Cavernous hemangioma mimicking schwannoma in the sacral intervertebral foramen: A case report

Sacral epidural cavernous hemangioma involving the intervertebral foramen is exceptionally rare and may closely mimic more common benign nerve sheath tumors on magnetic resonance imaging. We report the case of a woman in her mid-50s who presented with a 1-month history of nocturnal left lower-extremity pain and mild weakness. Contrast-enhanced lumbar magnetic resonance imaging revealed a strongly enhancing nodular lesion in the left S2 foraminal region, and schwannoma was considered preoperatively. The patient underwent microsurgical resection through a posterior midline approach. Intraoperatively, the lesion was dark red, soft, and hypervascular, raising suspicion for a vascular malformation rather than schwannoma. Frozen-section analysis suggested hemangioma, and postoperative histopathology confirmed cavernous hemangioma. The patient experienced marked postoperative relief of radicular pain, and follow-up analysis indicated complete symptom resolution without radiological evidence of residual lesion. This case emphasizes that cavernous hemangioma should be included in the differential diagnosis of sacral foraminal masses. Purely epidural cavernous hemangiomas centered in the sacral foramen are particularly rare and frequently misdiagnosed preoperatively as schwannoma; thus, careful preoperative planning, anticipation of intraoperative hypervascularity, and frozen-section histology may help guide safe resection.