Safety of Endoscopic Surgery for Spontaneous Intracerebral Hemorrhage in the Registry of Intracerebral Hemorrhage Treated by Endoscopic Hematoma Evacuation in Japan.

OBJECTIVE: The long history of treatment for intracerebral hemorrhage (ICH) includes the development of surgical procedures. However, few studies have demonstrated that surgery improved the functional outcome. The present study used the prospective Registry of Intracerebral hemorrhage treated by endoscopic hematoma evacuation of the outcomes in endoscopic surgery, which is widely followed in Japan, to try to establish clinical evidence. METHODS: The Registry of Intracerebral hemorrhage treated by endoscopic hematoma evacuation is a multicenter, prospective registry in Japan, and included 143 surgical cases treated by certified neurosurgeons. The etiology and the location of ICH was evaluated by univariate and multivariate analyses as follows: deep, surface, intraventricular hemorrhage, cerebellum, and surgical outcome. RESULTS: Hematoma location was deep in 44.8% of cases, intraventricular hemorrhage in 19.6%, surface in 21.7%, and cerebellum in 14.0%. Most cases were treated in the ultraearly stage within 8 hours. Mean hematoma evacuation rate was 83.6% and median residual hematoma volume was 3.0 ml. Duration of surgery was median 78 minutes. Rebleeding as a complication was observed in 6.7%, but only 2.9% were symptomatic. 2 cases required reoperation. Favorable outcome at 6 months was achieved in 35.8% of cases, with a mortality rate of 5.6%. CONCLUSIONS: Endoscopic surgery for spontaneous ICH is safe and comparable to conventional surgery. The time required for the procedure was significantly reduced, demonstrating the minimally invasive character of the surgical burden. However, this study did not establish whether minimally invasive surgery is superior to conservative treatment. Future randomized controlled trials should clarify the effectiveness of the treatment.

Andexanet Alfa for the Reversal of Factor Xa Inhibitor Activity: Prespecified Subgroup Analysis of the ANNEXA-4 Study in Japan.

AIMS: Andexanet alfa, a specific antidote to factor Xa (FXa) inhibitors, has been approved for clinical use in several countries, including Japan, based on the results from the phase 3 trial ANNEXA-4. We aimed to assess the efficacy and safety of andexanet alfa treatment in FXa inhibitor-related acute major bleeding in patients enrolled for ANNEXA-4 in Japan. METHODS: This prespecified analysis included patients enrolled at Japanese sites in the prospective, open-label, single-arm ANNEXA-4 trial. Eligible patients had major bleeding within 18 hours of oral FXa inhibitor administration. The coprimary efficacy endpoints were percent change in anti-FXa activity and proportion of patients achieving excellent or good hemostatic efficacy 12 hours post-treatment. RESULTS: A total of 19 patients were enrolled, all of whom had intracranial hemorrhage; 16 patients were evaluable for efficacy. Median percent reduction in anti-FXa activity from baseline to nadir was 95.4% in patients taking apixaban, 96.1% in patients taking rivaroxaban, and 82.2% in patients taking edoxaban. Overall, 14/16 patients (88%) achieved excellent or good hemostasis (apixaban, 5/5; rivaroxaban, 6/7; edoxaban, 3/4). Within 30 days, treatment-related adverse events (AEs) and serious AEs occurred in 2 and 5 patients, respectively. One patient died during follow-up, and 2 patients experienced thrombotic events. CONCLUSION: Treatment with andexanet alfa rapidly reduced anti-FXa activity with favorable hemostatic efficacy in Japanese patients with acute major bleeding. Serious AEs of thrombotic events during rapid reversal of anti-FXa activity arose as particular safety concerns in this population as with previous studies.

Aneurysmal Inflow Rate Coefficient Predicts Ultra-early Rebleeding in Ruptured Intracranial Aneurysms: Preliminary Report of a Computational Fluid Dynamics Study.

