Asian Journal of Case Reports in Surgery

5(4): 74-78, 2020; Article no.AJCRS.62646

Difficult Surgical Aspect of a Compressive

Hemangioma of the Cavernous Sinus in a
Neurosurgical Setting in Senegal: About a
Case and Review of the Literature
A. B. Thiam1, F. Athoumane1, M. Malangu1*, C. Mualaba1*, M. Faye1,
M. C. Ba1 and S. B. Badiane1
1
University Cheikh Anta Diop of Dakar, National University Hospital Center of FANN, BP 5035, Dakar,
Senegal.

Authors’ contributions

This work was carried out in collaboration among all authors. All authors read and approved the final
manuscript.

Article Information

Editor(s):
(1) Dr. Asmaa Fathi Moustafa Hamouda, Jazan University, Saudi Arabia.
Reviewers:
(1) José Zenou Costa Filho, University Federal of Alagoas, Brazil.
(2) Jenny Kam Lin Ku Lozano, Cayetano Heredia Peruvian University, Peru.
Complete Peer review History: http://www.sdiarticle4.com/review-history/62646

Received 15 September 2020

Case Report Accepted 18 November 2020
Published 10 December 2020

ABSTRACT

Cavernous sinuses Hemangiomas (CSH) are rare benign extra-axial tumours, mainly affecting
middle-aged women. Symptoms vary, but are usually due to a mass effect and include headaches,
changes in vision and paralysis of the cranial nerves [1]. They account for 13% of all intracranial
cavernous Hemangiomas, 3% of all benign tumours in the Cavernous sinus zone, 2% of all tumours
in the cavernous sinus zone and 0.4% to 2% of intracranial vascular malformations. The occurrence
of hemangioma within the cavernous sinus is rare. They do not cross the dural limits of the corpus
cavernosum and can reach large sizes without symptoms. In the published literature, several short
series describe the management of HSC, but despite advances in surgical techniques, they
continue to pose a formidable challenge to surgical management, primarily because of the critical
neurovascular environment. Current therapeutic modalities include microsurgical resection,
fractional radiotherapy and stereotactic radiosurgery; total resection is curable but can be at the
cost of intraoperative bleeding and new cranial nerve deficits [2,3]. Here we describe the clinical
_____________________________________________________________________________________________________

*Corresponding author: E-mail: mualabcl01@gmail.com;

