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Meningioma of the posterior fossa with intracanalicular enhancement

CLINICAL HISTORY:
This 46-year old patient has a 10 year history of hearing loss on the right side. She complains of several years of frontal and occipital headaches and periorbital pain on the right side. Recently she complains of deviation of the gait to the left, fatigue and disturbances of concentration and memory. Furthermore she noticed difficulties with swallowing in association with hoarseness.

CLINICAL NEUROLOGICAL EXAMINATION shows hypoesthesia in the territory of the right trigeminal nerve. Deafness on the right side is evident. There is nystagmus at right lateral gaze. There is a tendency to fall to the right, with right dysmetria and dysdiadochokinesia.

CT:
a) NON-CONTRAST SCAN (IMAGE 1): The fourth ventricle (arrow) is displaced to the left. A isodense mass is seen (arrowheads) within the right cerebellopontine angle.

b) CONTRAST ENHANCED SCAN (IMAGE 2): Homogeneous enhancement of the lesion is noted.

MRI:
a) TRANSAXIAL T2-WEIGHTED (2500/90/1) SPIN-ECHO SEQUENCE (IMAGES 3 AND 4): A huge well-circumscribed mass is seen (arrowheads) in the right cerebellopontine angle. The mass has homogeneous moderate hyperintensity, but with a clear radial pattern converging towards the right internal auditory canal. This internal auditory canal is not widened (arrow). Note substantial displacement of the brainstem and the fourth ventricle (long arrow) to the left.

b) CORONAL T1-WEIGHTED (500/20/1) SPIN-ECHO SEQUENCE (IMAGES 5 AND 6): The mass shows homogeneous signal, practically isointense to grey matter. Note the substantial compression and displacement of the brainstem, and the elevation of the tentorium.

c) CORONAL GADOLINIUM-ENHANCED SPIN-ECHO SEQUENCES (IMAGES 7 AND 8): There is a homogeneous enhancement of the tumor. Extension of the enhancement within the right internal auditory canal is noted (arrow). Furthermore supratentorial extension of the tumor via the incisura is noted (arrowheads).

ANGIOGRAPHY: Selective injection of the right ascending pharyngeal artery in the anteroposterior (IMAGE 9) and lateral (IMAGE 10) projections. The tumor is very hypervascular. Note the typical radial orientation of the supplying vessels of the tumor.

RADIOLOGICAL DIAGNOSIS is meningioma based on the broad implantation on the dura of the petrous bone, the homogeneous signal intensity, the homogeneous and intense enhancement of the lesion and the absence of widening of the internal auditory canal and meatus.

SURGICAL FINDINGS: At surgery, a large highly vascular tumor was found, firmly inserted upon the tentorium and the petrous bone. The tumor adhered to the brainstem and the cerebellum as well as to the cranial nerves. The tumor adhered to the margin of the internal acoustic meatus, but did not extend into the internal auditory canal. Total resection with preservation of the nerves was performed.

ANATOMOPATHOLOGY shows meningioma.

Note: The enhancement within the internal auditory canal has to be interpreted as a "dural tail sign".

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Fig. 1


Meningioma of the posterior fossa with intracanalicular enhancement, Fig. 1	Meningioma of the posterior fossa with intracanalicular enhancement, Fig. 2	Meningioma of the posterior fossa with intracanalicular enhancement, Fig. 3

Meningioma of the posterior fossa with intracanalicular enhancement, Fig. 4	Meningioma of the posterior fossa with intracanalicular enhancement, Fig. 5	Meningioma of the posterior fossa with intracanalicular enhancement, Fig. 6

Meningioma of the posterior fossa with intracanalicular enhancement, Fig. 7	Meningioma of the posterior fossa with intracanalicular enhancement, Fig. 8	Meningioma of the posterior fossa with intracanalicular enhancement, Fig. 9

Meningioma of the posterior fossa with intracanalicular enhancement, Fig. 10