Surgical Treatment of Cavernous Sinus Cavernomas: Evidence from Vietnam

Case Report Surgical Treatment of Cavernous Sinus Cavernomas: Evidence from Vietnam

Duc-Anh Nguyen 1, Hao The Nguyen 1, Thang Van Duong 1, Binh Hoa Pham 2 and Hoang-Long Vo 3,*

1 Department of Neurosurgery, Bach Mai Hospital, Hanoi 100000, Vietnam; [email protected] (D.-A.N.); [email protected] (H.T.N.); [email protected] (T.V.D.) 2 Department of Neurosurgery, 108 Military Central Hospital, Hanoi 100000, Vietnam; [email protected] 3 Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi 100000, Vietnam * Correspondence: [email protected]; Tel.: +84-98-540-6430

Received: 1 March 2020; Accepted: 13 May 2020; Published: 23 May 2020

Abstract: Cavernous sinus cavernomas, a rare vascular malformation, represents 3% of all benign cavernous sinus tumors. Both clinical and radiological signs are important for differentiating this condition from other cavernous sinus diseases. The best treatment is radical removal tumor surgery; however, due to the tumor being located in the cavernous sinus, there are many difficulties in the surgery. We report a case of a 35-year-old female who only presented sporadical headache. After serial magnetic resonance imaging acquisitions, a tumor measuring 30 mm in the left cavernous sinus and heterogenous enhencement was observed. Then, the patient underwent an operation with an extradural basal temporal approach. Postoperatively, the tumor was safely gross total removed. The patient developed left oculomotor nerve palsy but fully recovered after 3 months of acupunture treatment, and developed persistent left maxillofacial paresthesia. The surgical treatment for cavernous sinus cavernomas may be considered a best choice regarding safety and efficiency.

Keywords: cavernous sinus; cavernoma; tumors; meningioma; oculomotor nerve palsy

1. Introduction Cavernomas, a fourth common cerebral vascular malformation, can be diagnosed easily by magnetic resonance imaging [1]. However, cavernomas in the cavernous sinus is very rare and may be misdiagnosed with several other tumors, such as meningiomas, schwannomas, or pituitary adenomas. Cavernomas is a type of benign vascular tumor, and the patients with cavernomas can be treated if the tumor is totally removed. However, the tumor approach and resection is very diﬃcult with a high risk of morbidity and mortality due to the cavernomas being located in the cavernous sinus. Herein, we present a case of cavernous sinus cavernomas (CSC) that was successfully operated on at a central hospital and review the literature.

2. Case Presentation A 34-year-old female presented with a history of occassional headache without remarkable physical and neurological symptoms. Routine laboratory investigations and pituitary hormonal tests were all normal. She was taken for a magnetic resonance imaging and a mass was discovered in the region of the sellar and left parasellar. The size of the lesion was around 30 mm. It elicited a high signal on T1-weighted and T2-weighted images, strong enhanced gadolinium, and a homogenous intense

Reports 2020, 3, 16; doi:10.3390/reports3020016 www.mdpi.com/journal/reports Reports 2020, 3, 16 2 of 7 surrounding left cavernous internal carotid, pushing downward on the skull base and pushing the pituitary contralaterally (Figure1). ReportsThen, 2020, the3, x FOR patient PEER underwent REVIEW surgery to have resection via the extradural subtemporal approach.2 of 7 After craniotomy and exposing the way to the cavernous lateral wall, the rotundum foramen and ovale Then, the patient underwent surgery to have resection via the extradural subtemporal approach. foramen were continuously dissected. The dural layer of the cavernous lateral wall was rolled up to After craniotomy and exposing the way to the cavernous lateral wall, the rotundum foramen and expose the second and third branches of the trigeminal nerve and the Gasser ganglion. The maxillary ovale foramen were continuously dissected. The dural layer of the cavernous lateral wall was rolled nerve was sacriﬁced by using a sharp knife to open the internal layer of the cavernous sinus along the up to expose the second and third branches of the trigeminal nerve and the Gasser ganglion. The route of the nerve to access the tumor. At this point, the tumor was very soft, friable, and compressible maxillary nerve was sacrificed by using a sharp knife to open the internal layer of the cavernous sinus by cotton or spongel though it easily bled. The lesion was debulked, and controlled suction was along the route of the nerve to access the tumor. At this point, the tumor was very soft, friable, and performedcompressible to remove by cotton the or bulk spongel to nearly though total it tumor easily removal bled. The after lesion exposing was debulked, the cavernous and controlled segment of thesuction internal was carotid performed artery. to remove the bulk to nearly total tumor removal after exposing the cavernous

