Cavernous Sinus Hemangioma: Case Report and Review

Cavernous sinus hemangioma (CSH) is a rare lesion, representing only 2 to 3% of all pathologies within the cavernous sinus. Clinical presentation is similar for all cavernous sinus masses—pressure on nearby structures may result in diplopia, ptosis, trigeminal symptoms, and headache. Due to their rarity, CSH is often misdiagnosed as meningiomas, as the two lesions have many similarities on imaging studies. Distinguishing between these two lesions is critical, however, since accurate diagnosis can impact treatment and prognosis.

We present the case of a 57-year-old man with a 6-year history of progressive headache and facial paresthesia. MRI demonstrated a mass in the left cavernous sinus that was hypointense on T1-weighted images, hyperintense on T2-weighted images, and had heterogeneous peripheral enhancement. The patient was diagnosed radiographically with cavernous sinus meningioma and was taken to the operating room for endoscopic endonasal biopsy and debulking. During the operation, the lesion was found to be fibrous and very hypervascular, located entirely within the left cavernous sinus with moderate mass effect on the pituitary gland. Histological analysis of biopsy samples revealed fibrous tissue with numerous vascular channels, some containing organized thrombi. Differential diagnosis originally included an angiomatous meningioma, but the lack of EMA expression argued against this possibility and supported a final diagnosis of cavernous sinus hemangioma. The patient experienced significant improvement in his symptoms after surgery and was discharged home on postoperative day 1. The patient went on to receive adjuvant radiotherapy for control of his residual lesion.

Imaging studies play a key role in work-up of patients with cavernous sinus lesions, and can help differentiate CSH from meningioma. T1-weighted MRI scans generally reveal a hypointense or isointense well-defined mass that is homogenously hyperintense on T2-weighted sequences. This combination of findings helps differentiate CSH from typical meningiomas and schwannomas. Contrast enhancement is often heterogeneous with CSH, whereas meningiomas and schwannomas often demonstrate intense homogeneous enhancement with gadolinium administration. In select cases, angiography can help differentiate CSH from neoplastic lesions of the cavernous sinus due to angiographically detected vascular blush in up to 80% of patients with CSH. However, tissue diagnosis is the only definitive way to differentiate CSH from other lesions of the cavernous sinus and surgical exploration is generally indicated in symptomatic lesions with atypical imaging characteristics for meningioma or schwannoma.