Intrasellar Cavernous Malformations: Two Case Reports With a Systematic Review of Clinical Features, Surgical Management, and Outcomes

Background: Intrasellar cavernous malformations (ICMs) are rare vascular lesions that frequently mimic pituitary adenomas, creating major diagnostic and surgical challenges. Their marked vascularity confers a substantial risk of intraoperative hemorrhage. This systematic review evaluated the clinical presentation, management strategies, and outcomes of ICMs. Methods: PubMed, Scopus, and WOS were searched through April 2026 following PRISMA guidelines. Studies describing histologically or radiologically confirmed ICMs were included. Data on demographics, clinical presentation, treatment, complications, and outcomes were extracted. Two institutional cases were also analyzed. Results: Two institutional patients presented with headaches and sellar lesions initially diagnosed as adenomas. Both demonstrated marked intraoperative bleeding; immunohistochemistry confirmed ICMs. Resection was subtotal in one and gross total in the other, with no recurrence. The systematic review identified 21 studies comprising 26 patients. Visual deficits (69%) and headache (54%) predominated; most lesions were preoperatively misdiagnosed as nonfunctioning macroadenomas. Surgery was performed in 96%, predominantly via endoscopic endonasal transsphenoidal approaches. Subtotal resection was more frequent than gross total resection (54% vs. 35%). Nonetheless, clinical improvement reached 94%, with visual improvement or complete recovery occurring in 8 of 13 evaluable patients (62%). Although intraoperative bleeding occurred in 95% of cases, mortality was low (4.3%) and long-term functional status was favorable. Conclusions: ICMs are deceptive vascular lesions that require careful vigilance to minimize significant intraoperative hemorrhage. Although complete resection is often technically challenging, tailored surgical strategies can achieve favorable functional outcomes. Improved preoperative recognition remains essential for optimizing surgical planning and reducing morbidity.