CAVERNOUS HEMANGIOMA OF THE THIRD CRANIAL NERVE: CASE REPORT OBJECTIVE: The authors report a rare case of a cavernous hemangioma (CH) involving the third cranial nerve. CLINICAL PRESENTATION: A 25-year-old Caucasian woman presented with neuralgic facial pain that responded to pharmacological management. She had no neurological deficit. Magnetic resonance imaging scans revealed a space-occupying lesion in the interpeduncular cistern with no evidence of hemorrhagic event. Preoperative cere- brospinal fluid and blood samples were negative for cytology and tumor markers. INTERVENTION: The patient underwent craniotomy and exploration of the interpe- duncular cistern. A lesion with the raspberry-like appearance characteristic of a CH was found emerging from between the fibers and completely encircling Cranial Nerve III. The surgeon decided to leave the lesion in place to avoid creation of a new neuro- logical deficit in the young patient. The patient is asymptomatic with a stable radiolog- ical picture 18 months after surgery. CONCLUSION: CH should be considered as a possible differential diagnosis of extra- axial space-occupying lesions along the course of the cranial nerves. Resection with resulting deficit may not be indicated in patients presenting with normal neurological function. Further research and longer follow-up periods are required to better understand the natural history of CH involving the cranial nerves. KEY WORDS: Brain neoplasm, Cavernous hemangioma, Cranial nerves, Oculomotor, Surgical treatment Neurosurgery 61:E653, 2007 DOI: 10.1227/01.NEU.0000280031.45748.39 www.neurosurgery-online.com NEUROSURGERY VOLUME 61 | NUMBER 3 | SEPTEMBER 2007 | E653 CASE REPORTS Eyal Itshayek, M.D. Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel Xicotencatl Perez-Sanchez, M.D. Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel Jose E. Cohen, M.D. Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel Felix Umansky, M.D. Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel Sergey Spektor, M.D., Ph.D. Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel Reprint requests: Eyal Itshayek, M.D., Department of Neurosurgery, Hadassah-Hebrew University Medical Center, P.O. Box 12000, Kiryat Hadassah, Jerusalem, Israel 91120. Email: eyalit@md.huji.ac.il Received, January 6, 2007. Accepted, April 11, 2007. A 25-year-old woman with an unremark- able medical history presented with a 3-month history of pain in the right occipital and hemifacial regions. The pain was stronger at night and did not respond to con- ventional analgesia, but resolved when carba- mazapine was administered. Physical exami- nation was normal, and the patient had no neurological deficit. Computed tomographic scans of her head revealed an isodense mass without bony involvement in the right prepontine area just adjacent to the clivus. No enhancement was seen after administration of contrast material. T1-weighted magnetic resonance imaging (MRI) scans revealed a lesion with mixed high and low signal intensities, with only very sub- tle enhancement when gadolinium was admin- istered (Fig. 1, A and B). On T2-weighted MRI scans, the lesion had mixed signal intensity with low intensity predominance. The lesion was situated at the level of the oculomotor nerve and in close proximity to the dura of the cavernous sinus and tentorial edge. The patient was admitted to the neuro- surgery department for further investigation. When cerebrospinal fluid cytology and tumor markers in the blood and cerebrospinal fluid were negative, a decision was made to proceed with surgery. Intervention The patient underwent a right pterional craniotomy. As the medial portion of the syl- vian fissure was opened and the basal arach- noid cisterns were dissected, a red, multilocu- lated lesion with the raspberry-like appearance typical of a cavernous hemangioma (CH) came into view. The lesion was situated in the interpeduncular cistern ventral to the brain- stem, between the tentorial edge, the right internal carotid artery, and the basilar artery. The CH was arising from among the fibers of the oculomotor nerve and completely encircled