‘Gone without a Trace’: A Case of Spontaneous Resolution of Cavernous Sinus Hemangioma during Pregnancy

Sir, There are limited cases of cavernous sinus hemangioma reported in pregnancy. Most cases show rapid clinical and radiological progression in the near term or the early post-partum period, mandating intervention. The pathophysiology for such progression has been postulated to be the vascular, hemodynamic, and hormonal changes associated with pregnancy.[1,2] However, because pregnancy is reversible physiology, they should be expected to show a spontaneous resolution in size in the post-partum period, thus posing a therapeutic dilemma. We hereby report a case of cavernous sinus hemangioma in a 25-year-old primigravida that showed spontaneous post-partum clinic-radiological regression. Only one such spontaneous regression has been reported in the literature.[3] She presented to our facility during the sixth month of her gestation with complaints of the recent onset of a dull aching, holo-cranial headache, accompanied by a painless and progressive ptosis of the left eyelid, followed by diplopia on looking toward the right, persisting for one month. Upon clinical examination, she was diagnosed with complete left oculomotor nerve palsy without involvement of other cranial nerves. Imaging with an MRI brain revealed a 2.5 × 2 cm well-defined extra-axial, T1 hypointense, T2 hyperintense lesion limited to the left cavernous region, suggestive of a hemangioma, other differentials being a meningioma [Figure 1]. Given the adverse effects of gadolinium during pregnancy, contrast imaging was deferred. Following a comprehensive evaluation of the therapeutic alternatives, the patient ultimately opted for non-intervention throughout her gestation period, and she was not on any medication for the lesion. The patient had an uneventful antenatal period with a standard vaginal delivery. Subsequently, she attended a follow-up consultation eight months postpartum, wherein she reported that there was a marginal escalation in both the severity and frequency of headaches as the term approached and persisted for up to two months postpartum, followed by a gradual alleviation with complete resolution of diplopia and partial improvement of ptosis. Clinical assessment revealed approximately a 50% improvement in ptosis with no new neurological impairments. She elected to pursue treatment via gamma knife radiosurgery. However, a pre-procedural MRI of the brain demonstrated complete radiological regression [Figure 2] In light of both clinical and radiological improvements, radiosurgery was deferred, and the patient was placed under rigorous follow-up observation.Figure 1: T2 weighted MRI of the patient, axial and coronal cuts at the level of Sella, circled area showing a well-defined extra-axial T2 hyperintense lesion limited to the left cavernous sinus region. The left ICA (arrow) is seen separate from the lesionFigure 2: Follow-up imaging (3D fiesta and T1W contrast) 8 months post-partum shows complete radiological regression of the lesionConsidering the paucity of case reports of intracranial hemangiomas in pregnancy [Table 1], elucidating the natural history and hence the optimal management protocol for these lesions is difficult. Rapid progression of symptoms near term tends to divert the patients and clinicians towards mandating a definitive intervention.[4] However, in the absence of debilitating symptoms (rapidly progressive vision loss, intractable headache or facial pain, distressing diplopia) and with no significant intracranial mass effect, holding back till post-partum and following up with repeat imaging could help prevent unnecessary interventions in these patients.Table 1: Cases of cavernous sinus hemangioma in pregnancy reported in the literatureStatement of ethics The research was conducted ethically following the World Medical Association Declaration of Helsinki. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.