Rebleeding from a ruptured intracranial aneurysm has poor outcomes. Although numerous factors are associated with rebleeding, studies on computational fluid dynamics (CFD) on hemodynamic parameters associated with early rebleeding are scarce. In particular, no report of rebleeding in ultra-early phase exists. We aimed to elucidate the specific hemodynamic parameters associated with ultra-early rebleeding using CFD. In this study, the rebleeding group included patients with aneurysmal subarachnoid hemorrhage (aSAH) that rebled within 6 h from the onset. The control group included patients without rebleeding, observed for >10 h following the initial rupture. Clinical images after initial rupture and before rebleeding were used to build 3D vessel models for hemodynamic analysis focusing on the following parameters: time-averaged wall shear stress (WSS), normalized WSS, low shear area, oscillatory shear index, relative residence time, pressure loss coefficient, and aneurysmal inflow rate coefficient (AIRC). Five and 15 patients in the rebleeding and control groups, respectively, met the inclusion criteria. The World Federation of Neurosurgical Surgeons grade was significantly higher in the rebleeding group (p = 0.0088). Hemodynamic analysis showed significantly higher AIRC in the rebleeding group (p = 0.042). The other parameters were not significantly different between groups. There were no significant differences or correlations between SAH severity and AIRC. AIRC was identified as a hemodynamic parameter associated with ultra-early rebleeding of ruptured intracranial aneurysms. Thus, AIRC calculation may enable the prediction of ultra-early rebleeding.

[Treatment of Secondary Hydrocephalus after Subarachnoid Hemorrhage].

Hydrocephalus is one of the major complications secondly occurring with or after subarachnoid hemorrhage(SAH). Hydrocephalus can be classified into acute(≦ 48 h), subacute(3-14 days), or chronic phases(≧ 2 weeks)in which a cerebrospinal fluid(CSF)shunt is required as the curative treatment at the rate of approximately 30%. On the mechanism of hydrocephalus development, it is generally accepted that an inflammatory reaction and the ensuing fibrosis process impede continuous CSF flow outward to the sinus, terminally from arachnoid granulation, leptomeninges, or ventricle walls, in addition to the mechanical blockage due to SAH clots. Several factors associated with the severity of SAH, such as a high Hunt and Hess grade, intraventricular hemorrhage, and a ruptured aneurysm in the posterior circulation also predict the development of shunt-dependent hydrocephalus. The predictive scoring system is available. Effective treatment of hydrocephalus still involves the use of CSF shunts. No superiority between ventriculoperitoneal and lumboperitoneal shunts has been established. Even during oral, single antiplatelet treatment after coil embolization for ruptured aneurysms, curative shunt operation is possible with low frequency of hemorrhagic complications. Hydrocephalus should be diagnosed early and treated appropriately to improve the functional outcome of the patients after SAH.

Artificial Intelligence Trained by Deep Learning Can Improve Computed Tomography Diagnosis of Nontraumatic Subarachnoid Hemorrhage by Nonspecialists.

Subarachnoid hemorrhage (SAH) is a serious cerebrovascular disease with a high mortality rate and is known as a disease that is hard to diagnose because it may be overlooked by noncontrast computed tomography (NCCT) examinations that are most frequently used for diagnosis. To create a system preventing this oversight of SAH, we trained artificial intelligence (AI) with NCCT images obtained from 419 patients with nontraumatic SAH and 338 healthy subjects and created an AI system capable of diagnosing the presence and location of SAH. Then, we conducted experiments in which five neurosurgery specialists, five nonspecialists, and the AI system interpreted NCCT images obtained from 135 patients with SAH and 196 normal subjects. The AI system was capable of performing a diagnosis of SAH with equal accuracy to that of five neurosurgery specialists, and the accuracy was higher than that of nonspecialists. Furthermore, the diagnostic accuracy of four out of five nonspecialists improved by interpreting NCCT images using the diagnostic results of the AI system as a reference, and the number of oversight cases was significantly reduced by the support of the AI system. This is the first report demonstrating that an AI system improved the diagnostic accuracy of SAH by nonspecialists.

Impact of a learning health system on acute care and medical complications after intracerebral hemorrhage.

