Nest of Evil

83-year-old Caucasian female presented with headaches, fatigue and vision loss in the right eye. PMH is significant for HTN, HLD, meningioma, lumpectomy and radiation for breast cancer 1994&1998. No history of smoking. Meds: lisinopril, atorvastatin and metoprolol. ROS: fatigue, dizziness, balance problem and anxiety. Her recent MRI showed a plaque-like homogeneous enhancing dural based mass at the planum sphenoidale with involvement of left cavernous sinus measuring 3.6x 1.8x 3.8 cm only 0.2cm increase in each dimension compare to the imaging 6 months prior. BCVA 20/150, 20/40, 3+ RAPD OD, diffuse optic atrophy OD, sup optic atrophy OS. Visual field showed generalized constriction OD, inferior arcuate defect OS. OCT optic nerve: diffuse RNFL thinning OD, superior thinning OS. MRI orbit revealed involvement of orbital apex on the right side. She underwent surgical resection of tumor. Tumor progression in 3 months caused third N. palsy and vision loss on the left eye. VA 20/250 OD, LP OS. Pathology read as malignant tumor.