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Drożdż A, Wojciechowski T, Ciszek B, Stopa Z. Large intradiploic arachnoid cyst of the skull in child-a case report and new terminology proposition. Childs Nerv Syst 2024; 40:1271-1276. [PMID: 38127140 DOI: 10.1007/s00381-023-06255-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 12/15/2023] [Indexed: 12/23/2023]
Abstract
We present a rare finding of the arachnoid matter invaginating into the base of middle cranial fossa and creating an abnormal space. Presented entity was incidentally found in head CT scan of 12-year-old male. Based on the radiological characteristics in CT scans and MR images, the diagnosis of intradiploic arachnoid cyst (AC) was suggested. After surgical intervention and histopathological analysis of the specimen, the diagnosis was confirmed. We assume this is the first description of large intrasphenoid AC without any traumatic or iatrogenic cause. The literature provides many different terms for the phenomenon. We are proposing the term intradiploic arachnoid diverticulum as the more accurate for capturing the essence of the phenomenon. It provides clear differentiation of the entities from classical arachnoid cysts since they are of different anatomical localization (intradural vs. extradural) and etiopathogenesis. Management with arachnoid diverticulum is not yet established, but observation with serial imaging studies should be recommended as primary management in case of asymptomatic cyst. When cyst is symptomatic, surgical treatment may be required.
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Affiliation(s)
- Adrian Drożdż
- Department of Descriptive and Clinical Anatomy, Center for Biostructure Research, Medical University of Warsaw, 5 Chałubińskiego St, 02004, Warsaw, Poland.
- Department of Pediatric Neurosurgery, Bogdanowicz Memorial Hospital for Children, 4/24 Niekłańska St, 03924, Warsaw, Poland.
- Department of Neurosurgery, Bródno Masovian Hospital, 8 Kondratowicza St, 03242, Warsaw, Poland.
| | - Tomasz Wojciechowski
- Department of Descriptive and Clinical Anatomy, Center for Biostructure Research, Medical University of Warsaw, 5 Chałubińskiego St, 02004, Warsaw, Poland
| | - Bogdan Ciszek
- Department of Descriptive and Clinical Anatomy, Center for Biostructure Research, Medical University of Warsaw, 5 Chałubińskiego St, 02004, Warsaw, Poland
- Department of Pediatric Neurosurgery, Bogdanowicz Memorial Hospital for Children, 4/24 Niekłańska St, 03924, Warsaw, Poland
| | - Zygmunt Stopa
- Department of Maxillofacial Surgery, Medical University of Warsaw, 4 Lindleya St, 02005, Warsaw, Poland
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Brotis A, Vlychou M, Ioannidis I. Incidental Petrous Apex Cephalocele Presenting With Transient Global Amnesia: A Case Report and Rapid Literature Review. Cureus 2024; 16:e51778. [PMID: 38322086 PMCID: PMC10844894 DOI: 10.7759/cureus.51778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2024] [Indexed: 02/08/2024] Open
Abstract
Transient global amnesia (TGA) constitutes a rare clinical entity that manifests with temporary memory without any other neurological manifestation. Several pathogenetic mechanisms have been implicated, including temporal hypoperfusion, venous congestion, and cortical spreading potentials. Accordingly, the only relevant imaging findings are hippocampal CA1 areas of restricted diffusion on diffusion-weighted images. In the current case report, we present the rare case of a patient with TGA associated with bilateral petrous apex cephalocele (PAC). A 63-year-old female presented with a single episode of transient memory. The brain MRI showed a bilateral PAC and an empty sella. The patient was neurologically intact upon examination and was conservatively managed. There was no symptom recurrence during the six months of follow-up. We hypothesize that the presence of the meningocele could be associated with the pathogenesis of TGA. To the best of our knowledge, this is the first case of a petrous apex meningocele presenting with TGA. Most previously reported patients were females in their fourth decade of life, usually presenting with headaches or incidentally. Almost half of the cases were bilateral, with an empty sella. Surgical treatment was reserved for symptomatic patients with cerebrospinal fluid leaks and excruciating trigeminal neuralgia. Patients with TGA may be associated with temporal lesions, including PAC. Likewise, PAC is an extremely rare clinical entity that could occasionally present with TGA.
