Abstract

BackgroundCavernous malformations (CMs) are benign vascular anomalies that most commonly occur in intra-axial locations but rarely develop in the suprasellar region. Suprasellar CMs pose unique diagnostic and therapeutic challenges due to their proximity to critical neurovascular structures, such as the optic chiasm, pituitary stalk, and hypothalamus. Although visual disturbances and headaches are typical symptoms of suprasellar CMs, cognitive impairment, especially memory loss, has rarely been reported.

Case DescriptionWe present the case of a 58-year-old woman who developed progressive memory impairment for over 1 year. Magnetic resonance imaging revealed a 2.5 cm heterogeneous, lobulated lesion in the suprasellar region, exerting a mass effect on the optic chiasm and hypothalamus. The patient underwent endoscopic endonasal transsphenoidal resection with pituitary hemitransposition to achieve complete removal of the lesion. Pathological examination confirmed the diagnosis of CM. At the 6-month follow-up, the patient demonstrated modest improvement in memory function, which remained stable through the extended follow-up period of 31 months.

ConclusionThis case highlights the rare presentation of memory impairment in suprasellar CM and underscores the importance of considering CMs in the differential diagnosis of suprasellar lesions. The endoscopic endonasal approach with pituitary hemitransposition provides an effective surgical pathway that allows complete resection. Early diagnosis and tailored surgical intervention may improve outcomes of patients with a suprasellar CMs. Further research is necessary to understand the relationship between suprasellar CMs and cognitive dysfunction.

Keywords: Cavernous malformation, Endoscopic endonasal surgery, Memory loss, Pituitary hemitransposition, Retroinfundibular, Suprasellar

INTRODUCTION

Cavernous malformations (CMs), also known as cavernomas, cavernous angiomas, or cavernous hemangiomas, are benign vascular anomalies characterized by abnormally dilated blood vessels without intervening brain parenchyma. CMs affect approximately 0.2–0.5% of the general population, with a slight female predominance.[ 1 ]

CMs predominantly manifest as intra-axial supratentorial lesions (72–85%), followed by the infratentorial compartment (10–23%) and the spinal cord (5%).[ 6 ] However, CMs occasionally develop in extra-axial locations, such as lateral and third ventricles, pineal region, cranial nerves, optic chiasm, and dural/tentorial spaces, presenting unique diagnostic and therapeutic challenges.[ 4 , 14 ]

In this report, we present a case of a 58-year-old patient diagnosed with a suprasellar CM. In addition, we reviewed the relevant literature, focusing on the characteristics, diagnostic strategies, and surgical approaches associated with this particular type of CM.

CASE DESCRIPTION

A 58-year-old female with a history of diabetes mellitus presented with a 1-year history of progressive worsening memory loss. Family members reported that she frequently forgot conversations within 5 min and had difficulty recalling events from earlier in the day, leading to repetitive behaviors. On cognitive assessment, the patient scored 18 on the Montreal Cognitive Assessment (MoCA)[ 9 ] with significant deficits in recall memory (0/5), visuospatial/executive domains, and attention. Visual examination yielded unremarkable results, and the patient denied experiencing headaches, seizures, or symptoms related to abnormal pituitary function.

Magnetic resonance imaging (MRI) revealed a 2.3 × 2.5 × 2.5 cm lobulated, heterogeneous lesion in the suprasellar region, exhibiting mixed signal intensities and no enhancement [ Figures 1a , 1b ]. Gradient-echo imaging demonstrated a blooming artifact consistent with hemosiderin deposition [ Figure 1c ]. The lesion was located in the retroinfundibular area, with a mass effect on the optic apparatus and hypothalamus [ Figure 1d ]. The mesial temporal areas appeared normal bilaterally, and there were no signs of hydrocephalus or additional intracranial lesions.

Figure 1:

Preoperative magnetic resonance imaging revealed a suprasellar mass with mixed hypo- and hyperintense signals on (a) T1- and (b) T2-weighted images. The mass displaced the floor of the third ventricle upward, nearly reaching the level of the fornices, while the hippocampi on both sides appeared unremarkable. (c) On gradient echo imaging, the mass exhibited marked hyposignal intensity, indicative of blood signal within the tumor. (d) Gadolinium-enhanced sagittal images demonstrated heterogeneous enhancement of the mass, which was located in the retrochiasmatic region.

