerves and chiasm, a clear signal of an ongoing edema. Cerebral angiography showed no vascular malformation. The results of routine blood and serum examinations were normal. Endocrinological studies of the pituitary function were unremarkable. After 3 days, the patient underwent a gross-total resection of the lesion through an extended endoscopic, endonasal, transsphenoidal route. The resection of the lesion was combined with the opening of the third ventricle through the lamina terminalis. A careful reconstruction of the skull base was performed, with abdominal fat, nasal septal flap, and fibrin glue. After the operation, the visual symptoms improved immediately. On discharge, visual acuity was 20/50 in the right eye and 20/20 in the left eye. The patient had a transient incomplete hypopituitarism and mild diplopia which improved after few weeks. After 1 month, the neurological examination was unremarkable. Postoperative MR scan is showed in and . Histological findings confirmed the presence of a CM, showing hemosiderin, reactive fibrohistiocytic, ectatic vascular channels, and dilated cavernous spaces. On immunohistochemistry, the lesion was positive for CD34 staining, marker for endothelial lining, and was negative for elastin staining, thus ruling out an arteriovenous malformation. See showing the main steps of the endoscopic surgery.\nThe PubMed search engine () was used to perform an internet Medline literature research based on the following keywords “chiasma,” “optic,” “sovrasellar,” “CM,” “endoscopic,” and “transsphenoidal” with different combination. There were no limitations as to the timeframe, language, and publication type on the search process. We also cross-checked the references of the articles retrieved by looking for further papers of potential interest.
A 40-year-old female with past medical history of migraine and no family history of CM, presented with unilateral scotomas with a gradual onset over 7 months and progressive visual deterioration, referred as blurred vision of the right eye (RE), with a significant worsening few days before seeking medical care.\nShe was initially admitted at Ophthalmology outpatient clinic for observation. The ophthalmologic evaluation revealed a decreased visual acuity (7/10) and a visual field defect on the RE. Her left eye (LE) was completely normal (10/10, without field defect). The computerized campimetry (CC) disclosed a supero-inferior arciform defect in the RE. LE CC was normal [].\nVisual evoked potential responses showed results compatible with a right second cranial nerve dysfunction due to compressive optic neuropathy on the RE. A noncontrast enhanced computed tomography (CT) scan was performed and revealed a spontaneous hyperdense focal nodular lesion, heterogeneous, with irregular contours and a punctate area of increased attenuation coefficient related to calcification, on the right optic-carotid cistern, adjacent to the ipsilateral ON. No surrounding edema or mass effect was documented. No evidence of subarachnoid or intraventricular hemorrhage [].\nBased on the CT scan result, the patient was referred to the outpatient clinic of the Neurosurgery Department. She completed the diagnostic neuro-imaging evaluation with a CT angiography (CTA) [], a magnetic resonance imaging (MRI), and a MR angiography (MRA) of the brain.\nThe MRI showed a focal solitary well-defined rounded lesion involving the right ON in its intracranial prechiasmatic segment, sparing the chiasm. The T1-weighted noncontrasted sequence showed a spontaneously hyperintense lesion [Figures -]. In the T2-weighted MRI, the lesion exhibited a heterogeneous signal intensity and a peripheral hypointense rim [. No large vessels adjacent to the lesion were identified.\nThe MRA demonstrated a hyperintense mass due to hemosiderin. No enlarged vessels were identified [].\nThese features were considered to be consistent with an occult vascular malformation, presenting an inner hematoma (blood and blood by-products in various states of evolution) surrounded by a peripheral hemosiderin rim, suggesting the diagnosis of a CM of the intracranial segment of the right ON.\nThe patient complaints remained unchanged for one week. After this period of time, she was electively operated on, through a right pterional craniotomy. An intradural optic canal unroofing, through a drilling technique, was performed to completely expose and microsurgically remove the CM []. The CM was found over the superior surface of the ON at the entrance of the optic canal with an anterior canalicular extension.