INTRODUCTION: Patients with stroke often experience pneumonia during the acute stage after stroke onset. Oral care may be effective in reducing the risk of stroke-associated pneumonia (SAP). We aimed to determine the changes in oral care, as well as the incidence of SAP, in patients with intracerebral hemorrhage, following implementation of a learning health system in our hospital. METHODS: We retrospectively analyzed the data of 1716 patients with intracerebral hemorrhage who were hospitalized at a single stroke center in Japan between January 2012 and December 2018. Data were stratified on the basis of three periods of evolving oral care: period A, during which conventional, empirically driven oral care was provided (n = 725); period B, during which standardized oral care was introduced, with SAP prophylaxis based on known risk factors (n = 469); and period C, during which oral care was risk-appropriate based on learning health system data (n = 522). Logistic regression analysis was performed to evaluate associations between each of the three treatment approaches and the risk of SAP. RESULTS: Among the included patients, the mean age was 71.3 ± 13.6 years; 52.6% of patients were men. During the course of each period, the frequency of oral care within 24 hours of admission increased (P < .001), as did the adherence rate to oral care ≥3 times per day (P < .001). After adjustment for confounding factors, a change in the risk of SAP was not observed in period B; however, the risk significantly decreased in period C (odds ratio 0.61; 95% confidence interval 0.43-0.87) compared with period A. These associations were maintained for SAP diagnosed using strict clinical criteria or after exclusion of 174 patients who underwent neurosurgical treatment. CONCLUSIONS: Risk-appropriate care informed by the use of learning health system data could improve care and potentially reduce the risk of SAP in patients with intracerebral hemorrhage in the acute stage.

Interval between endoscopic surgery and decreased intracranial pressure related to putaminal hemorrhage prognosis.

BACKGROUND: Endoscopic evacuation of a putaminal hemorrhage is effective and minimally invasive; however, it may not result in sufficient brain decompression. While monitoring postoperative intracranial pressure (ICP) is likely useful, specific ICP data in patients with a putaminal hemorrhage are limited. The aim of this study was to determine the association between postoperative ICP and the prognosis of patients with putaminal hemorrhage after endoscopic surgery. METHODS: We retrospectively analyzed 24 consecutive patients with a putaminal hemorrhage in whom ICP monitoring after endoscopic surgery was performed. Clinical data regarding hematoma volume, evacuation rate, onset-to-treatment time, operation time, ICP max, ICP peak out time (T peak out), and neurological outcomes on discharge were investigated. RESULTS: From August 2011 to October 2015, 24 patients with a putaminal hemorrhage were analyzed. Consciousness on admission and hemorrhage volume were associated with poor outcomes after endoscopic surgery for putaminal hemorrhage. The hematoma volume, operation time, and evacuation rate of hemorrhage were correlated to early peak out of ICP. Furthermore, a T peak out ≤24 h was significantly associated with good neurological outcomes on discharge. CONCLUSIONS: Our data suggest that early peak out (≤24 h) of ICP after endoscopic surgery is predictive of a good prognosis following putaminal hemorrhage. Operation time and evacuation rate of hemorrhage could hasten peak out of ICP and improve outcomes in patients with a putaminal hemorrhage after endoscopic surgery.

Cranial Reconstruction with Titanium Mesh for Open Depressed Skull Fracture in Children: Reports of Two Cases with Long-term Observation.

In the treatment of open depressed skull fracture in pediatric cases, it is preferable to use the patient's own bone material rather than artificial material. However, there are occasions when self-material reconstruction may be impossible. In such cases the safe option is to leave the defect until future replacement of the skull becomes possible, however this often causes such children to experience severe limitations to school life. We present two thought-provoking cases in which we solved such issues by early stage cranioplasty using a titanium mesh. The first case involved a 9-year-old boy who sustained a depressed fracture in the right temporal region after falling down a riverbank. Although he underwent surgical repair, bacterial infection forced removal of the bone flap postoperatively. His school life was severely restricted and sports activities were prohibited due to the residual regional bone defect. Cranial reconstruction with a titanium mesh made it possible for him to enjoy a more active lifestyle. The second case involved a 7-year-old boy who sustained a right frontal depressed fracture in a traffic accident. The fractured skull was promptly replaced by a titanium mesh at the initial surgery due to the extreme degree of bone fragmentation. Both boys returned to school life enjoying normal activities and without any complications for up to 8 years now. The cases presented here indicate that early cranioplasty even using artificial material is not only safe but enables school age patients to participate in physical activities. From the standpoint of physical and psychological development, early stage cranioplasty with titanium mesh may be a valuable treatment option for pediatric open depressed skull fracture.

Histological analysis of infiltrating macrophages in the cerebral aneurysm walls.

A series of recent evidences suggested activated macrophages have broadly two distinct forms that possess opposite functions for the process of inflammation: classically activated macrophages (M1/kill macrophages) and alternatively activated macrophages (M2/repair macrophages) according to their functions and expression markers. To elucidate what roles those two phenotypes of macrophages play in the evolution of cerebral aneurysm, the presence of macrophages inside the aneurysm walls was assessed with an immunohistochemical approach. The portions of the aneurysm domes deflated after neck clipping were utilized for the further histological examinations, including immunostainings with five antibodies to identify macrophage subpopulations. In this study, contrary to the previous reports, the following various ratios of subtypes were observed in the aneurysm walls: M1 > M2 (2 cases), M1 < M2 (2 cases), M1 = M2 (3 cases). While M1-like macrophages have been typically regarded as a main driver of the degenerating process, these surprisingly richer presences of M2-like macrophages in the aneurysm walls suggests that an unrecognized biological process might be in play in aneurysm development.