(a) (b)

FigureFigure 1. 1. Contrast-enhancedContrast-enhanced magneticmagnetic resonance imaging examination of of the the brain. brain. (a (a,b,b) )Pre Pre contrast contrast coronalcoronal andand sagital T1w T1w showed showed an an extra extra axial axial sella sellarr and and left left parasellar parasellar mass mass with with hyperintensity, hyperintensity, the thecavernous cavernous internal internal carotid carotid artery artery is pushed is pushed inferiorly inferiorly and andencased encased by the by lesion. the lesion. (c) Coronal (c) Coronal T2w T2wshowed showed a high a high signal signal intensity intensity of ofthe the mass. mass. (d ()d Initial) Initial gadolinium-enhanced gadolinium-enhanced axial axial T1w T1w showed showed heterogenousheterogenous enhancementenhancement ofof thethe mass.mass.

HistopathologicalHistopathological examinationexamination ofof thethe mass revealed a cavernous cavernous haemangioma haemangioma with with many many large large cysticallycystically vesselsvessels ﬁlledfilled byby bloodblood cellscells withwith an irregular thickness of of the the walls walls covered covered by by benign benign flat ﬂat endothelialendothelial cellscells (Figure(Figure2 2).). AfterAfter surgery,surgery, thethe patientpatient presentedpresented leftleft ptosis,ptosis, left eye exotropia (due (due to to traumatrauma ofof thethe thirdthird nerve),nerve), andand leftleft maxillarymaxillary numb numbnessness (due (due to to trauma trauma of of the the V2 V2 nerve) nerve) (Figure (Figure 3).3). However,However, the the symptomssymptoms ofof thirdthird nervenerve palsy completely recovered recovered after after rehabilitation rehabilitation for for 3 3months. months. AtAt the the moment, moment, the the patientpatient onlyonly hashas permanantpermanant numbnessnumbness in the left cheek. All procedures performed in study involving human participant was in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The patient and her family were Reports 2020, 3, 16 3 of 7

informed about our intension to involve her in a case study and they agreed to partake in the study. They signed the concern form before the operation was carried out according to all surgical protocols. ReportsReports 2020 2020, 3, x, 3FOR, x FOR PEER PEER REVIEW REVIEW 3 of3 7 of 7

(a) (a) (b)( b)

FigureFigureFigure 2. 2.Histopathology2. HistopathologyHistopathology revealing revealing large large numbers numbers of thin-walledof thin-walled vascular vascular vascular sinusoids, sinusoids, sinusoids, with with with a single a asingle single layerlayerlayer of of endothelium-linedof endothelium-lined endothelium-lined capillaries, capillaries,capillaries, and andand scanty scantyscanty connective connective tissue. tissue. (a) (H&E, (aa)) H&E, H&E, 100×; 100×; 100 (b) ;((H&E,bb) )H&E, H&E, 250×. 250×. 250 . × × H&E,H&E,H&E, hematoxylin hematoxylin hematoxylin and andand eosin. eosin.eosin.

Figure 3. Two-day postoperative computed tomography scan images. FigureFigure 3.3. Two-day postoperative computed tomography scan scan images. images.