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Petrous bone lesions: surgical implementation and outcomes of extradural subtemporal approach. Acta Neurochir (Wien) 2021; 163:2881-2894. [PMID: 34420107 DOI: 10.1007/s00701-021-04962-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 07/31/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Petrous bone lesions (PBLs) are rare with few reports in the neurosurgical literature. In this study, the authors describe our current technique of extradural subtemporal approach (ESTA). The objective of this study was to evaluate the role and efficacy of ESTA for treatment of the PBLs. To our knowledge, this is the largest reported clinical series of using an ESTA-treated PBLs in which the clinical outcomes were evaluated. METHODS Between 1994 and 2019, 67 patients with PBLs treated by ESTA were retrospectively reviewed. Extent of resection, neurological outcomes, recurrence rate, and surgical complications were evaluated and compared with previous studies. The indications, advantages, limitations, and outcomes of ESTA were analyzed according to pathology. RESULTS This series included 7 facial nerve schwannomas (10.4%), 16 cholesterol granulomas (23.9%), 16 chordomas (23.9%), 6 chondrosarcomas (9%), 5 trigeminal schwannomas (7.5%), 9 epidermoids/dermoids (13.4%), and 8 other pathologies (11.9%). The most common location of PBLs operated with ESTA was at the petrous apex and rhomboid areas (68.7%). Gross total resection was achieved in 35 (55.6%). Symptomatic improvement occurred in 56 patients (83.6%). Complications occurred in 7 (10.4%) of cases including one mortality. Nine patients (17%) had recurrence within the mean follow-up 71 months. Compared to previous literature, our results demonstrated comparable outcomes but with higher rates of hearing and facial nerve preservation as well as minimal morbidity. From our results, ESTA is an effective therapeutic option for lesions located at the rhomboid and petrous apex, particularly when patients presented with intact facial and hearing function. CONCLUSION Our series demonstrated that ESTA provided satisfactory outcomes with excellent benefits of hearing and facial function preservation for patients with petrous bone lesions. ESTA should be considered as a safe and effective therapeutic option for selected patients with PBLs.
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Abstract
OBJECTIVE To characterize the radiologic findings of petrous apex cephalocele (PAC) in a patient cohort, and report the surgical management for three symptomatic PAC patients and cerebrospinal fluid (CSF) leak via the middle cranial fossa approach. STUDY DESIGN Retrospective case series. SETTING Academic center. PATIENTS Thirty-five patients with PAC were identified by review of the imaging archive between 2008 and 2019 (29 females; mean, 55 yrs; range, 4-86 yrs). All patients underwent magnetic resonance imaging of the skull base and/or computed tomography examination. INTERVENTIONS Surgical repair of PAC. MAIN OUTCOME MEASURES Radiologic features of PAC. RESULTS Radiological features of PAC: 25.7% bilateral; partial or expanded empty sella in 82.9%; arachnoid pits in 14.2%; and enlarged CSF space of optic nerve sheath in 20.0%. Coexisting pathology included temporal, sphenoid, and bilateral jugular foramen meningocele; as well as cribriform, middle crania fossa, and right temporal defect. Three case studies describing the surgical course of spontaneous CSF leak secondary to PAC were managed with the middle cranial fossa approach. CONCLUSIONS PAC is an exceedingly unusual cause for CSF leak in the adult and pediatric population. A middle fossa approach may be used to treat CSF leak as a result of PAC. Typically, CSF otorrhea originates from an encephalocele that extends via a bony defect in the tegmen tympani or tegmen mastoideum. However, on occasion the source of the CSF otorrhea is not via the tegmen, instead defects in the middle fossa floor, medial to the ridge for the gasserian ganglion (tubercle of Princeteau), need to be considered.
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Miccoli G, Cicala D, Spennato P, Imperato A, Ruggiero C, Cinalli G. Cavum trigeminale cephalocele associated with intracranial hypertension in an 18-month-old child: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 1:CASE21136. [PMID: 35855463 PMCID: PMC9245737 DOI: 10.3171/case21136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 03/18/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND
Cavum trigeminale cephaloceles (CTCs) are characterized by a cystic appearance and extension of the posterolateral aspect of Meckel’s cave into the superomedial portion of the petrous apex. A possible mechanism is a transient or sustained increase of intracranial pressure transmitted to Meckel’s cave, leading to its secondary herniation, in the presence of predisposing local factors. The majority of CTCs are incidental findings. Among symptomatic cases, headache, trigeminal neuralgia, cerebrospinal fluid leak, vertigo, ataxia, facial numbness, hearing loss, diplopia, and other visual disturbances have been described.
