PMC7771477_01
(a, b and d) T1 magnetic resonance imaging sequences showing a lesion with contrast enhancement in the crural cistern near the right posterior clinoid process. (c) Angio-computed tomography excluded connections of the lesion with the Willis circle.
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F1
T1- and T2-weighted images were characterized by a mixed intensity while the enhancement after gadolinium administration was homogeneous [Figure 1]. An angio-computed tomography (CT) scan excluded an aneurysmatic origin of the lesion [Figure 1].
Intraoperative images (a-g). (a) A right pterional approach was performed and optic-carotid cistern was opened to identify the right internal carotid artery (ICA). Then, (b) intraoperative green video angiography confirmed that the lesion did not arise from the Willis circle. (c) A blackberry-like lesion was observed behind the medial wall of the right ICA, and, after a sharp dissection of the surrounding arachnoid membranes, (d) the strict relationship of the lesion with the right III cranial nerve was observed. (e) Thus, dissection from the nerve was performed and then the lesion was removed. (f and g) At the end of the procedure, the III cranial nerve was spared.
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F2
After having reached optic-carotid cistern and followed the posterior communicating artery (PCoA), a brown and blackberry-like lesion was found, strictly adherent to the III CN [Figure 2]. The intraoperative fluorangiography confirmed the absence of relationships between the lesion and Willis circle [Figure 2]. However, the lesion did not have dural attachments and the dissection of its anterior component was easier than the posterior one that was strictly related to the third CN [Figure 2]. III CN was performed [Figure 2]. In the immediate postoperative period, the right III CN palsy was still present and only minimal improvement was noticed at discharge.
(a) Postoperative computed tomography scan showing gross total resection (GTR). (b) Three-month follow-up postoperative magnetic resonance imaging at showing GTR with no signs of recurrence.
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F3
Histological diagnosis confirmed the suspicion of III CN CM [Figure 3].
Medium power (a and b, x100) HE images showing a vascular lesion comprising dilated vessels with thin walls. Marked signs of recent and past bleeding are present, including widespread hemosiderin globules. These findings were deemed to be consistent with a cavernous hemangioma.
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F4
The 3-month MRI did not show recurrence while the last clinical examination, obtained after 12 months from surgery, did not found CN worsening and the patient still presented a Grade 2 right palpebral ptosis, with diplopia due to the ophthalmoplegia [Figure 4].