3. DiscussionAllAll procedures procedures performed performed in studyin study involving involving human human participant participant was was in accordancein accordance with with the the ethicalethical standards standards of theof the institutional institutional and/or and/or national national research research committee committee and and with with the the 1964 1964 Helsinki Helsinki Cavernomas haemangiomas, also known as cavernous angiomas or cavernomas, are benign tumors declarationdeclaration and and its itslater later amendments amendments or orcomparable comparable ethical ethical standards. standards. The The patient patient and and her her family family defined as vascular malformations formed of abnormal dilated vascular spaces with no intervening werewere informed informed about about our our intension intension to involveto involve her her in ain case a case study study and and they they agreed agreed to partaketo partake in thein the neural tissue [2]. Most of them occur within cerebral parenchyma,; however, they are sometimes found study.study. They They signed signed the the concern concern form form before before the the op erationoperation was was carried carried out out according according to allto allsurgical surgical in the lateral wall of the ventricle, brainstem, cerebellum, basal ganglions, dura, and pituitary fossa [3]. protocols.protocols. Lesions located in the cavernous sinus are very rare [1]. At this region, it is neccessary to differentiate 3. fromDiscussion3. Discussion some other lesions, such as meningiomas, schwannomas, pituitary macroadenomas, lymphomas, metastase tumor, dermatomas, or aspergillomas. In terms of epidemiology, CSCs usually present in Cavernomas haemangiomas, also known as cavernous angiomas or cavernomas, are benign middle-agedCavernomas females, haemangiomas, about 50 years also old known [4–6]. Regardingas cavernous histopathology, angiomas or CSCscavernomas, have characteristics are benign tumors defined as vascular malformations formed of abnormal dilated vascular spaces with no thattumors are similardefined to as lesions vascular of themalformations intracerebral formed parenchyma of abnormal but have dilated a diff vascularerent clinical spaces picture with andno intervening neural tissue [2]. Most of them occur within cerebral parenchyma,; however, they are radiologicintervening findings neural [7tissue]. [2]. Most of them occur within cerebral parenchyma,; however, they are sometimes found in the lateral wall of the ventricle, brainstem, cerebellum, basal ganglions, dura, sometimesInitial symptoms found in the are lateral usually wall headache of the andventricle, dysfuntion brainstem, of the cerebellum, cranial nerves basal passing ganglions, through dura, the and pituitary fossa [3]. Lesions located in the cavernous sinus are very rare [1]. At this region, it is cavernousand pituitary sinus, fossa presenting [3]. Lesions as ptosis, located diplopia, in the cavernou or facial neuralgia,s sinus are and very decreased rare [1]. At visual this acuity.region, These it is neccessary to differentiate from some other lesions, such as meningiomas, schwannomas, pituitary areneccessary non-specific to differentiate because many from lesions some inother the cavernouslesions, such sinus as meningiomas, can cause symptoms schwannomas, like this. pituitary macroadenomas,macroadenomas, lymphomas, lymphomas, metastase metastase tumor, tumor, dermatomas, dermatomas, or orasperg aspergillomas.illomas. In Interms terms of of epidemiology,epidemiology, CSCs CSCs usually usually present present in middle-agedin middle-aged females, females, about about 50 50years years old old [4–6]. [4–6]. Regarding Regarding histopathology,histopathology, CSCs CSCs have have characteristics characteristics that that are are similar similar to lesionsto lesions of theof the intracerebral intracerebral parenchyma parenchyma butbut have have a different a different clinical clinical picture picture and and radiologic radiologic findings findings [7]. [7].

