Radiologic clue to cavernous sinus hemangioma diagnosis

Abstract

We describe a case of a 57-year-old woman presenting initially with diplopia who later developed retro-orbital and retroauricular pain. Examination showed right abducens nerve palsy and subsequent right trigeminal nerve hyperesthesia. Neuroimaging revealed a well-defined mass confined to the right cavernous sinus, with high T2 signal intensity and homogeneous enhancement on postgadolinium T1-weighted images. A meningioma was initially considered as the most likely diagnosis. The lesion grew over months, extending into the Meckel's cave and the pituitary fossa. Dynamic T1-weighted images revealed striking and progressive centripetal enhancement, leading to a revised diagnosis of cavernous sinus hemangioma (CSH). CSH is a rare benign extra-axial tumor, which is highly vascularized, and is frequently misdiagnosed as meningioma or schwannoma. The combination of very high T2 signal intensity and progressive centripetal contrast enhancement highly suggest CSH diagnosis. Given the significant risk of bleeding and mortality associated with surgical intervention, it is crucial to recognize CSH preoperatively to plan a meticulous surgical approach.