Clipping on Crossed Wrapping Method for Ruptured Blood Blister-Like Aneurysm of the Internal Carotid Artery: Technical Note and Long-Term Results.

BACKGROUND: We have been performing the clipping on crossed wrapping (COCW) method using 2 strips of cotton on patients with an internal carotid artery blood blister-like aneurysm (IC-BLA). This method is reliable in preventing the clips from slipping off and the aneurysm walls from being damaged during clipping, and it enables more appropriate and safer clipping. Here we report the technical details of this method and the long-term outcomes of patients receiving this procedure. METHODS: Fifteen of 1275 (1.5%) patients with a ruptured cerebral aneurysm who received treatment at the Saiseikai Kumamoto Hospital during the period from January 1, 1999, to December 31, 2016, had an IC-BLA. All 15 patients were treated with COCW, except for the first patient, who was treated using a single strip of cotton. The long-term outcome of the treatment was analyzed. RESULTS: The mean follow-up period was 74 months. The first patient experienced rerupture of an aneurysm 10 days after the operation. No complications or regrowth of an aneurysm were observed in the remaining 14 patients during the follow-up period, except for 1 patient who received a reoperation for the regrowth of an aneurysm. As the final outcome, the numbers of patients with a Modified Rankin Score of 0, 3, and 6 were 13, 1, and 1, respectively. CONCLUSIONS: It is suggested that COCW is a treatment that enables safe and long-term management of lesions in IC-BLAs.

Multiple Cerebral Aneurysms Associated With Neurofibromatosis Type 1.

Neurofibromatosis type 1 (NF1) is a rare disease with an incidence of approximately one in every 3000 births. NF1 is mainly recognized as a tumor suppressor. Vasculopathy in NF1 is well described in the literature, but the association between NF1 and cerebral aneurysm has not been determined. We report a case of a 67-year-old female with NF1 accompanied by 8 cerebral aneurysms. Two of the patient's unruptured aneurysms, the large distal anterior cerebral artery (ACA) aneurysm and anterior communicating artery aneurysm, were initially treated with microsurgical clipping. The peripheral ACA aneurysm gradually increased in size and ruptured after 5 years. Coil embolization was performed for the ruptured aneurysm. Four of the 5 remaining unruptured aneurysms were treated surgically. The patient is currently well, without neurological deficit, and coil embolization is scheduled for the last remaining aneurysm. NF1 is a probable risk factor for multiple cerebral aneurysms due to vessel wall vulnerability. Therapeutic indications for patients with NF1 who show multiple cerebral aneurysms include strict follow-up and aggressive treatment to avoid subarachnoid hemorrhage.

Palliative lumboperitoneal shunt for leptomeningeal metastasis-related hydrocephalus: A case series.

BACKGROUND: Leptomeningeal metastasis-related hydrocephalus causes distress to patients with end-stage cancer through headache and other symptoms by elevating intracranial pressure, thus reducing quality of life. Ventriculoperitoneal shunt has been used as a treatment option in palliative care. We review four cases of patients who underwent lumboperitoneal shunt for leptomeningeal metastasis-related hydrocephalus. CASES: All patients suffered from severe headache and nausea. The primary lesion was histologically diagnosed as lung adenocarcinoma in each case. The duration from diagnosis to onset of hydrocephalus symptoms ranged from 0 to 52 (mean 26) months. Cerebrospinal fluid pressure in every case was above the normal range due to high intracranial pressure. Case management: Conventional procedures for lumboperitoneal shunt were employed for all patients. Adjustable pressure valves were retrofitted into the shunt system. Case outcome: Three patients demonstrated significant improvement of clinical symptoms and quality of life after placement of lumboperitoneal shunts. In two cases, not only did performance status improve to independent daily activity but also comparatively long-term survival was achieved due to subsequent chemotherapies after surgery. No symptoms of peritoneal dissemination by floating cancer cells in cerebrospinal fluid were seen in any patients. CONCLUSION: Lumboperitoneal shunt appears to improve quality of life if the patient is suffering from symptoms of leptomeningeal metastasis-related hydrocephalus. Compared to ventriculoperitoneal shunt, lumboperitoneal shunt is less invasive and simpler, providing a suitable option for frail patients with end-stage cancer. Adjustable pressure shunt valves can cope with varying symptoms and ventricle sizes.