OBSERVATIONS
The authors describe a case of an 18-month-old male patient referred to their hospital with drowsiness, vomiting, left cranial nerve VI palsy, and papilledema. Neuroradiological investigation revealed the presence of a CTC with a swollen aspect of the left pontine hemisection and indirect signs of intracranial hypertension. The patient was managed with implantation of a ventriculoperitoneal shunt.
LESSONS
CTCs are rare lesions that are difficult to recognize on neuroimaging, in which they can be mistaken for tumoral or inflammatory lesions. The most frequent asymptomatic forms should be considered as “leave-me-alone” lesions. In cases of intracranial hypertension, according to a supposed theory on the origin of CTCs, the authors recommend treating only the intracranial hypertension instead of performing more invasive surgical procedures, especially in pediatric patients.
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Affiliation(s)
- Giovanni Miccoli
- Department of Neurosciences, Pediatric Neurosurgery Unit, Santobono-Pausilipon Children’s Hospital, Naples, Italy
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Division of Neurosurgery, University Federico II, Naples, Italy; and
| | - Domenico Cicala
- Department of Neurosciences, Division of Neuroradiology, Santobono-Pausilipon Children’s Hospital, Naples, Italy
| | - Pietro Spennato
- Department of Neurosciences, Pediatric Neurosurgery Unit, Santobono-Pausilipon Children’s Hospital, Naples, Italy
| | - Alessia Imperato
- Department of Neurosciences, Pediatric Neurosurgery Unit, Santobono-Pausilipon Children’s Hospital, Naples, Italy
| | - Claudio Ruggiero
- Department of Neurosciences, Pediatric Neurosurgery Unit, Santobono-Pausilipon Children’s Hospital, Naples, Italy
| | - Giuseppe Cinalli
- Department of Neurosciences, Pediatric Neurosurgery Unit, Santobono-Pausilipon Children’s Hospital, Naples, Italy
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Abstract
The petrous apex is a pyramidal-shaped structure which is difficult to examine due to difficult anatomical location. Lesions in the petrous apex can be managed surgically or they can be incidental lesions, which are managed conservatively. Petrous apex cephaloceles (PAC) are the cystic lesion due to herniation in the Meckel's cave of temporal bone. Bilateral PAC is a very rare phenomenon with only 21 cases reported in the literature so far. We present here a case of bilateral PAC, who presented with headache and was managed conservatively.
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Affiliation(s)
- Aastha Pruthi
- Department of Radiodiagnosis, People's College of Medical Sciences and Research Centre, Bhopal, Madhya Pradesh, India
| | - Garjesh Rai
- Department of Radiodiagnosis, People's College of Medical Sciences and Research Centre, Bhopal, Madhya Pradesh, India
| | - Ketan Mehra
- Department of Urology, AIIMS Bhopal, Bhopal, Madhya Pradesh, India
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Suero Molina E, Revuelta Barbero JM, Ewelt C, Stummer W, Carrau RL, Prevedello DM. Access to Meckel's cave for biopsies of indeterminate lesions: a systematic review. Neurosurg Rev 2021; 44:249-259. [PMID: 32040778 PMCID: PMC7850998 DOI: 10.1007/s10143-020-01247-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 01/20/2020] [Indexed: 01/12/2023]
Abstract
Accessing Meckel's cave (MC) is surgically challenging. Open approaches are complex and often correlated with high morbidity. Endoscopic approaches emerged in the last decade as feasible alternatives to open approaches, especially for sampling indeterminate lesions. This article first analyses available routes to approach Meckel's cave and presents furthermore an illustrative case. We conducted a systematic review and reported according to the guidelines for preferred reporting items for systematic reviews and meta-analyses (PRISMA). Various surgical approaches identified through the search are evaluated and discussed in detail. Additionally, we report on a case of woman with a lesion in MC, which was accessed through an endoscopic transpterygoid approach subsequently diagnosed as a diffuse large B cell lymphoma. Our search delivered 75 articles that included case reports (n = 21), cadaveric studies (n = 32), clinical articles (n = 16), review of the literatures (n = 3), as well as technical notes (n = 2) and a radiological manuscript (n = 1). Open routes included lateral approaches with many variations, mainly intra- and extradural pterional approaches and anterior petrosal, as well as a retrosigmoid intradural suprameatal and a lateral transorbital approach. Endoscopically, MC was reached via approaches that included transpterygoid, transorbital or infraorbital fissure routes. Percutaneous approaches, e.g. through the foramen ovale, were also described. Multiple surgical approaches to MC are currently available. Their different characteristics as well as individual patient factors, such as clinical history and the localization of the disease, have to be considered when choosing a surgical corridor. Studies included in this review highlight the endonasal endoscopic transpterygoidal technique as an excellent corridor for biopsies in the ventral MC.