 Thiam et al.; AJCRS, 5(4): 74-78, 2020; Article no.AJCRS.62646
presentation, imaging results and difficult surgical management of a patient with cavernous
sinusHemangioma enveloping the cavernous segment of the carotid artery, which made surgical
resection difficult.
Keywords: Hemangioma; cavernous sinus; surgery.
1. INTRODUCTION
Cavernous sinuses Hemangiomas (CSH) remain
rare, benign extra-axial tumours, mainly affecting
middle-aged women. Symptoms vary, but are
generally dominated by headache and cavernous
sinus syndrome [1]. They account for 13% of all
intracranial cavernous hemangiomas, 3% of all
benign tumours in the Cavernous Sinus area, 2%
of all tumours in the Cavernous Sinus area and
0.4% to 2% of all intracranial vascular
malformations. The current therapeutic
modalities include microsurgical resection,
fractional radiotherapy and stereotactic
radiosurgery (SRS), while total resection can
heal but at the cost of Intraoperative bleeding
and new cranial nerve deficits [2,3]. Here we
describe the clinical presentation, imaging results
and surgical management of a patient with CSH
enveloping the cavernous segment of the carotid
artery, which made surgical resection difficult.
2. PRESENTATION OF CASE
A 47 year old patient with no particular history,
who had complained about headache and
seizures that had been evolving since one year.
His clinical examination was mainly dominated
by a left cavernous sinus syndrome.
The cerebral CT scan (Fig. 1) revealed a
voluminous left intracavernous lesion
spontaneously iso-dense, homogeneously
enhanced after injection of contrast agent
lateralised at the sellaire level. Brain Magnetic
Resonance Imaging (Fig. 2) revealed an
expansive process in the left intracavernous
cranium: hypo intense in T1, homogeneously
hyper intense in T1 gadolinium, hyper intense in
T2 and hyper intense in T2 Flair, lateralized at
the saddle level of 64.6 mm x 61.5 mm x 47.1
mm and exerts a mass effect on the V3 with
dilatation of the lateral ventricles, sheathing the
carotid siphon, the M1 portion of the middle
cerebrum and the optic nerve.
Microsurgical excision was carried out using a
sub temporal left extra dural approach. The
detachment of the temporal dura mater from the
75
concomitant base was done for the exposure of
the middle meningeal artery, after coagulation of
the latter, we directly noticed a tumour enlarging
the foramen ovale; we dissected the
periforaminal dura mater which allowed us to
expose the foramen rotundum, the foramen
ovale, the petrous part of the temporal bone in
order to see well the petrous portion of the
internal carotid artery; we then proceeded to
open the capsule and debulking the tumour
which had proved to be very haemorrhagic; After
haemostasis, we proceeded with the
individualisation of the intracavernous portion of
the internal carotid artery and then performed a
tumour dissection , a coagulation of its capsule
which allowed the tumour to collapse; we
disconnected all the blood supply of carotid origin
which facilitated, without any risk of
haemorrhage, a monobloc excision of the
cavernous portion of the tumour, leaving an
intracavernous tumour cord which was difficult to
dissect because of the tumour's
vascularnervous relations; after that we proceed
with the closure.
The postoperative follow-up was marked by the
amendment of the cavernous syndrome and the
postoperative CT scan (Fig. 3) showed an
intracavernous tumour cord with resection of the
large part. The anatomopathological examination
concluded that there was a hemangioma of the
cavernous sinus.
3. DISCUSSION
Cavernous sinus hemangioma is the rare
vascular tumour derived from vascular
malformations seen most often in middle-aged
women. The cavernous sinus is an area filled
with nerves and blood vessels. The highly
vascular nature of Cavernous Sinus
Hemangiomas and their proximity to cranial
nerves and the intracavernous portion of the
carotid artery make them difficult to resect
surgically. Traditional surgical resection can
cause cranial nerve dysfunction and massive
bleeding [4]. As in most literature [1-10], our
patient was middle-aged and presented on
admission with a left cavernous sinus syndrome
clinically found in any patient.
 Thiam et al.; AJCRS, 5(4): 74-78, 2020; Article no.AJCRS.62646

A B

Fig. 1. CT brain scan. a voluminous left intracavernous lesion spontaneously iso-dense (A),
homogeneously enhanced after injection of lateralized contrast material at the sellaire level (B)

A B

Fig. 2. MRI an expansive left intracranial intracavernosal process hypo intense in T1 (A), hyper
intense in T1 gadolinium homogeneously (B), lateralized at the sellaire level of 64.6 mm x 61.5
mm x 47.1 mm and exerts a mass effect on the V3 with dilation of the lateral ventricles,
sheathing the carotid siphon, the M1 portion of the middle cerebrum and the optic nerve

Fig. 3. CT post-operative brain scan: subtotal exeresis of the lesion with tumour residue at the
lateral wall of the left cavernous sinus