Effectiveness of Endoscopic Surgery for Comatose Patients with Large Supratentorial Intracerebral Hemorrhages.

To evaluate the effectiveness of endoscopic surgery for life-threatening large brain hemorrhage, we reviewed our empirical cases of comatose patients with large supratentorial intracerebral hemorrhage. Among 35 patients with putaminal or subcortical hemorrhage that was evacuated endoscopically, 14 cases (40%) presented both findings of neurological grade IV for severity and hematoma volume exceeding 70 mL in the recent 3 years (endoscope group), whereas 8 cases with the same conditions were treated by conventional craniotomy for the preceding 3-year period (craniotomy group). Between these two groups, mean age was higher and duration of surgery was shorter in the endoscope group, but no significant differences in hematoma size or evacuation rate were recognized. In the 10 cases that presented with signs of cerebral herniation (neurological grade IVb) and required emergent decompression, the preparation time for surgery tended to be shorter in the endoscope group, although the difference was not significant. Additional ventricular drainage was performed in 7 cases and showed a supplemental effect of reducing intracranial pressure (ICP). Consequently, all patients in the endoscope group were rescued without decompressive large craniectomy, even with symptoms of cerebral herniation. In conclusion, endoscopic surgery has the potential to offer an effective therapeutic option for comatose patients with large supratentorial intracerebral hemorrhages, matching conventional craniotomy for emergent treatment in terms of mortality and management of ICP.

De novo formation and rupture of an intracranial aneurysm 10 months after normal findings on conventional magnetic resonance angiography in a patient with no history of intracranial lesions: case report.

A 40-year-old male smoker presented with a ruptured saccular aneurysm that formed de novo 10 months after normal magnetic resonance (MR) angiography findings. Computed tomography of the head at the second admission showed subarachnoid hemorrhage in the interhemispheric fissure and anterior basal cistern. MR and conventional cerebral angiography revealed an aneurysm arising from the anterior communicating artery (AcomA). MR angiography performed 10 months earlier, when he experienced transient loss of consciousness, revealed no anomalies at the AcomA. Intraoperatively, the de novo aneurysm was found to be a typical saccular aneurysm with a fragile wall.

[A case of lumboperitoneal shunt as an effective palliative tool in a patient with leptomeningeal metastasis].

A 64 year-old woman with a diagnosis of lung adenocarcinoma was admitted to our neurosurgical division in February, 2007, suffering from severe headache and dizziness. Systemic chemotherapy had been repeated for multiple metastases to the bone and cerebral cortex since 7 months before. Reexamination with MRI revealed mild hydrocephalus without cortical metastasis. Cytological analysis of the cerebrospinal fluid (CSF) provided the diagnosis of leptomeningeal metastasis. Removal of 8 ml of CSF dramatically alleviated the patient's symptoms. To improve the quality of her remaining life, she underwent lumboperitoneal (L-P) shunt using a Strata adjustable pressure valve. Severe headache disappeared and other symptoms gradually improved after the operation. She survived for 10 months after the shunt placement, perticipating in family life for 6 months. Pressure level of the Strata valve was changed twice according to the degree of hydrocephalus and functioned well while her life lasted. The present case showed that L-P shunt is one of the effective palliative procedures and an adjustable pressure valve is available for this kind of CSF shunt in patients with leptomeningeal metastasis.

Postoperative quality of life of patients treated for asymptomatic unruptured intracranial aneurysms.

OBJECT: The aim of this study was to assess the quality of life (QOL) of patients who underwent surgery for asymptomatic unruptured intracranial aneurysms (UIAs). METHODS: The authors assessed QOL in 149 patients who had undergone microsurgical clipping of asymptomatic UIAs. They surveyed these patients using universal methods such as the 36-Item Short Form Health Survey (SF-36) for health-related QOL and the Hospital Anxiety and Depression Scale for anxiety and depression assessments. RESULTS: The patients' mean scores for each of the eight domains of SF-36 were comparable to those of a Japanese reference population. Analysis of data from the average-QOL and low-QOL subgroups showed that the low-QOL group contained a higher number of patients with preexisting heart diseases and restricted activities of daily living. Operative procedures and complications did not affect QOL. CONCLUSIONS: Because 86% of the patients who underwent surgery manifested a QOL similar to the reference population, the authors suggest that elective surgery for asymptomatic UIAs is a reasonable treatment, especially in patients who are troubled by the risk of rupture. Postoperative decreases in QOL are not invariably attributable to the operation or its associated complications, but may be correlated with other chronic disorders. To select the appropriate treatment for asymptomatic UIAs, neurosurgeons and patients need information on the expected postoperative QOL.

