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Hemangioblastoma, case 1 Hemangioblastoma, case 2 Hemangioblastoma, case 3 Hemangioblastoma, intraventricular Hemangiopericytoma Hemangiopericytoma, anaplastic Hemangiopericytoma, evolution Meningioma, atypical: case 1 Meningioma, atypical: case 2 Meningioma, convexity, T2 hyperintense Meningioma, cystic Meningioma en plaque Meningioma, intraventricular, possibly anaplastic Meningioma, lipoblastic Meningioma, multiple Meningioma of the cavernous sinus Meningioma of the cavernous sinus, totally calcified Meningioma of the cerebellopontine angle Meningioma of the falx cerebri, case 1 Meningioma of the falx cerebri, case 2 Meningioma of the falx cerebri, case 3 Meningioma of the falx cerebri with invasion of the superior sagittal sinus Meningioma of the foramen magnum Meningioma of the olfactory groove, case 1 Meningioma of the olfactory groove, case 2 Meningioma of the posterior fossa with intracanalicular enhancement Meningioma of the sellar diaphragm Meningioma of the sphenoid Meningioma of the tentorium, case 1 Meningioma of the tentorium, case 2 Meningioma of the tentorium with extension through the incisura tentorii Meningioma of the tentorium with supra- and infratentorial extension Meningioma of the tuberculum sellae Meningioma, pseudocystic Meningioma, totally calcified Meningioma wiht bone invasion Meningioma with hyperostosis of the bone Pseudomeningioma, metastasis Solitary fibrous tumor, case 1 Solitary fibrous tumor, case 2 Typical meningioma, convexity

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Meningioma of the foramen magnum

CLINICAL HISTORY:
This 71-year old female patient suffers from progressive instability for one year. Meanwhile a progressive left hemiparesis is developing. Now and then she notes a strange feeling in the left hand with tremor and spontaneous flexion of the fingers. Now she is admitted urgently because of sudden increase in the gait disturbances and development of swallowing and speech disturbances.

NEUROLOGICAL EXAMINATION reveals an unsteady gait with tendency to fall to the right side at Romberg test. There is a curtain sign in the pharynx on the left. Atrophy and paresis of the left side of the tongue is present. There is paresis of the elevator muscles of the left shoulder and a left arm paresis. Finger-nose test reveals a left dysmetria. These findings point to a lesion with brainstem compression and palsy of nerves IX, XI and XII.

CT:
a) NON-CONTRAST CT (IMAGE 1) shows a heavily calcified lesion (arrowheads) in the foramen magnum, with displacement and compression of the brain stem.

b) CONTRAST-ENHANCED CT (IMAGE 2) shows intense enhancement of the lesion (arrowheads).

MRI:
a) TRANSAXIAL T2-WEIGHTED SPIN-ECHO (2500/90/1) SEQUENCE (IMAGES 3 AND 4) demonstrates the mass (arrow) in the foramen magnum, with relatively hypointense character. The lesion markedly compresses and displaces the brainstem (arrowheads).

b) TRANSAXIAL T1-WEIGHTED SPIN-ECHO (680/20/1) SEQUENCE (IMAGES 5 AND 6) shows a lesion (arrowheads) isointense with grey matter.

c) TRANSAXIAL GADOLINIUM-ENHANCED T1-WEIGHTED SPIN-ECHO SEQUENCE (IMAGES 7 AND 8) shows homogeneous and intense enhancement of the tumor (arrowheads).

d) CORONAL (IMAGES 9 AND 10) AND SAGITTAL (IMAGES 11 AND 12) GADOLINIUM-ENHANCED T1-WEIGHTED SPIN-ECHO SEQUENCE demonstrates a broad base of the tumor on the left anterolateral surface of the foramen magnum and the clivus. A dural tail is present in both directions (white arrowhead). The vertebral artery (black arrowheads) is adherent to the tumor.

RADIOLOGICAL DIAGNOSIS is meningioma of the foramen magnum based on the extraaxial location, the broad implantation on the dura mater of the foramen magnum and the clivus, and the homogeneous enhancement.

SURGICAL INTERVENTION was performed via left cerebellopontine angle craniotomy. The tumor appeared to originate from the dura of the foramen magnum and the clivus in the midline and in the left paramedian region. The C1 and C2 spinal nerves were seen overlying the tumor. The vertebral artery was deeply imbedded in the mass and had to be carefully dissected. The spinal branch of the accessory nerve was seen over the posterior aspect of the tumor. Cranial nerves VII, VIII, IX, X and XI had to be dissected from the mass. The tumor had a very hard consistency and was highly vascularised. Total resection was possible.
IMAGE 13 gives an orientation of the operative field.

Video 1
Sequence 1: The tumor is visualized as a mass, reaching from the clivus to the cervical spinal canal. The accessory nerve and the vertebral artery are stretched by the mass.
Sequence 2: In another incidence, the accessory nerve is seen as it reaches the vagal and glossapharyngeal nerves.
Sequence 3: The tumor is progressively removed with biopsy forceps.
Sequence 4: Nerve root C1 is carefully dissected from the spinal component of the tumor.
Sequence 5: Pieces of the spinal component of the tumor are removed.
Sequence 6: Dissection of the vertebral artery from the tumor.

ANATOMOPATHOLOGICAL EXAMINATION shows a cellular mass with bipolar cells with elongated nuclei, located in spirals around the blood vessels. Psammoma bodies were seen, consistent with meningioma.

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Fig. 1


Meningioma of the foramen magnum, Fig. 1	Meningioma of the foramen magnum, Fig. 2	Meningioma of the foramen magnum, Fig. 3

Meningioma of the foramen magnum, Fig. 4	Meningioma of the foramen magnum, Fig. 5	Meningioma of the foramen magnum, Fig. 6

Meningioma of the foramen magnum, Fig. 7	Meningioma of the foramen magnum, Fig. 8	Meningioma of the foramen magnum, Fig. 9

Meningioma of the foramen magnum, Fig. 10	Meningioma of the foramen magnum, Fig. 11	Meningioma of the foramen magnum, Fig. 12

Meningioma of the foramen magnum, Fig. 13