Intradural clival chordoma: a case report

Intrasellar hemorrhagic chordoma masquerading as pituitary apoplexy: case report and review of the literature

BACKGROUND AND IMPORTANCE

Chordomas are centrally located, expansile soft tissue neoplasms that arise from the remnants of the embryological notochord. Hemorrhagic presentation is exceedingly rare and can resemble pituitary apoplexy. Moreover, a purely intrasellar location of a chordoma is extremely uncommon. We report a case of a hemorrhagic intrasellar chordoma in an adult male, which presented similarly to pituitary apoplexy and was resolved with surgical resection.

CLINICAL PRESENTATION

A 69-year-old male presented with a 4 week history of acute onset headache and concurrent diplopia, with significantly reduced testosterone and slightly reduced cortisol. His left eye demonstrated a sixth cranial nerve palsy. Magnetic resonance imaging of the brain showed a large hemorrhagic mass in the pituitary region with significant compression of the left cavernous sinus and superior displacement of the pituitary gland. The patient underwent an endoscopic endonasal transsphenoidal approach for the resection of the lesion. Near total resection was achieved. Final pathology revealed chordoma with evidence of intratumoral hemorrhage, further confirmed by immunopositive stain for brachyury. Post-operatively, the patient had improved diplopia and was discharged home on low dose hydrocortisone. At 3-month follow-up, his diplopia was resolved and new MRI showed stable small residual disease.

CONCLUSIONS

Apoplectic chordomas are uncommon given chordoma's characteristic lack of intralesional vascularity and represent a diagnostic challenge in the sellar region. Our unique case demonstrates that despite our initial impression of pituitary apoplexy, this was ultimately a case of apoplectic chordoma that responded well to endoscopic endonasal surgery.

Chordoma of the Clivus with Metastasis to Femur

Chordomas are aggressive and invasive tumors that are notoriously famous for their recurrence and metastasis. They present with diverse manifestations, usually with lower cranial nerve involvement. Here, we present the first reported case of chondroid chordoma with femur metastasis. A 71-year-old lady presented to us with a headache and diplopia. MRI of the brain revealed an enhanced broad and destructive mass in the infrasellar region with complete destruction of the clivus, right cavernous sinus. She underwent multiple surgeries along with gamma knife and proton therapy. The patient later presented with a trochanteric fracture and needed a hip replacement. Biopsy curettage of the femur lesion revealed a chondroid chordoma of the femur. The patient died later of a chest infection. Multimodality treatment is required in chordoma management, including surgery, gamma knife, and proton therapy. A firm discerning eye is required in the elderly toward metastatic spread to the femur in cases presenting with fractures of long bones.

Nonenhancing intracranial intradural chordoma mimicking an epidermoid cyst on magnetic resonance imaging: a case report

Chordomas are relatively rare malignant tumors derived from embryonic notochord remnants. Most intracranial chordomas show extradural extension and cause bone erosion. However, a small percentage of these tumors are exclusively intradural and tend to show less aggressive features, although local recurrence and metastatic spread have been described. Intradural chordomas with imaging features similar to epidermoid cysts are exceedingly rare. We describe the case of a nonenhancing and nondestructive intradural prepontine chordoma showing restricted diffusion on magnetic resonance imaging on a 44-year-old man who presented with acute-onset vertigo and vomiting. Subtotal resection of the lesion was performed followed by adjuvant radiation therapy. Histopathological examination revealed a chordoma. This case report highlights the need to include intradural chordomas in the differential diagnosis of a nonenhancing and nondestructive prepontine intradural lesion demonstrating restricted diffusion. Gross total resection, adjuvant radiation therapy in cases of macro/microscopical residual disease and regular follow-up imaging assessment are warranted due to the possibility of local recurrence and metastatic dissemination.

Retropharyngeal chordoma extending to the spinal cord, mimicking a neurogenic tumor: a case report and literature review

Chordomas are rare, locally aggressive bone malignancies with poor prognoses. However, those with minimal or no bone involvement are more easily resectable because of their well-delineated margins and thus have better prognoses. Such extraosseous chordomas of the spine are localized both intradurally and extradurally. Only a few case reports have focused on extraosseous, extradural spinal chordomas. Radiologically, this type of chordoma has a dumbbell shape; however, dumbbell-shaped spinal tumors are traditionally thought to be neurogenic tumors (i.e., schwannomas or neurofibromas). We herein report a unique case involving a woman with a dumbbell-shaped extraosseous chordoma protruding predominantly into the retropharyngeal space. A 44-year-old woman presented for evaluation of a left submandibular mass. A T2-hyperintense, gadolinium-enhancing mass was found in her cervical spinal canal, protruding through the C2/3 neural foramen into the retropharyngeal space with minimal vertebral involvement. The initial diagnosis was a neurogenic tumor, most likely a schwannoma. After subtotal removal, the pathologic diagnosis was a chordoma. Because chordomas and schwannomas have significantly different prognoses, caution is warranted when a dumbbell-shaped tumor is identified in the spine with minimal or no vertebral deterioration on radiology. This report also provides the first thorough review of extraosseous dumbbell-shaped intraspinal–extraspinal chordomas.

