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| Year : 2011 | Volume
: 57
| Issue : 3 | Page : 258-259 |
Large cavernous hemangioma of the skull base associated with an angular artery aneurysm
X Wang, J Li, G Li, C You
Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| Date of Web Publication | 22-Sep-2011 |
Correspondence Address:
G Li
Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu
China
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0022-3859.85228
How to cite this article:
Wang X, Li J, Li G, You C. Large cavernous hemangioma of the skull base associated with an angular artery aneurysm. J Postgrad Med 2011;57:258-9 |
Sir,
Skeletal cavernous hemangiomas (CHs) are uncommon tumors, accounting for only 0.7% of all osseous neoplasms. [1] The occurrence of skull CHs in combination with aneurysm are rarer. To our knowledge, only Hidenori et al. had reported a CH associated with middle meningeal aneurysm. [2] Thus, we describe a rare case of skull base CH in association with an angular artery aneurysm.
A 24-year-old male had a painless supraorbital swelling for 7 years, which was solid, unpulsatile on the left part but pulsatile on the right. The swelling had been slowly developing since the past 7 years. Computerized tomography (CT) of the head showed a mass with a size of 37.7 mm Χ 61.7 mm Χ 67.5 mm in the left skull base and involving the supraorbital wall, sphenoid sinus and ethmoid sinus [Figure 1]. CT angiography showed that the left frontal bone and orbital roof were destroyed, the outer table was invaded and the thick blood vessels within it could be seen. Meanwhile, an aneurysm measuring 11 mm in diameter located on the enlarged angular artery was seen [Figure 2]. | Figure 1: Computerized tomography demonstrates lesions with osseous spicules in keeping with hemangiomas involved with left frontal bone, supraorbital wall, sphenoid sinus and ethmoid. The central portion of this lesion revealed subtle striated trabeculations and retained a thin sclerotic rim of peripheral bone condensation, and the boundary was clear. Both the inner and the outer tables of the skull were eroded
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 | Figure 2: Computerized tomography angiography showed an aneurysm measuring 11 mm in diameter located on the enlarged angular artery. Meanwhile, the thick blood vessels within the swelling could be seen
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A biopsy of the lesion and clipping of the aneurysm were performed at the secondary hospital. Histological examination confirmed the diagnosis of CH [Figure 3]. The bleeding during the operation was quite difficult to control. Because of the danger of uncontrollable bleeding, the patient was referred to our department for further treatment. Digital subtraction angiography revealed an affluent-blood lesion with the feeding arteries of facial artery, ophthalmic artery and an angular artery. No obvious drainage veins were found. Embolization with Onyx glue was performed firstly and the angular artery was embolized [Figure 4]. Three days after the embolization, the lesion and peripheral portion of the bone was surgically resected without significant blood loss. The postoperative course was uneventful. The patient recovered well without any neurological deficit. | Figure 3: Photograph showing the thin-walled expanded vascular structures layered with endothelial cells between the fibrous bony trabeculae (H and E, x100)
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 | Figure 4: Cerebral angiography of the left external carotid artery (anteroposterior view) showing the feeding arteries originating from the facial artery, ophthalmic artery and embolized angular artery
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CH can occur in all bones of the calvarium, including the maxilla and the mandible. The parietal bones are thought to be the most commonly affected, and anterior skull base is less affected. Although any age may be involved, CHs are usually identified in middle-aged patients. Women are affected two to four times more than men. [3]
Aneurysm may occur associated with CH. Hidenori et al. reported a CH associated with the middle meningeal artery (MMA) aneurysm. They thought that the resultant increased hemodynamic stress and the medial defects of the MMA probably contributed to the formation of true aneurysms. In our case, the angular artery was feeding the CH of the skull and, therefore, the increased hemodynamic stress may contribute to the formation of angular aneurysm. Resection of the aneurysm is necessary because it may be broken to form hemorrhea.
Correct preoperative diagnosis is very important to avoid the risk of substantial hemorrhage in patients with CHs. Differential diagnosis includes fibrous dysplasia, meningioma, osteoma, dermoid cyst, osteogenic sarcoma, aneurysmal bone cyst, cholesteatoma, Paget's disease, osteitis fibrosa cystica and hyperparathyroidism. CT demonstrates the radiating spicules and the scalloped nonsclerotic borders of the lesion. The contrast enhancement and hypointense bony spicules with marked T2 hyperintensity are well demonstrated on magnetic resonance imaging studies. [4]
Surgical excision is the most efficient way to deal with CH. [5] Because of the multiple arteries supplying the lesion, embolization was performed before the operation in order to decrease the blood supply. Therefore, we recommend embolism before operation for those patients with large vascular CHs.
| :: References | |  |
| 1. | Daizo Y, Yuichi S, Toshiro S, Akira, T. Cavernous hemangioma of the skull in a neonate. Childs Nerv Syst 1999;15:351-3. 
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| 2. | Ohta H, Tanazawa T, Osuka K, Ito Y, Fukatsu T. True aneurysms of the middle meningeal artery associated with cavernous hemangioma of the skull: Case report. Neurol Med Chir 1991;31:203-5.
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| 3. | Kuzeyli K, Usul H, Cakir E, Caylan R, Rei A, Baykal S, et al. Multifocal intradiploic cavernous hemangioma of the skull associated with nasal osteoma. Acta Neurochir 2003;145:323-6.
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| 4. | Cosal M, Eser O, Aslan A, Korkmaz S, Boyaci G, Aktepe F. Intradiploic cavernous hemangioma of the skull in a child: A case report. Childs Nerv Syst 2008;24:975-7.
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| 5. | Stefan H, Alfred A, Stefan K. Cavernomas of the skull: Review of the literature 1975-2000. Neurosurg Rev 2002;25:56-62.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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