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 Thiam et al.; AJCRS, 5(4): 74-78, 2020; Article no.AJCRS.62646
Brain Magnetic Resonance Imaging is has an
important role in monitoring hemangiomas of the
cavernous sinus. These lesions usually show
hypo or iso intensity on T1-weighted images and
hyper intensity on T2-weighted images; these
imaging results alone confer a differential
diagnosis of meningiomas, Schwannomas,
pituitary adenomas and hemangiomas of the
cavernous sinus. MRI of hemangiomas of the
cavernous sinus usually reveals a hyper T2
intensity, a linear intra-tumour hypo intensity
usually washed out by homogeneous
improvement in intravenous contrast, probably
representing thin-walled vessels in the vascular
malformation. Hemangiomas of the cavernous
sinus generally appear more hyper intense than
meningiomas and pituitary tumours, and a
heterogeneous enhancement pattern of
hemangiomas may differentiate them from the
intense enhancement observed with
Schwannomas. Some studies have observed
hyper intensity with peripheral enhancement
leading to a model central hyper intensity with
timed contrast administration which is classically
seen in hepatic cavernous hemangiomas [1,5]. In
our context, the tumour was on MRI hypo-intense
in T1 (Fig. 1A), homogeneously hyper-intense in
T1 gadolinium (Fig. 1B), A B hyper-intense in T2
and hyper-intense in T2 Flair, which is identical to
what is reported in the literature. Surgical
management depends on the type of lesion.
Cavernous Sinus Tumours can be divided into
three types: Type I (tumour originating from the
Cavernous Sinus) such as hemangiomas and
metastases, Type II (tumours originating from the
side wall of the Cavernous Sinus) such as
meningiomas and Schwannomas and Type III
(foreign origin and occupying Cavernous Sinus)
such as pituitary adenomas, chordomas,
nasopharyngeal carcinoma, petroclival
meningioma [3].
Several surgical approaches are possible for the
removal of a hemangioma of the cavernous
sinus, notably the intradural, extradural and
endoscopic trans sphenoidal endo nasal
approach [6,7,3,8]. In our context, tumour
removal was performed by sub temporal extra
dural approach, leaving an intimate tumour cord
on the lateral wall of the cavernous sinus,
adjacent to the vascular and nerve structures of
the region.
The postoperative follow-up was marked by the
remission of the cavernous syndrome. Several
per and postoperative surgical complications of
77
hemangiomas of the cavernous sinus are
possible, including haemorrhage, death,
ophthalmoplegia, rarely permanent paralysis of
the abducens nerve.
Morbidity and mortality after surgery for
cavernous sinus injuries is generally 38% [1,4].
Contrary to the literature, our patient's
postoperative sequelae were marked by the
amendment of the cavernous syndrome and no
postoperative neurological signs. Because of the
high mortality and morbidity rates associated with
surgery, if complete surgical resection cannot be
achieved, radiotherapy should be considered
[1,4,7,9,10].
Stereotactic radiosurgery has given good
postoperative results as primary and
complementary therapy. Radiation-induced
thrombosis of the tumour blood vessels reduces
the volume of the tumour, leading to reduction in
size or cessation of tumour growth with
resolution of the symptoms of nerve centre
compression. Scar formation with preoperative
radiation could prevent subsequent surgical
resection. Treatment of small lesions with
radiosurgery and large ones with fractional
stereotactic radiotherapy is still controversial.
The strategy remains to use stereotactic
radiosurgery for small tumours (3cm
preoperatively, radiotherapy is conventionally
used to reduce the tumour [3].
Although recommended, radiotherapy is difficult
to access in our environment due to the low
social level of our populations, thus limiting
optimal care.
4. CONCLUSION
Hemangiomas of the cavernous sinus are rare
extra-axial benign tumours, whose clinic is often
dominated by headache and cavernous sinus
syndrome (Diplopia, ptosis or paralysis of the
extra ocular nerve). Magnetic resonance imaging
often shows a hyper intense T2 lesion with
improvement after gadolinium administration.
The surgical management of these lesions
depends on the clinic and the size of the tumour.
Surgical resection is sometimes difficult because
of the vascular-nervous connections at the site of
the lesion, there may be significant morbidity and
surgery is not indicated in asymptomatic patients.
Radiotherapy plays an essential role in the
management of these tumours, with excellent
long-term control rates.
 Thiam et al.; AJCRS, 5(4): 74-78, 2020; Article no.AJCRS.62646

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