[Self-assesed quality of life in patients who underwent surgery for asymptomatic meningiomas].

The aim of our study was to assess the quality of life (QOL) of patients operated on for asymptomatic meningioma and to assess the correlation between QOL and operative complications. Of 21 surgically treated patients, 6 (28.6%) presented with persistent neurological impairments or events considered to be treatment-related. Seventeen patients participated in the QOL survey using MOS Short-Form 36-Item Health Survey (SF-36) for health-related QOL issues and the Hospital Anxiety and Depression Scale (HADS) for anxiety nd depression assessment. The mean scores for each of the 8 domains of SF-36 were comparable with these of a Japanese reference population. When we divided the patients into 2 groups according to the degree of headache, activity of daily living, or complications, the QOL of patients with persistent headache declined in the SF-36 domains related to physical function and vitality. Minor neurological impairments developed by 4 patients did not affect their QOL. In conclusion, surgery for asymptomatic meningioma has no negative impact on postoperative QOL if the surgical complications are minor. On the other hand, physical activities in some patients were hampered due to persistent headache. Besides the treatment-related morbidity and mortality rates, QOL issues should also be included in treatment indications for asymptomatic meningioma.

Improvement of quality of life in patients surgically treated for asymptomatic unruptured intracranial aneurysms.

OBJECTIVE: To compare the preoperative and postoperative health-related quality of life (QOL) and psychological state of patients with asymptomatic unruptured intracranial aneurysms (ICAs) who underwent elective surgery. METHODS: Out of 67 patients who underwent neck clipping of ICAs, we assessed the QOL of 61 patients using Short Form-36 (SF-36); their psychological state was rated on the Hospital Anxiety and Depression Scale (HADS) before, 3 months, and 1 and 3 years after treatment. RESULTS: The preoperative mean scores for each of the eight SF-36 domains except bodily pain were significantly lower in the study population than in the reference population. 14 (20.9%) patients experienced surgical complications defined as neurological deterioration and/or abnormal CT findings within 30 days of the operation. Despite some complications, the QOL of all operated patients returned to the mean level of the reference population 3 years after treatment. At 3 months after surgery, the scores for psychosocial activities and general health perception were transiently below the preoperative levels. According to the HADS, the patients experienced mild anxiety before the operation; it disappeared by the third postoperative month. CONCLUSIONS: Preoperatively, patients with unruptured ICAs reported a significantly decreased QOL. It further declined transiently after elective surgery, but it returned to the mean level recorded for the reference population within 3 years. Our findings suggest that these patients derived significant QOL benefits from their surgery. Hence subjective QOL issues should be considered in deciding whether treatment-related risks and their natural history, such as their potential rupture, warrant surgery of asymptomatic unruptured ICAs.

Cavernous malformation of the optic chiasm: case report.

We report a 14-year-old boy with cavernous malformation of the optic chiasm. He had a 2-year history of gradually worsening visual disturbance. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a suprasellar mass, findings compatible with craniopharyngioma. The mass was biopsied and histological examination confirmed cavernous malformation. On the second day after the biopsy, he suffered chiasmal apoplexy due to intratumoural haemorrhage, lost visual acuity and developed a field cut. Cavernous malformations arising from the optic nerve and chiasm are extremely rare; only 29 cases have been reported to date. Most patients manifested acute visual acuity and visual field disturbances. Although MRI findings of cavernous malformations in the brain parenchyma have been reported, MRI findings on the optic nerve and chiasm may not be completely diagnostic. Of the 29 documented patients, 16 underwent total resection of the lesion without exacerbation of their preoperative symptoms; in some cases, resection was complicated by risk of damage to the surrounding neural tissue. As patients may suffer intratumoural haemorrhage after biopsy or partial removal of the lesion, the advisability of surgical treatment of cavernous malformations of the optic nerve and chiasm must be considered carefully.