Pediatric primary intracranial Ewing's sarcoma involving cavernous sinus: an untamed evil

Pediatric cavernous sinus Ewing's sarcoma (CS-ES) is an exceptionally rare and aggressive form of primary intracranial Ewing's sarcoma. Primary intracranial ES itself accounts for less than 1% of all childhood ES, with ES representing less than 1% of all childhood malignancies. CS-ES poses significant diagnostic and therapeutic challenges, with only seven cases reported in the literature and a mere three in pediatric patients. We present a case of a 2-year-old boy with CS-ES, whose clinical course was marked by right orbital apex syndrome, severe headaches, and rapid neurological deterioration. Imaging revealed a homogenous, contrast-enhancing mass in the cavernous sinus. Despite initial management with dexamethasone, the patient's condition worsened rapidly, necessitating a ventriculoperitoneal shunt for communicating hydrocephalus and subsequent surgical intervention. Intraoperative findings included a soft, moderately vascular tumor with areas of necrosis and infiltrating critical structures. Histopathology confirmed Ewing's sarcoma with CD99 and vimentin positivity, and a high Ki-67 index. Due to rapid disease progression, the patient expired before completing adjuvant therapy. This case underscores the poor prognosis associated with pediatric CS-ES, exacerbated by the anatomical challenges of the cavernous sinus and the limited window for intervention due to rapid tumor progression. Early clinical suspicion, prompt intervention, and a simultaneous multidisciplinary approach are crucial for managing this rare and lethal entity. Our literature review highlights the critical need for improved therapeutic strategies and underscores the importance of considering CS-ES in differential diagnoses to facilitate timely and effective treatment.