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Affiliation(s)
- E Suero Molina
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, A1, 48149, Munster, Germany.
| | - J M Revuelta Barbero
- Department of Otolaryngology-Head and Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
- Department of Neurological Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - C Ewelt
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, A1, 48149, Munster, Germany
| | - W Stummer
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, A1, 48149, Munster, Germany
| | - R L Carrau
- Department of Otolaryngology-Head and Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
- Department of Neurological Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - D M Prevedello
- Department of Otolaryngology-Head and Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
- Department of Neurological Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
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Breen JT, Edwards CR, Cornelius RS, Hazenfield JM, Kohlberg GD, Samy RN, Pensak ML. Utility of Magnetic Resonance Imaging in Differentiating Cerebrospinal Fluid Leak from Middle Ear Effusion. Otolaryngol Head Neck Surg 2019; 161:493-498. [DOI: 10.1177/0194599819847153] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
ObjectiveTo demonstrate the clinical utility, sensitivity, and specificity of standard magnetic resonance imaging (MRI) sequences in differentiating temporal bone cerebrospinal fluid leaks from all other middle ear effusions.Study DesignRetrospective imaging review.SettingAcademic medical center.SubjectsPatients with cerebrospinal fluid leaks or other middle ear effusions who also underwent MRI.MethodsPatients were assigned to cerebrospinal fluid leak and other effusion cohorts based on clinical course, findings at surgery/myringotomy, and beta-2 transferrin fluid analysis. Reviewers blinded to the clinical outcome examined T1-weighted, T2-weighted, diffusion-weighted, fluid-attenuated inversion recovery (FLAIR), and 3-dimensional (3D) acquired T2-weighted MRI sequences. For each sequence, fluid imaged in the temporal bone was graded as either similar or dissimilar in signal intensity to cerebrospinal fluid in the adjacent subarachnoid space. Signal similarity was interpreted as being diagnostic of a leak. Test characteristics in predicting the presence of a leak were calculated for each series.ResultsEighty patients met criteria (41 leaks, 39 other effusions). The 3D T2 series was 76% sensitive and 100% specific in diagnosing a leak, and FLAIR was 44% sensitive and 100% specific. The T1-weighted (73% sensitive, 69% specific), T2-weighted (98% sensitive, 5.1% specific), and diffusion-weighted (63% sensitive, 66% specific) series were less useful.ConclusionsMRI, with attention to 3D T2 and FLAIR series, is a noninvasive and highly specific test for diagnosing cerebrospinal fluid leak in the setting of an indeterminate middle ear effusion.
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Affiliation(s)
- Joseph T. Breen
- Department of Otolaryngology–Head and Neck Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Colin R. Edwards
- Department of Otolaryngology–Head and Neck Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Rebecca S. Cornelius
- Department of Radiology, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - J. Michael Hazenfield
- Department of Radiology, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Gavriel D. Kohlberg
- Department of Otolaryngology–Head and Neck Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Ravi N. Samy
- Department of Otolaryngology–Head and Neck Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Myles L. Pensak
- Department of Otolaryngology–Head and Neck Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
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Bigder MG, Helmi A, Kaufmann AM. Trigeminal neuropathy associated with an enlarging arachnoid cyst in Meckel's cave: case report, management strategy and review of the literature. Acta Neurochir (Wien) 2017; 159:2309-2312. [PMID: 28762108 DOI: 10.1007/s00701-017-3262-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 06/27/2017] [Indexed: 01/03/2023]
Abstract
We describe a rare case and novel management strategy of painful trigeminal neuropathy caused by an arachnoid cyst confined to Meckel's cave. A 57-year-old female presented with several years of progressive trigeminal pain and signs of trigeminal deafferentation, including sensory loss, corneal anesthesia and mastication muscle atrophy. Medical treatment with carbamazepine provided partial and temporary pain control. Surgical treatment was eventually performed by aspiration of the arachnoid cyst through the foramen ovale using a percutaneous approach. The patient experienced relief of pain and improvement of numbness and muscle strength. To our knowledge, this is the first case description of a percutaneous drainage of a Meckel's cave arachnoid cyst.
