A 33-year-old female presented 3 months postpartum with a headache of moderate severity and progressive visual loss in both eyes. On examination, the patient's Glasgow coma scale (GCS) was 15/15. Visual field examination showed left homonymous incomplete hemianopia. Her visual acuity was 20/25 in the right eye and 20/30 in the left eye. Her discs and macula were healthy bilaterally. Extraocular movements were intact and pupils were reactive. The rest of her examination was unremarkable. Complete endocrine workup was normal.\nMagnetic resonance imaging (MRI) revealed a large heterogeneous, hyperintense, hemorrhagic right suprasellar extra-axial complex cystic structure measuring 31 × 30 × 90 mm on T1-weighted images. There was mass effect on the adjacent hypothalamus and third ventricle displacing them toward the left and superiorly in addition to the optic pathway. The pituitary stalk was displaced toward the left. The lesion encased the right posterior cerebral artery and displaced the right carotid artery laterally []. Computed tomography (CT) arteriography demonstrated a completely thrombosed center. The imaging findings were compatible with suprasellar CM.\nThe patient underwent right frontal craniotomy and gross total resection of her suprasellar intrachiasmatic large infiltrative hemorrhagic CM. Organizing blood clots with reactive fibrohistiocytic and inflammatory reaction admixed with some ectatic vascular channels suggestive of a vascular malformation were noted. There were small foci admixed with granulation tissue, showing some dilated cavernous spaces that would be compatible with a vascular malformation such as cavernous angioma. On immunohistochemistry, the lesion was CD163+, CD20 rare, CD3+, CD34+, CD31+, CD38+, CTK−, EMA plasma cells, GFAP−, S100 dendritic cells, SMA vascular smooth muscle.\nThe patient had an uneventful operative course. Her visual acuity improved to 20/20 in both eyes. Extraocular muscles showed mild limitation of both eyes in an upward gaze. Otherwise, she was stable with no neurological deficits. Follow-up MRI at 12 months revealed complete removal of the suprasellar hemorrhagic CM with no evidence of a residual lesion or recurrence [].
A 17-year-old boy complained of a 2-month history of visual field defects. Two months prior to this, he experienced sudden deterioration of visual acuity on his left eye and visual field defects on the right. His symptoms remained unchanged for the next 2 months. Upon admission, his visual acuity was 0.05 in the left eye and 0.7 in the right eye. Goldmann perimetry field test showed right homonymous hemianopsia without left eye foveal sparing. Brain MR imaging showed a poorly enhanced lesion 1.9 × 1.7 × 2.1 cm in size in the posteroinferior aspect of the optic chiasm (). The mass extended to the perimesencephalic cistern with multiple stages of hemorrhage. A differential diagnosis included CM, craniopharyngioma and germ cell tumor. To decompress the mass effect around the optic chiasm and improve the patient's visual symptoms, surgical decompression via subfrontal interhemispheric approach was performed. A brownish discoloration was noted around the left side of optic chiasm and tract. A dark chocolate-colored hematoma gushed out, and a mulberry-like lesion was removed. The pathological diagnosis was consistent with the CM. The postoperative MR imaging showed partial resection of CM (). At the patient's 1-year follow-up, his visual acuity improved (1.0/0.4), although visual field defect remained unchanged. However, 2 years after the first operation, the patient complained of worsening visual acuity (0.3/finger count 10 cm). Visual field examination showed impairments in which the left eye only detected the right lower quadrant in the visual field and the right eye had nasal hemianopsia. MR imaging revealed recurrent bleeding (). The patient underwent a second operation resulting in a partial resection. Immediately following the second operation, his visual acuity (0.4/finger count 10 cm) and field improved slightly.