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 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.