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Bilateral Petrous Apex Cephaloceles and Skull Base Attenuation in Setting of Idiopathic Intracranial Hypertension. Otol Neurotol 2016; 37:e256-7. [DOI: 10.1097/mao.0000000000001092] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Pross SE, Uribe Cardenas R, Ahn ES, Matthew Stewart C. Recurrent meningitis in a child with bilateral cochlear implantation associated with a petrous apex encephalocele: a case report and literature review. ACTA OTO-LARYNGOLOGICA CASE REPORTS 2016. [DOI: 10.1080/23772484.2016.1193426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Jamjoom DZ, Alorainy IA. The association between petrous apex cephalocele and empty sella. Surg Radiol Anat 2015; 37:1179-82. [DOI: 10.1007/s00276-015-1489-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 05/06/2015] [Indexed: 10/23/2022]
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Dobre MC, Fischbein N. 'Do not touch' lesions of the skull base. J Med Imaging Radiat Oncol 2014; 58:458-63. [PMID: 24964828 DOI: 10.1111/1754-9485.12195] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Accepted: 05/22/2014] [Indexed: 11/29/2022]
Abstract
Imaging of the skull base presents many challenges due to its anatomical complexity, numerous normal variants and lack of familiarity to many radiologists. As the skull base is a region which is not amenable to physical examination and as lesions of the skull base are generally difficult to biopsy and even more difficult to operate on, the radiologist plays a major role in directing patient management via accurate image interpretation. Knowledge of the skull base should not be limited to neuroradiologists and head and neck radiologists, however, as the central skull base is routinely included in the field of view when imaging the brain, cervical spine, or head and neck with computed tomography or magnetic resonance imaging, and hence, its nuances should be familiar to general radiologists as well. We herein review the imaging findings of a subcategory of lesions of the central skull base, the 'do not touch' lesions.
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Affiliation(s)
- Mircea C Dobre
- Department of Radiology, Stanford Hospitals and Clinics, Stanford, California, USA
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Arachnoid cyst associated to spontaneous CSF fistula and massive pneumocephalus. Acta Neurochir (Wien) 2012; 154:1941-2. [PMID: 22878454 DOI: 10.1007/s00701-012-1465-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2012] [Accepted: 07/26/2012] [Indexed: 10/28/2022]
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Imaging case of the month: Cystic lesions of the petrous apex: identification based on magnetic resonance imaging characteristics. Otol Neurotol 2012; 33:e75-6. [PMID: 22801043 DOI: 10.1097/mao.0b013e3182635289] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Razek AA, Huang BY. Lesions of the petrous apex: classification and findings at CT and MR imaging. Radiographics 2012; 32:151-73. [PMID: 22236899 DOI: 10.1148/rg.321105758] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The petrous apex is a complex region of the central skull base that is surrounded by a number of important vascular and neural structures and can be home to a wide range of disease processes. Lesions arising in or spreading to the petrous apex cause varied and occasionally severe clinical sequelae, which typically result from mass effect or direct invasion of the cranial nerves, brainstem, or internal carotid artery. Because the petrous apex is not amenable to direct examination, cross-sectional imaging with computed tomography and magnetic resonance (MR) imaging plays an important role in diagnosis and characterization of lesions occurring there. Petrous apex lesions can be classified on the basis of their origin into the following categories: developmental lesions, inflammatory lesions, benign tumors, malignant tumors, vascular lesions, and osseous dysplasias. The most common lesions arising in the petrous apex are cholesterol granulomas, which can be reliably diagnosed with MR imaging due to their high signal intensity on both T1-weighted images and T2-weighted images. In addition, one should also be familiar with anatomic variants or pseudolesions in the petrous apex that can be mistaken for pathologic conditions.
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Affiliation(s)
- Ahmed Abdel Razek
- Department of Diagnostic Radiology, Mansoura Faculty of Medicine, Mansoura, Egypt
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Ohkawa T, Nakao N, Uematsu Y, Itakura T. Temporal lobe encephalocele in the lateral recess of the sphenoid sinus presenting with intraventricular tension pneumocephalus. Skull Base 2011; 20:481-6. [PMID: 21772809 DOI: 10.1055/s-0030-1261261] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
A basal encephalocele often shows an insidious clinical course. Only two cases of temporal lobe encephalocele accompanied with tension pneumocephalus have previously been reported. In this paper, we describe a case of lateral sphenoid sinus encephalocele presenting with intraventricular tension pneumocephalus. A 54-year-old man was referred to our institution presenting with intraventricular tension pneumocephalus. He had undergone ventriculoperitoneal shunt placement for postmeningitis hydrocephalus 3 months before this admission. Precise imaging examinations detected evidence suggestive of a lateral sphenoidal sinus recess encephalocele. Endoscopic transnasal approach was performed for surgical repair of the encephalocele. The encephalocele was removed with subsequent repair of the bony defect. Histological examination showed that the encephalocele includes a part of the ventricular system. This indicates that air might enter directly into the ventricular system after rupture of the temporal lobe encephalocele. A lateral sphenoid sinus encephalocele would potentially cause intraventricular tension pneumocephalus, although pneumocephalus is an extremely unusual complication of this type of basal encephaloceles.