Reports 2020, 3, 16 4 of 7

In the magnetic resonance imagings, the lesion revealed an enhanced homogenous mass encircling the cavernous segment of the internal carotid artery without occluding it. This might be related to the natural character of the tumor. With cavernomas in the cavernous sinus, the blood stream through the lesion was homogenous, contrary to cavernomas intracerebral parenchyma, with no bleeding inside the tumor, and no calcification. Cerebral cavernomas appeared as “popcorn-shaped” or “berry-shaped”, which showed isointense in magnetic resonance imagings with a rim of signal loss due to hemosiderin. This was a specific radiological feature of parenchymal cavernomas, but it seldom happens with extra axial cavernomas, especially in the cavernous sinus [7]. In the magnetic resonance imaging, CSCs were homogenous; hyperintense in T1w, T2w, and T2 Flair; showed contrast enhancement; and rarely had intratumor bleeding or calcification (Figure1). A computed tomography scanner and magnetic resonance imaging can be used to differentiate from three other common lesions, which are meningiomas, schwannomas, and pituitary microadenomas [8]. Meanwhile, CSCs present as a well-demarcated mass, isointense or hypointense on T1w compared to the surrounding cerebral tissue, meningiomas are much more isointense, and schwannomas have a tendency to be hypointense. All of them have contrast enhencement. On the radiological images, CSC appears with a clear boundary, and isointense or slightly hyperintense in T1w and T2w compared to parenchymal tissue. Whereas, meningiomas are more isointense, while schwannomas tend to have a slightly low density compared to brain parenchyma. All three types of these tumors show contrast enhancement after the injection. However, schwannomas often catch contrast material irregularly and are speckled due to the alternation between the regions of increased and decreased signal, while meningiomas and CSCs can catch contrast material quite uniformly. In addition, the presence of calcification clumps in the tumor or the presence of bone erosion around the tumor is more likely to suggest meningeal lesions [3,9]. This phenomenon is less common in schwannomas and cavernous angiomas in the sinus cavity. Most CSCs have sinus occlusion images, or even complete obstruction on the angiography film [1]. The angiographic images in patients with schwannomas tumors are variable, with no characteristic signs. As for meningiomas, the images reveal a strong vascularization and strong enhancement, homogeneously late after injection. Schwannomas tends to be more hypointense than the brain parenchyma in the T1w, and homogeneously hyperintense in the T2w. Whereas, meningiomas usually have a similar signal, with the parenchymal tissue both in T1w and T2w. Both types of tumors have strong enhancement and are quite homogeneous with meningiomas. For CSC, the lesions had a clear boundary with the surrounding structures, increasing the signal or a mixed signal in T1w and T2w. However, unlike the parenchymal cavernomas, the tumor was not hypointense at the edge [10]. After magnetic contrast injection, the tumor was very strong and showed relatively homogeneous enhancement. This feature was similar to previous reports of cavernous hemangiomas in the cavernous sinus cavity [4,5,8]. Occasionally, an increased signal image on T2-weighted images has also suggested lesions of the CSC. With other lesions in the cavernous sinus, such as metastatic tumor, granuloma, chordoma, lymphoma, and aspergilloma, this showed as hyperintense in T2w, but the signal was not homogeneous and the boundary was not clear. Accurate diagnosis of the tumor is extremely important, because it involves surgical tactics and surgical procedures [8]. In essence, CSC is benign, slowly growing, and absolutely curable if the tumor is completely removed by surgery. However, operation is a huge challenge because of the tumor location in the cavernous sinus, high risk of bleeding, difficulty in stopping the bleeding, as well as the risk of damage to the cranial nerves located in the sinuses (such as III, IV, V, VI nerves) [11,12]. Previous reports showed that the rate of total removal of tumors by microsurgical surgery was only 30–44% [13], while the complication rate was very high. Therefore, resection of CSC is considered a dangerous procedure. Various methods have been proposed, such as inserting a balloon into the carotid artery to reduce blood flow through the sinuses and reduce bleeding [11,14], pre-opt radiotherapy to reduce vascular growth [11,15,16], injecting a vasoconstrictor into the tumor (such as alcohol, and bio fibrin glue) [17,18], Reports 2020, 3, x FOR PEER REVIEW 5 of 7

