Intraoperative biopsy challenges: Cavernous sinus meningioma mimic

We report the case of a 56-year-old female patient with controlled Human Immunodeficiency Virus (HIV) who presented with binocular diplopia and a known sixth cranial nerve palsy. Imaging revealed a lesion centered in the right cavernous sinus (CS) causing mass effect and displacement of adjacent structures. Progressive cranial nerve involvement led to surgical intervention. Intraoperative biopsy yielded inconclusive results, with initial suspicion pointing toward meningioma. Definitive diagnosis was only possible after paraffin-embedded histopathology confirmed a CS hemangioma. Postoperative management included pain control and corticosteroid tapering. The patient remains stable under multidisciplinary follow-up. This case underscores the diagnostic challenges of CS lesions and the limitations of intraoperative biopsy in differentiating vascular tumors from meningiomas and other CS neoplasms such as schwannomas should be taken into account.