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Affiliation(s)
- Toshika Ohkawa
- Department of Neurological Surgery, Wakayama Medical University, Wakayama, Japan
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Karkas A, Righini CA, Spinato L, Lefournier V, Schmerber S. [Petrous apex lesions]. ACTA ACUST UNITED AC 2009; 126:283-93. [PMID: 19782962 DOI: 10.1016/j.aorl.2009.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2009] [Accepted: 08/31/2009] [Indexed: 11/27/2022]
Affiliation(s)
- A Karkas
- Clinique universitaire oto-rhino-laryngologie, CHU A.-Michallon, BP 217, 38043 Grenoble cedex 09, France
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Stark TA, McKinney AM, Palmer CS, Maisel RH, Truwit CL. Dilation of the subarachnoid spaces surrounding the cranial nerves with petrous apex cephaloceles in Usher syndrome. AJNR Am J Neuroradiol 2008; 30:434-6. [PMID: 18945801 DOI: 10.3174/ajnr.a1283] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Limited studies of brain MR imaging findings in Usher syndrome have reported atrophy with enlarged subarachnoid spaces. However, the specific appearance of the subarachnoid spaces surrounding the cranial nerves has not yet been described. Herein we describe the skull base MR imaging findings in an adult with Usher syndrome. Multiple cranial nerve exits were enlarged to the point of causing cephaloceles with bony remodeling. A combination of uncommon findings in this rare disorder raises the question of an etiologic association.
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Affiliation(s)
- T A Stark
- Department of Radiology, University of Minnesota Medical School & Hennepin County Medical Center, Minneapolis, MN 55415, USA
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Abstract
PURPOSE OF REVIEW The present review summarizes the current theories on arachnoid cyst formation, the common presentations of cysts surrounding or eroding the temporal bone from the middle and posterior cranial fossae, the diagnostic strategies and the management considerations and options. RECENT FINDINGS Arachnoid cysts are most common in the middle cranial fossa and rarely present in association with the petrous apex. They are frequently found incidentally on imaging studies performed in the workup for unrelated symptoms. When they do cause symptoms, these are usually nonspecific. Thus it is important to establish the relationship between the two. Peripetrosal arachnoid cysts may cause cranial nerve deficits in addition to symptoms related to intracranial hypertension. Small asymptomatic cysts are managed conservatively with serial imaging. Large symptomatic cysts are often managed surgically with shunting, open excision or open or neuroendoscopic fenestration or marsupialization. The management of large asymptomatic cysts depends on the patient and cyst characteristics. SUMMARY Peripetrosal arachnoid cysts are often incidental findings. Careful selection of surgical candidates is of utmost importance. Multiple surgical options with similar success rates are available. The rates and profile of their complications may differ. Overall, approximately 70% of patients experience improvement in their symptoms with surgery.
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Affiliation(s)
- Ricardo Cristobal
- Otology, Neurotology, and Skull Base Surgery, Bobby R. Alford Department of Otolaryngology - Head and Neck Surgery, Baylor College of Medicine, Houston, Texas 77030, USA
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Isaacson B, Kutz JW, Roland PS. Lesions of the petrous apex: diagnosis and management. Otolaryngol Clin North Am 2007; 40:479-519, viii. [PMID: 17544693 DOI: 10.1016/j.otc.2007.03.003] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Management of petrous apex pathology poses a unique challenge even to the most seasoned skull base surgeons. The central location in the skull base with adjacent critical neurovascular structures makes access to this region more than a trivial matter. Significant advances in diagnostic imaging have greatly facilitated the diagnosis of petrous apex lesions. The introduction of modern skull base surgery techniques also has provided skull base surgeons with numerous avenues to the petrous apex while significantly decreasing morbidity. The latest diagnostic and management strategies are discussed and an update of some of the more common pathologic entities is provided.
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Affiliation(s)
- Brandon Isaacson
- Department of Otolaryngology-Head and Neck Surgery, The University of Texas-Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9035, USA.
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