Various methods have been proposed, such as inserting a balloon into the carotid artery to reduce blood flow through the sinuses and reduce bleeding [11,14], pre-opt radiotherapy to reduce Reportsvascular2020 growth, 3, 16 [11,15,16], injecting a vasoconstrictor into the tumor (such as alcohol, and bio fibrin5 of 7 glue) [17,18], inducing hypotension during surgery [19], and using an autologous blood recovery machine during surgery [20]. inducing hypotension during surgery [19], and using an autologous blood recovery machine during In terms of the surgical approach, each of the authors had their own choice, but all of them surgery [20]. discussed requests, such as the ability of expanding the surgical field, controlling the internal carotid In terms of the surgical approach, each of the authors had their own choice, but all of them discussed artery, preserving cranial nerves, and limitting blood loss. Goel et al. chose the frontal subtemporal requests, such as the ability of expanding the surgical field, controlling the internal carotid artery,preserving approach [21], while several other authors have chosen the frontotemporal orbital zygomatic cranial nerves, and limitting blood loss. Goel et al. chose the frontal subtemporal approach [21], while approach (FTOZ approach) [22]. In this circumstance, we used the extradural subtemporal approach several other authors have chosen the frontotemporal orbital zygomatic approach (FTOZ approach) [22]. owing to the ability to control bleeding. In addition, intradural dissection risks temporal lobe In this circumstance, we used the extradural subtemporal approach owing to the ability to control bleeding. contusion, causing post-operation seizure. In addition, intradural dissection risks temporal lobe contusion, causing post-operation seizure. After detaching the dura from the skull base towards the cavernous sinus, the dura was After detaching the dura from the skull base towards the cavernous sinus, the dura was continuously rolled up to reveal V3, V2, and V1. This was a very safe non-bleeding method and was continuously rolled up to reveal V3, V2, and V1. This was a very safe non-bleeding method clearly shown to be effective in Goel’s study (1997) [23] and Li’s study (2015) [4]. The V2 branch was and was clearly shown to be effective in Goel’s study (1997) [23] and Li’s study (2015) [4]. The V2 chosen to sacrifice to make entry because this nerve only has a feeling function for the ipsilateral branch was chosen to sacrifice to make entry because this nerve only has a feeling function for the maxillary area and its position is safer, resulting in low risk to damage of the internal carotid artery ipsilateral maxillary area and its position is safer, resulting in low risk to damage of the internal carotid and cranial nerves in the cavernous sinus cavity. artery and cranial nerves in the cavernous sinus cavity. After incising the inner layer of the lateral wall of the cavernous sinus, along the path of the V2 After incising the inner layer of the lateral wall of the cavernous sinus, along the path of the V2 branch nerve and partial resection this nerve, the tumor inside the sinus was exposed as a soft porous branch nerve and partial resection this nerve, the tumor inside the sinus was exposed as a soft porous mass that was easy to bleed but it could be stopped by squeezing or spongel. The tumor could be mass that was easy to bleed but it could be stopped by squeezing or spongel. The tumor could be completely dissected, and separated from the carotid artery and the sinus cavity with a blunt tool to completely dissected, and separated from the carotid artery and the sinus cavity with a blunt tool to avoid damaging the blood vessels in the sinus. Some authors suggested that CSC should be removed avoid damaging the blood vessels in the sinus. Some authors suggested that CSC should be removed in bloc dissection [8,11,24]; however, this method is only suitable for small and medium tumors. For in bloc dissection [8,11,24]; however, this method is only suitable for small and medium tumors. For large tumors, they should be taken in small pieces (debulking dissection) to stop bleeding with large tumors, they should be taken in small pieces (debulking dissection) to stop bleeding with pressed pressed cotton, which will reduce blood loss and bleeding during surgery. In the places where veins cotton, which will reduce blood loss and bleeding during surgery. In the places where veins flow into flow into the cavernous sinus, after tumor resection, we used a spongel inserted into it to stop the the cavernous sinus, after tumor resection, we used a spongel inserted into it to stop the bleeding. With bleeding. With the bleeding from the artery feeders, mini clips were used, and electronical the bleeding from the artery feeders, mini clips were used, and electronical coagulation was limitted coagulation was limitted due to ICA constriction. We observed that this method of hemostasis was due to ICA constriction. We observed that this method of hemostasis was very effective, which ensured very effective, which ensured that the surgical field was not flooded by blood, helping the dissection that the surgical field was not flooded by blood, helping the dissection and resection process to be and resection process to be increasingly more safe and reducing blood loss. During the operation, the increasingly more safe and reducing blood loss. During the operation, the sinus cavity was opened in a sinus cavity was opened in a straight line, parallel to the V2 nerve; hence, as the dissection on the straight line, parallel to the V2 nerve; hence, as the dissection on the arch of the sinus cavity, we had to arch of the sinus cavity, we had to lift the lateral wall of the cavernous sinus upward. This lift the lateral wall of the cavernous sinus upward. This manipulation might have damaged the thrid manipulation might have damaged the thrid nerve, leading to thrid nerve paralysis postoperatively. nerve, leading to thrid nerve paralysis postoperatively. However, this condition was temporary, as the However, this condition was temporary, as the third nerve was almost fully recovered after third nerve was almost fully recovered after acupuncture for 3 months. The phenomenon of maxillary acupuncture for 3 months. The phenomenon of maxillary facial numbness (corresponding to the V2 facial numbness (corresponding to the V2 branch) has been predicted intra surgery. Postoperative branch) has been predicted intra surgery. Postoperative magnetic resonance imaging showed that magnetic resonance imaging showed that the tumor was mostly removed (Figure4). the tumor was mostly removed (Figure 4).

