Intrasellar Cavernous Hemangioma, a Rare Condition Causing Both Radiological And Clinical Difficulties- a Case Report

Introduction: Intrasellar cavernous hemangiomas constitute an extremely rare group of findings in endocrinological practice. Diagnosis remains challenging due to non-characteristic symptoms and neuroradiological features which may resemble those of pituitary adenomas. Presentation of the Case: We present a case of female born in 1941, diagnosed with a hemangioma cavernosum located in the Sella turcica. In 2004 our patient presented with uncharacteristic symptoms: syncopes and chronic headaches. Computed tomography (CT) of the head revealed an intrasellar hyperdense tumor mass with radiological features suggesting a pituitary adenoma. In 2005 the patient underwent transcranial resection of the sellar mass, with subsequent oculomotor nerve palsy. In histopathological examination, diagnosis of cavernous hemangioma was determined. Between 2005 and 2020 patient was asymptomatic, with multiple follow-up head MRIs scans, showing gradual progression in size of the intrasellar tumor. The patient was consulted by a neurosurgeon, with no direct indications for surgical approach found. Furthermore, due to suprasellar expansion into the direct proximity of the right optic nerve, the patient was disqualified for Gamma-Knife radiotherapy. The last MRI of the hypothalamic-pituitary area in 2020 revealed a polycyclic, homogeneous, 33x31x29 mm mass, filling in the space of the Sella turcica, with strong enhancement after contrast administration. Invasion of the surrounding structures, including the clivus, right cavernous sinus and right trigeminal cave were described. Bilaterally, internal carotid arteries and right optic nerve adhered directly to the lesion. Pituitary gland was compressed by the tumor mass. In July 2020, in order to verify the ambiguous radiological and clinical characteristics of the lesion including tumor regrowth and its invasiveness, a transsphenoidal partial resection was performed. Tissue samples were collected for the histopathological examination, which confirmed the initial diagnosis of cavernous hemangioma originating from the cavernous sinus. During a multidisciplinary tumor board, having taken into consideration relatively stable clinical condition and high risk possible surgical complications, the patient was currently disqualified from neurosurgical re-operation nor radiotherapy. Surprisingly, during whole follow up, patients pituitary function remained unimpaired. A watchful waiting approach, with radiological and endocrinological follow up were scheduled. Conclusion: To date, only few cases of intrasellar cavernous hemangiomas have been reported. Intrasellar hemangiomas may originate from the vascular tissue of the cavernous sinus. Surgical removal remains the recommended treatment modality, but radiosurgery could be a therapeutic option as well. Stable patients with no clinical symptoms may remain in observation.