Surgical management and visual outcomes of optic-pathway cavernous malformations: A comprehensive literature review of 80 reported cases (1979 – 2025)

Objective

Cavernous malformations (CMs) of the optic chiasm, optic tract, and hypothalamus are exceedingly rare. Most patients present with acute or progressive visual loss, and surgery aims to maximize visual recovery while minimizing neural manipulation. We describe an updated review of all reported operated optic-pathway cavernomas to clarify surgical strategies and visual outcomes.

Methodology

PubMed, MEDLINE, and Google Scholar were searched with the terms optic pathway cavernoma, optic chiasm cavernoma, hypothalamic cavernoma, and surgical outcomes. Eighty published cases (1979 – May 2025) were analyzed for presentation, surgical corridor, extent of resection, and postoperative vision.

Results

Among 80 patients (42 females, 36 males; mean age 34.9 ± 11.7 years), visual disturbance was the initial symptom in 75/78 with available data (96.2 %); headache occurred in 29 (37 %). Surgical corridors included fronto-temporal/pterional (55 %), mid-line subfrontal or inter-hemispheric (16 %), orbito-zygomatic (6 %), EEA/TNTS (6 %), and other or unspecified craniotomies (16 %). Gross-total resection (GTR) was achieved in 59 patients (73.8 %). Post-operative vision (reported in 75 patients) improved in 54 (72.0 %), stabilised in 17 (22.7 %), and deteriorated in 4 (5.3 %). GTR conferred the highest likelihood of improvement (78.9 % vs 50 % after subtotal resection). The EEA/TNTS corridor, now reported in six cases, allowed complete excision without brain retraction or Sylvian fissure dissection and achieved visual improvement or stability in all patients.

Conclusion

Early surgical excision offers visual improvement or preservation in more than 94 % of optic-pathway CM cases, with GTR the strongest predictor of favourable outcome. The endoscopic endonasal route, when guided by neuronavigation and multilayer skull-base reconstruction, provides direct mid-line access with minimal manipulation of critical perforators and should be considered a first-line corridor for mid-line chiasmatic or retro-chiasmatic lesions.