Cavernous angioma of the cavernous sinus: imaging findings

Abstract

-Cavernous angiomas (cavernomas) of the cavernous sinus are uncommon, with only scattered reports in literature. Unlike their parenchymatous counterparts, they are intensely enhancing para-sellar masses, iso/hypointense in T1-and hyperintense in T2-weighted images. Differential diagnosis with parasellar meningiomas and schwannomas can be difficult. We report three cases of this condition, describing findings of diffusion-weighted imaging in this kind of lesion for the first time in literature.KEY WORDS: cavernous angioma, cavernous sinus, magnetic resonance imaging, computed tomography, angiography.Angioma cavernoso do seio cavernoso: achados aos exames de imagem RESUMO -Angiomas cavernosos (cavernomas) do seio cavernoso são lesões incomuns, com poucos relatos na literatura especializada. Ao contrário dos cavernomas parenquimatosos, são massas para-selares intensamente captantes, isointensas a hipointensas em T1 e hiperintensas em T2 nas imagens de ressonância magnética. O diagnóstico diferencial com meningiomas e schwannomas para-selares pode ser difícil. Relatamos os achados de imagem de três casos desta entidade, descrevendo os achados da ressonância magné-tica ponderada em difusão neste tipo de lesão pela primeira vez na literatura. PALAVRAS-CHAVE: angioma cavernoso, seio cavernoso, ressonância magnética, tomografia computadorizada, arteriografia.Cavernous angioma of the cavernous sinus is an extremely rare condition, and its differential diagnosis with tumors, namely para-sellar meningiomas and schwannomas, is often difficult. They are richly vascularized lesions, made up of a network of dilated, thin-walled vessels, and are responsible for less than one percent of all intracranial masses. The advent of magnetic resonance imaging (MRI) raised new diagnostic perspectives for this condition as we report in the study. METHODThis study was approved by the committee of Ethics of Clinica Radiologia Vila Rica, Brasilia DF, Brazil.Three female patients, with 42-years-old (patient 1), 45-years-old (patient 2) and 37-years-old (patient 3), are, respectively, presented with complaints of right-sided cranial nerves deficits (III nerve [patients 2 and 3], V1 nerve [patient 2] and VI nerve [patients 1 and 2]) and headaches. All of them underwent magnetic resonance imaging and cerebral digital subtraction angiography (DSA). Patients 2 and 3 were also submitted to computed tomography (CT). In all patients, MRI revealed well-delimited right para-sellar lesions, uniformly isointense in T1-weighted images and hyperintense in T2-, T2-and FLAIRweighted images, brightly enhancing after intra-vascular infusion of gadolinium. Diffusion-weighted sequence, performed in patient 3, revealed an isointense mass.

Cavernous Sinus Cavernous Hemangioma Largely Extending Into the Sella Turcica and Mimicking Pituitary Adenoma -Case Report-

“…The preoperative misdiagnosis rate is reported as up to 66.7 to 87.5%. 9,14,22) In the present case, our preoperative diagnosis was nonfunctioning pituitary macroadenoma. MR imaging demonstrates pituitary adenomas are hypointense to isointense on T 1 -weighted images and variable intensity on T 2 -weighted images.…”

Dynamic Enhancement Features of Cavernous Sinus Cavernous Hemangiomas on Conventional Contrast-Enhanced MR Imaging

“…However, markedly homogeneous enhancement is more compatible with the diagnosis of CHCH. 10 Progressive contrast "filling in" was more frequently seen in our series, but in the literature, there is only 1 case report of CSCH about progressive contrast "filling in" on conventional contrast-enhanced MR imaging. 29 In our opinion, 3 causes may account for this frequency in our study.…”

“…9 When these characteristics present, a diagnosis of CSCH is strongly suggested. 10 However, they are actually nonspecific because angioblastic meningiomas and neurilemomas may have similar MR appearances, and it is quite difficult to differentiate them relying solely on the above-mentioned MR features. 11 Fortunately, as a pathognomonic MR feature of cavernous hemangiomas in the liver revealed by the traditional dynamic contrast-enhanced T1-weighted spin-echo study, progressive contrast "filling in" was frequently found on conventional contrast-enhanced T1-weighted sequences in our series.…”

Magnetic Resonance Standard for Cavernous Sinus Hemangiomas: Proposal for a Diagnostic Test

“…However, our study as well as reports from inside and outside China all pointed out [15,22,23,24,25,26,27,28] that MRI shows CSHs with a low intensity or isointensity on T1-weighted images and with a high signal intensity on T2-weighted images. CSHs were intensely enhanced by gadolinium-DTPA at a dose of 0.15 mmol/kg.…”

“…Compared with meningiomas and neurilemmomas, CSHs are more sensitive to radiation therapy [14,32,33], and the peripheral dose of <10 Gy for gamma knife treatment may lead to a satisfactory effect and can be tolerated by organs vulnerable to radiation such as the optic nerves and brain stem. Fractionated CyberKnife therapy for large CSHs theoretically may have a widened scope with radiosurgery, and in practice, we have already accumulated some experience as well [24]. However, this also should be based on a definite imaging diagnosis.…”