Meckel’s Cave Cavernous Hemangioma: Diagnostic Considerations of a Rare Entity

Cavernous hemangiomas (CM) are tumor-like lesions consisting of an overgrowth of dilated, sinusoidal vessels or capillaries. When found in the neuroaxis, they are typically intra-axial. However, they can rarely present in extra-axial locations with the majority of these located within the cavernous sinus. While many will grow within the sinus and expand to compress the adjacent Meckel’s cave, primary CM originating from Meckel’s cave is rare with only three prior reported cases. While surgery and radiosurgery are mainstay treatments of Meckel’s cave tumors such as schwannomas and meningiomas, CMs by contrast are primarily treated surgically with radiosurgery having a less clear role. Here, we present a rare case of CM arising Meckel’s cave.

A 50 year-old male presented with right-side facial dysesthesia and burning pain in the V2/V3 distributions, dizziness, and diffuse headache. A well-circumscribed, 2.3 × 2 × 1.5 cm contrast-enhancing mass isolated to the right Meckel’s cave was visualized on MRI which was originally thought to most likely be a trigeminal schwannoma. High-resolution CISS sequences revealed splaying of the trigeminal nerve fibers laterally. Given that the lesion was limited to Meckel’s cave and that the trigeminal nerve fibers were displaced laterally, an anterior corridor was favored as opposed to a lateral approach. An endoscopic endonasal transpterygoid approach was performed for gross-total resection of what was pathologically confirmed to be CM. Intraoperatively, the mass was noted to be firm and red in color and distinctly different from a schwannoma. Notably, partial division of V2 had to be performed to increase exposure and visualization given that the CM did not expand foramen rotundum. During resection, the lateral wall of the cavernous sinus was completely visualized and never breached, confirming isolation of the mass to Meckel’s cave. Postoperatively, MRI confirmed gross-total resection and the patient had an expected decrease in right-sided V2 sensation but otherwise had no other complications.

CM isolated to Meckel’s cave is rare. However, it should be considered within the differential diagnosis for Meckel’s cave tumors as treatment considerations of CMs are different from other tumors in this location. A well-circumscribed appearance combined with lack of expansion of skull base foramina may be clues to help distinguish it from more common pathologies in this location.

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No conflict of interest has been declared by the author(s).