Endoscopic Endonasal Approach in Clival Chordoma Surgery: Case Series

Chordomas are rare and slow-growing locally destructive bone tumors that can develop in the craniospinal axis. It is commonly found in the sacrococcygeal region whereas only 25-35% are found in the clival region. Headache with neurological deficits are the most common clinical presentations. Complete surgical resection either via open or endoscopic endonasal approaches are the main mode of treatment. Here, we report a series of 5 cases of clival chordomas which was managed via endoscopic endonasal approaches in our center. A retrospective analysis of patients who had undergone endoscopic endonasal resection of clival chordoma in Sarawak General Hospital from 2014 to 2018. A total of 5 cases were operated on endoscopically via a combine effort of both the otorhinolaryngology team and the neurosurgical team during the study period from year 2013 to 2018. From our patient, 2 were female and 3 were male patients. The main clinical presentation was headache, squinting of eye and nasopharyngeal fullness. All our patient had endoscopic endonasal debulking of clival tumor done, with average of hospital stay from 9 - 23 days. Pos-operatively, patients were discharged back well. Endoscopic endonasal resection of clival chordomas gives good surgical resection results with low morbidity rates and therefore can be considered as a surgical option in centers where the surgical specialties are available.

Intradural Chordoma of Cerebellopontine Angle: Case Report and Review

BACKGROUND

Chordomas are rare, notochord-derived neoplasms. Of these tumors, intradural chordomas are exceedingly rare. Most occur within the prepontine, parasellar, or other midline intradural locations. An intradural chordoma arising from the cerebellopontine angle has not been described previously.

CASE REPORT

We describe the first case of an intradural chordoma originating from the left cerebellopontine angle resected over the course of 2 operations.

CONCLUSIONS

Intradural chordomas are rare and can arise anywhere in the posterior fossa. Lack of bony involvement on computed tomography and magnetic resonance imaging are indicative of this pathology when there is also a lack of markers indicating the presence of more common cerebellopontine angle tumors. Treatment goals should include gross total resection and possible radiation therapy.

A Case of Ecchordosis Physaliphora in the Prepontine Cistern: A Rare Entity in the Differential Diagnosis of an Epidermoid Cyst

BACKGROUND

Ecchordosis physaliphora (EP) is a benign notochordal remnant that is usually asymptomatic. We report a case of a symptomatic large EP mimicking an epidermoid cyst.

CASE DESCRIPTION

A 44-year-old woman presented with right facial dysesthesia. Brain magnetic resonance imaging showed a mass with a diameter of 3.2 cm that was hypointense on T1-weighted imaging, hyperintense on T2-weighted imaging, isointense to hyperintense on diffusion-weighted imaging, and hyperintense on apparent diffusion coefficient map (1.2-1.6 × 10^-3 mm²/second). There was no apparent contrast enhancement. Differential diagnoses included epidermoid cyst, dermoid cyst, EP, chordoma, chondrosarcoma, neurenteric cyst, and arachnoid cyst. Clinicopathologic examination revealed that the mass was an EP.

CONCLUSIONS

EP in the prepontine cistern should be considered in the differential diagnosis of epidermoid cyst.

Clinical-Radiologic Correlation of Extraocular Eye Movement Disorders: Seeing beneath the Surface

Extraocular eye movement disorders are relatively common and may be a significant source of discomfort and morbidity for patients. The presence of restricted eye movement can be detected clinically with quick, easily performed, noninvasive maneuvers that assess medial, lateral, upward, and downward gaze. However, detecting the presence of ocular dysmotility may not be sufficient to pinpoint the exact cause of eye restriction. Imaging plays an important role in excluding, in some cases, and detecting, in others, a specific cause responsible for the clinical presentation. However, the radiologist should be aware that the imaging findings in many of these conditions when taken in isolation from the clinical history and symptoms are often nonspecific. Normal eye movements are directly controlled by the ocular motor cranial nerves (CN III, IV, and VI) in coordination with indirect input or sensory stimuli derived from other cranial nerves. Specific causes of ocular dysmotility can be localized to the cranial nerve nuclei in the brainstem, the cranial nerve pathways in the peripheral nervous system, and the extraocular muscles in the orbit, with disease at any of these sites manifesting clinically as an eye movement disorder. A thorough understanding of central nervous system anatomy, cranial nerve pathways, and orbital anatomy, as well as familiarity with patterns of eye movement restriction, are necessary for accurate detection of radiologic abnormalities that support a diagnostic source of the suspected extraocular movement disorder. ^©RSNA, 2016.