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) (c) (d) 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