The hidden dangers: Delayed fatal apoplexy in adult-onset optic pathway glioma following biopsy

• The conclusion and discussion part of the manuscript have been revised. • Quality of the figures, annotations and their appropriate descriptions is amended. • The Histologic evidence of optic pathway PCA after the craniotomy and biopsy is provided. • New references published in the last 15 years have been added as well. • The grammar and writing have also been revised. • All the revisions on major and minor comments of reviewers are highlighted in yellow. Optic pathway gliomas (OPG) are the most common primary neoplasm of the optic pathway. They are most commonly seen in children less than 8 years of age. Adult onsets OPG are rare entity. Hemorrhage (Apoplexy) in these tumors is rare and it is extremely rare to occur late after a biopsy. We describe a 33 years old right handed male patient presented with status epilepticus and right side motor preference of 5 h duration. He was on 3rd month post operation after Craniotomy and open biopsy was taken for a suspected OPG. Imaging showed massive intatumoral hemorrhage with no evident vascular abnormalities. The initial Pathology report showed pilocytic astrocytoma (PCA). He underwent Craniotomy and hematoma evacuation with right side Kochers point external ventricular drain (EVD). He had significant initial neurologic improvement but on 5th post-operative day (POD) he had re-bleeding with a fatal outcome. Apoplexy in optic pathway and hypothalamic gliomas is a rare event. While some risk factors for tumor apoplexy in optic pathway gliomas have been identified, the potential for a biopsy to precipitate delayed bleeding merits cautious consideration. Ultimately, clinical management strategies for these delicate lesions must be individually tailored, weighing the diagnostic yield against the potential for procedural complication.