The patient underwent endoscopic endonasal transsphenoidal surgery with pituitary hemitransposition for resection of the lesion.[ 3 ] Intraoperatively, the mass was identified as an extra-axial, soft, friable, brown lesion located in the suprasellar area, compressing the optic chiasma and adhering to the hypothalamus [ Figure 2 ]. Complete resection was achieved, and the skull base defect was repaired using artificial dura, fat grafts, and a nasoseptal flap.

Figure 2:

Intraoperative findings during the endoscopic endonasal transsphenoidal approach demonstrate identification and resection of the cavernoma from the floor of the third ventricle, following transposition of the pituitary gland to the left.

Postoperatively, the patient recovered uneventfully, with no headaches, visual impairment, or evidence of cerebrospinal fluid leakage. She experienced transient diabetes insipidus for 1 week, with intact pituitary hormone function. Pathological examination confirmed the diagnosis of a CM [ Figure 3 ]. Postoperative MRI showed complete resection of the CM [ Figure 4 ]. At 6 months, the patient’s memory slightly improved, with a MoCA score of 24, with the most marked improvement observed in the recall memory domain (3/5). Extended follow-up at 31 months postoperatively showed that the patient’s cognitive function remained stable, with no further improvement or deterioration in memory performance.

Figure 3:

Histopathological examination of hematoxylin and eosin stain in (a) ×40 and (b) ×100 magnification of the lesion reveals multiple variably sized vascular spaces lined by flattened endothelial cells with hemosiderin deposition in surrounding brain parenchyma. Immunohistochemistry demonstrates endothelial cell lining of vascular channels with (c) CD31 staining and highlights supporting glial stroma with (d) glial fibrillary acidic protein staining.

Figure 4:

The postoperative magnetic resonance imaging revealed complete resection of the suprasellar cavernoma, as evidenced on both (a) T2-weighted and (b) gadolinium-enhanced images.

DISCUSSION

Suprasellar CMs are exceedingly rare, accounting for <1% of all CMs. The suprasellar region, which includes critical structures such as the optic chiasm, pituitary stalk, and hypothalamus, makes the management of lesions in this area particularly complex. The clinical presentation of suprasellar CMs is diverse, reflecting the critical structures in proximity. Visual disturbances (56%) and headaches (38%) are the most common presenting symptoms of suprasellar CMs.[ 18 ] However, our case uniquely presented progressive memory loss as the primary symptom, with an incidence reported between 13.3% and 30.8% in the previous literature.[ 13 , 15 ]

The relationship between suprasellar masses and memory impairment has been documented in various pathologies. Previous studies have shown that lesions affecting the hypothalamic-mammillary region can result in significant memory deficits due to disruption of the Papez circuit.[ 5 ] A notable study reported four patients with reversible Korsakoff-like syndromes caused by retrochiasmatic lesions compressing the mammillary bodies, with three cases involving large pituitary macroadenomas.[ 16 ] These patients experienced rapid resolution of memory deficits following treatment interventions. The fourth patient had a cystic craniopharyngioma that compressed midline diencephalic structures, resulting in similar cognitive impairments. This highlights the role of the mammillary bodies and anterior thalamic nuclei in memory function, suggesting that pressure from these lesions, rather than direct neural damage, is primarily responsible for the observed memory loss.

In cases of suprasellar CMs specifically, memory impairment can occur through various mechanisms, including direct compression of memory structures such as the fornices and mammillary bodies, effects of hemorrhagic events, and potential seizure activity. A documented case of a 52-year-old woman with progressive anterograde amnesia due to a suprasellar and third ventricular CM demonstrated significant improvement in cognitive function following surgical resection, indicating that memory loss was primarily due to pressure effects rather than irreversible damage.[ 11 ]

The MRI findings in our case are consistent with the typical imaging characteristics of CMs, including the mixed signal intensities of multistage blood, commonly referred to as the “popcorn appearance,” and the blooming artifact in gradient-echo imaging.[ 8 , 19 ] Moreover, CM typically exhibits minimal or no enhancement, distinguishing them from more common lesions in the suprasellar area, such as pituitary adenoma, craniopharyngioma, or meningioma. As a result, CM in the suprasellar location poses a diagnostic challenge for differentiating CM from other lesions. As noted by several authors,[ 7 , 11 ] CMs in extra-axial locations can be misdiagnosed as other entities, such as craniopharyngiomas or meningiomas, underscoring the importance of considering CMs in the differential diagnosis. This case report also highlights the need for radiologists and neurosurgeons to consider CMs in the differential diagnosis of suprasellar lesions, particularly in cases with atypical radiographic features, which may help reduce diagnostic delays and subsequently improve patient outcomes. Diagnostic delays are common in suprasellar cavernomas, with a mean time to diagnosis of 22 months reported in the literature. Our case aligns with this finding, as the patient’s symptoms progressed over a year before diagnosis. This delay highlights the importance of early neuroimaging in patients presenting with progressive cognitive decline, even in the absence of other neurological signs.

