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Meningioma of the sphenoid

CLINICAL HISTORY:
This 53-year old alcoholic patient complained of progressive decrease in strength of the right hand and drooping of the right corner of the mouth.

NEUROLOGICAL EXAMINATION shows mild paresis of the right leg and arm, with central facial nerve paresis on the right.

CT:
a) NON-CONTRAST SCAN (IMAGE 1): Presence of a huge partially calcified (arrowheads) mass above the sphenoid ridge on the left side.

b) CONTRAST-ENHANCED SCAN (IMAGE 2): Homogeneous contrast enhancement of the lesion.

MRI:
a) TRANSAXIAL T2-WEIGHTED (2500/90/1) SPIN-ECHO SEQUENCE (IMAGE 3): Confirmation of huge mass in the left deep frontotemporal region. The mass is in close contact with the temporal bone and the sphenoid ridge. The lesion has an overall slight hyperintense character, but with focal markedly hypointense signal (arrows) due to calcification. Some edema is noted.

b) CORONAL T1-WEIGHTED (640/20/1) SPIN-ECHO SEQUENCE (IMAGES 4 AND 5): The tumor is broadly implanted on the bone of the anterior temporal fossa and continues along the cavernous sinus to the anterior cranial fossa. The middle cerebral artery is markedly displaced upwards (arrowheads), together with the entire left temporal lobe and the Sylvian fissure (arrow). Note midline shift to the right.

c) CORONAL (IMAGES 6 AND 7) AND SAGITTAL (IMAGES 8 AND 9) GADOLINIUM-ENHANCED SPIN-ECHO SEQUENCES: The tumor shows slightly inhomogeneous enhancement with recognition of some radial patern of enhancement. A dural tail is seen along the temporal bone (arrow images 6 - 7). The tumor adheres to the cavernous sinus and continues over the planum sphenoidale, where again a dural tail is noted (arrow image 9). The right internal carotid artery is severely compressed and narrowed by the tumor (arrow image 8). Furthermore the middle cerebral artery is elevated (arrowheads image 6).

ANGIOGRAPHY: selective left internal artery injection in the anteroposterior projection (IMAGES 10 AND 11): Narrowing of the supraclinoid portion of the right internal carotid artery. Marked medial displacement of this portion. The left middle cerebral artery is markedly displaced in an upward and posterior direction, and is narrowed. Note tumor hypervascularity arising from ethmoidal branches of the ophthalmic artery and temporal branches of the middle cerebral artery.

RADIOLOGICAL DIAGNOSIS is meningioma of the sphenoid ridge, based on the broad implantation on the dura of the sphenoid bone with extraaxial location and the homogeneous enhancement.

SURGICAL FINDINGS: At surgery the tumor was very broadly implanted on the dura of the sphenoid bone, in the middle as well as in the anterior cranial fossa. The internal carotid artery was surrounded by tumor. Medially the tumor extended up to the olfactory nerve. Tumor resection was almost total, except for a small layer that was in close contact with the cavernous sinus and a second part that was tightly adherent to the middle cerebral artery.

ANATOMOPATHOLOGICAL DIAGNOSIS is meningioma.

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Fig. 1

Meningioma of the sphenoid, Fig. 1
Meningioma of the sphenoid, Fig. 2
Meningioma of the sphenoid, Fig. 3
Meningioma of the sphenoid, Fig. 4
Meningioma of the sphenoid, Fig. 5
Meningioma of the sphenoid, Fig. 6
Meningioma of the sphenoid, Fig. 7
Meningioma of the sphenoid, Fig. 8
Meningioma of the sphenoid, Fig. 9
Meningioma of the sphenoid, Fig. 10
Meningioma of the sphenoid, Fig. 11