Figure 4. Cont. Reports 2020, 3, 16 6 of 7 Reports 2020, 3, x FOR PEER REVIEW 6 of 7

Figure 4. Three-month postoperative magnetic resonance imaging. Figure 4. Three-month postoperative magnetic resonance imaging. 4. Conclusions 4. ConclusionsCavernoma of the cavernous sinus is a rare vascular malformation with no specifically clinical signs, requiringCavernoma a differential of the diagnosis cavernous from sinus meningiomas, is a rare vascul schwannomasar malformation of the with cranial no nerve,specifically and pituitary clinical adenomassigns, requiring in the a sinusdifferential cavity. diagnosis Tumor removal from meni is reallyngiomas, challenging schwannomas due to of the the location cranial in nerve, the sinus and cavity,pituitary high adenomas vascularity, in the many sinus cranial cavity. nerves, Tumor and removal the carotid is really artery challenging surrounding. due to However, the location from in the Vietnamesesinus cavity, authors’s high vascularity, experience ma ofny successful cranial nerves, resection and ofthe a carotid cavernoma artery of surrounding. the cavernous However, sinus by thefrom extradural the Vietnamese subtemporal authors’s approach experience and stop-bleeding of successful techniques,resection of the a cavernoma ability of removing of the cavernous an entire tumorsinus isby positive, the extradural offering goodsubtemporal treatment approach results for and such stop-bleeding cases. techniques, the ability of removing an entire tumor is positive, offering good treatment results for such cases. Author Contributions: Conceptualization, D.-A.N. and H.T.N.; Methodology, D.-A.N., T.V.D., and B.H.P.; Investigation, D.-A.N. and H.T.N.; Data Curation, D.-A.N., H.T.N., B.H.P., T.V.D. and H.-L.V.; Writing—Original DraftAuthor Preparation, Contributions: D.-A.N. Conceptualization, and H.-L.V.; Writing—Review D.-A.N. and H.T.N.; & Editing, Methodology, D.-A.N. and D.-A.N., H.-L.V.; Visualization,T.V.D., and B.H.P.; T.V.D. andInvestigation, B.H.P.; Supervision, D.-A.N. and H.T.N., H.T.N.; B.H.P. Data and Curation, T.V.D. All D.-A.N., authors haveH.T.N., read B.H.P., and agreed T.V.D. to theand published H.-L.V.; versionWriting— of theOriginal manuscript. Draft Preparation, D.-A.N. and H.-L.V.; Writing—Review & Editing, D.-A.N. and H.-L.V.; Funding:Visualization,This T.V.D. research and received B.H.P.; no Supervision, external funding. H.T.N., B.H.P. and T.V.D. All authors have read and agreed to the published version of the manuscript. Acknowledgments: All authors sincerely thank the patient and her families. All members working at Department ofFunding: Neurosurgery This research (Bach Maireceived Hospital) no external during funding. the treatment time are gratefully acknowledged.