Total surgical resection is considered the primary treatment for CMs, demonstrating efficacy in alleviating symptoms and preventing complications such as hemorrhage.[ 12 , 17 ] In the case of suprasellar CMs, surgical approaches must be carefully tailored to the specific location and size of the lesion, necessitating comprehensive preoperative planning. Xu and Yang[ 18 ] reviewed 87 suprasellar CM cases and examined the surgical approaches used. Of these, craniotomies were performed in 84 cases, typically through lateral or midline approaches, while a transsphenoidal approach was employed in three cases. Among the cases of the transsphenoidal approach, the patient improved, partially improved, and deteriorated in one case each. Kulason et al.[ 11 ] reported that a case of suprasellar CM was managed using the transsphenoidal approach. However, due to the retroinfundibular lesion extending into the third ventricle, the surgical corridor was inadequate for effective resection, necessitating a secondary craniotomy for gross total resection. In our case, despite the retroinfundibular lesion, the pituitary hemitransposition as an adjunct to the endoscopic transsphenoidal approach successfully provided an adequate surgical corridor, enabling complete resection of the suprasellar CM. This technique has been described as an effective method for expanding surgical access, particularly in cases with a narrow infrachiasmatic window or when the lesion extends into the third ventricle.[ 2 , 10 ]

The prognosis following surgical treatment of suprasellar CMs is generally favorable, particularly when total lesion resection is achieved, and early intervention is provided. Several studies have shown that surgical excision can result in significant improvement or resolution of initial symptoms, such as headaches and visual disturbances.[ 11 , 18 ] However, the prognosis for memory impairment remains poor, especially when the CM is located in regions critical for memory processing.[ 13 ] In our case, the improvement of the MoCA score was predominantly observed in the recall memory domain, indicating that surgical resection potentially alleviated the pressure effect on memory-related structures. However, cognitive recovery remains limited, presumably due to irreversible structural damage caused by the lesion. In addition, the relationship between CMs and cognitive impairment is complex, with various factors, including the duration of symptoms, surgical trauma, completeness of resection, and patient-specific characteristics, contributing to postoperative outcomes.[ 15 ] Further studies regarding the relationship between suprasellar CMs and cognitive function are necessary to improve the understanding of these outcomes.

Several limitations of this case report warrant acknowledgment. As a single case study, our findings may not be generalizable to the broader population of patients with suprasellar CMs. Although we documented cognitive improvement using the MoCA score, a more comprehensive neuropsychological assessment battery would have provided deeper insights into specific domains of cognitive function and recovery patterns. To address these limitations, future investigations should focus on establishing a multicenter registry of suprasellar CMs to elucidate their natural history and optimize management strategies. Furthermore, comparative studies evaluating outcomes between traditional craniotomy and endoscopic endonasal approaches would provide valuable evidence for determining optimal surgical corridors in these challenging cases.

CONCLUSION

Suprasellar CMs are rare lesions characterized by complex clinical presentations, challenging diagnostics, and intricate therapeutic approaches. This case report highlights the atypical presentation of a patient with suprasellar CM exhibiting progressive memory loss as the primary symptom attributable to the mass effect of the lesion on the structures critical for memory processing. Precise differential diagnosis through imaging is crucial, as suprasellar CMs can mimic other suprasellar pathologies. The endoscopic endonasal transsphenoidal approach, augmented by pituitary hemitransposition, provides an effective surgical corridor for complete resection, demonstrating its potential in select cases. Early surgical intervention may improve symptoms and mitigate complications, although the cognitive outcomes remain variable. Further research is warranted to elucidate the relationship between suprasellar CMs and cognitive deficits, which may inform future management strategies and enhance patient outcomes.

Ethical approval

The Institutional Review Board has waived the ethical approval for this study.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

Disclaimer

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.

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