ConflictsAcknowledgments: of Interest: AllThe authors declaresincerely no conflictthank the of interest.patient and her families. All members working at Department of Neurosurgery (Bach Mai Hospital) during the treatment time are gratefully acknowledged. References Conflicts of Interest: The authors declare no conflict of interest. 1. Lupret, V.; Negovetić,L.; Smiljanić,D.; Klanfar, Z.; Talan-Hranilović,J. Cavernous haemangioma in cavernous Referencessinus: Case report of rare location. Neurol. Croat. 1992, 41, 241–246. 2. Rosenblum, B.; Rothman, A.S.; Lanzieri, C.; Song, S. A cavernous sinus cavernous hemangioma: Case report. 1. Lupret, V.; Negovetić, L.; Smiljanić, D.; Klanfar, Z.; Talan-Hranilović, J. Cavernous haemangioma in J. Neurosurg. 1986, 65, 716–718. [CrossRef][PubMed] cavernous sinus: Case report of rare location. Neurol. Croat. 1992, 41, 241–246. 3. Goto, Y.; Yamabe, K.; Aiko, Y.; Kuromatsu, C.; Fukui, M. Cavernous hemangioma in the cavernous sinus. 2. Rosenblum, B.; Rothman, A.S.; Lanzieri, C.; Song, S. A cavernous sinus cavernous hemangioma: Case Neurochirurgia 1993, 36, 93–95. [CrossRef][PubMed] report. J. Neurosurg. 1986, 65, 716–718. 4. Li, M.-H.; Zhao, J.L.; Li, Y.Y.; Zheng, C.H.; Xu, G.S.; Hong, T. Extradural transcavernous approach to 3. Goto, Y.; Yamabe, K.; Aiko, Y.; Kuromatsu, C.; Fukui, M. Cavernous hemangioma in the cavernous sinus. cavernous sinus cavernous hemangiomas. Clin. Neurol. Neurosurg. 2015, 136, 110–115. [CrossRef] Neurochirurgia 1993, 36, 93–95. 5. Li, H.; Zhang, B.; Wang, W.; Wei, M.H.; Liu, B.Y.; Wu, Z. Clinical Features, Intradural Transcavernous Surgical 4. Li, M.-H.; Zhao, J.L.; Li, Y.Y.; Zheng, C.H.; Xu, G.S.; Hong, T. Extradural transcavernous approach to Management, and Outcomes of Giant Cavernous Sinus Hemangiomas: A Single-Institution Experience. cavernous sinus cavernous hemangiomas. Clin. Neurol. Neurosurg. 2015, 136, 110–115. World Neurosurg. 2019, 125, e754–e763. [CrossRef] 5. Li, H.; Zhang, B.; Wang, W.; Wei, M.H.; Liu, B.Y.; Wu, Z. Clinical Features, Intradural Transcavernous 6. Yin, Y.-H.; Yu, X.G.; Xu, B.N.; Zhou, D.B.; Bu, B.; Chen, X.L. Surgical management of large and giant cavernous Surgical Management, and Outcomes of Giant Cavernous Sinus Hemangiomas: A Single-Institution sinus hemangiomas. J. Clin. Neurosci. 2013, 20, 28–133. [CrossRef] Experience. World Neurosurg. 2019, 125, e754–e763. 7. Lombardi, D.; Giovanelli, M.; De Tribolet, N. Sellar and parasellar extra-axial cavernous hemangiomas. 6. Yin, Y.-H.; Yu, X.G.; Xu, B.N.; Zhou, D.B.; Bu, B.; Chen, X.L. Surgical management of large and giant Acta Neurochir. 1994, 130, 47–54. [CrossRef] cavernous sinus hemangiomas. J. Clin. Neurosci. 2013, 20, 28–133. 7. Lombardi, D.; Giovanelli, M.; De Tribolet, N. Sellar and parasellar extra-axial cavernous hemangiomas. Acta Neurochir. 1994, 130, 47–54.

Reports 2020, 3, 16 7 of 7

8. Ibrahim, D.; El Fiki, A.; Hafez, M.; Saleem, S. Report of a case of cavernous haemangioma of the cavernous sinus. BJR Case Rep. 2019, 5, 20190031. [CrossRef] 9. Lee, A.G.; Miller, N.R.; Brazis, P.W.; Benson, M.L. Cavernous sinus hemangioma. Clinical and neuroimaging features. J. Neuroophthalmol. 1995, 15, 225–229. [CrossRef] 10. Katayama, Y.; Tsubokawa, T.; Miyazaki, S.; Yoshida, K.; Himi, K. Magnetic resonance imaging of cavernous sinus cavernous hemangiomas. Neuroradiology 1991, 33, 118–122. [CrossRef] 11. Linskey, M.E.; Sekhar, L.N. Cavernous sinus hemangiomas: A series, a review, and an hypothesis. Neurosurgery 1992, 30, 101–1088. [CrossRef][PubMed] 12. Namba, S. Extracerebral cavernous hemangioma of the middle cranial fossa. Surg. Neurol. 1983, 19, 379–388. [CrossRef] 13. Park, C.K.; Choi, S.K.; Kang, I.H.; Choi, M.K.; Park, B.J.; Lim, Y.J. Radiosurgical considerations for cavernous sinus hemangioma: Long-term clinical outcomes. Acta Neurochir. 2016, 158, 313–318. [CrossRef][PubMed] 14. Zhou, L.-F.; Mao, Y.; Chen, L. Diagnosis and surgical treatment of cavernous sinus hemangiomas: An experience of 20 cases. Surg. Neurol. 2003, 60, 31–36. [CrossRef] 15. Mori, K.; Handa, H.; Gi, H. Cavernomas in the middle fossa. Surg. Neurol. 1980, 14, 21–31. 16. Rigamonti, D.; Pappas, C.T.E.; Spetzler, R.F.; Johnson, P.C. Extracerebral cavernous angiomas of the middle fossa. Neurosurgery 1990, 27, 306–310. [CrossRef] 17. Nepper-Rasmussen, H.; Bjerre, P.; Jørgensen, K. Endovascular neuroradiologic interventions. Embolization of aneurysms and arteriovenous malformations. Sclerotherapy of cavernous hemangiomas. Ugeskr. Laeger 1993, 155, 3471–3476. 18. Hashimoto, M.; Yokota, A.; Ohta, H.; Urasaki, E. Intratumoral injection of biobond adhesive for removal of cavernous sinus hemangioma. J. Neurosurg. 2000, 93, 1078–1081. [CrossRef] 19. Ohata, K.; El-Naggar, A.; Takami, T.; Morino, M.; El-Adawy, Y.; El-Sheik, K.; Inoue, Y.; Hakuba, A. Eﬃcacy of induced hypotension in the surgical treatment of large cavernous sinus cavernomas. J. Neurosurg. 1999, 90, 702–708. [CrossRef] 20. Li, Z.-H.; Wu, Z.; Zhang, J.T. Surgical Management and Outcomes of Cavernous Sinus Hemangiomas: A Single-Institution Series of 47 Patients. World Neurosurg. 2019, 122, e1181–e1194. [CrossRef] 21. Goel, A.; Muzumdar, D.; Sharma, P. Extradural approach for cavernous hemangioma of the cavernous sinus: Experience with 13 cases. Neurol. Med. Chir. 2003, 43, 112–119. [CrossRef][PubMed] 22. Suri, A.; Ahmad, F.U.; Mahapatra, A.K. Extradural transcavernous approach to cavernous sinus hemangiomas. Neurosurgery 2007, 60, 483–489. [CrossRef][PubMed] 23. Goel, A. The extradural approach to lesions involving the cavernous sinus. Br. J. Neurosurg. 1997, 11, 134–138. [CrossRef][PubMed] 24. Nadkarni, A.G. Cavernous haemangioma in the cavernous sinus. Br. J. Neurosurg. 1995, 9, 77–80. [CrossRef] [PubMed]

© 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).