Radiological Category Neuroradiology Principal Modality MRI Case Report

Radiological Category: Neuroradiology Principal Modality: MRI Case Report # 0003 Submitted by: Majdi Radaideh , M. D. Faculty reviewer: Clark Sitton, MD Date accepted: 29 January 2003

Case History 35 -year-old female with severe headaches and visual field symptoms. The patient also complained of left sided weakness.

Radiological Presentations T 1 w/o gadolinium

Radiological Presentations T 1 w/o gadolinium

Radiological Presentations T 2 and PD

Radiological Presentations T 1 post Gad

Radiological Presentations T 1 post gadolinium

Test Your Diagnosis Which one of the following is your choice for the appropriate diagnosis? After your selection, go to next page. • • • Craniopharyngioma Pituitary adenoma with suprasellar extension Metastasis Hypothalamic, chiasmatic glioma Dermoid, teratoma Cavernous sinus meningioma

Findings and Differentials 1 - T 1 homogenous hypointense right parasellar / suprasellar mass. 2 - Intense contrast enhancement with dural extension having the appearance of dural tail that extends to the dura of the right cranial fossa and right tentorium. 3 - The mass is encasing the right supraclinoid ICA, causing severe narrowing and leads to slow flow and enhancement in the petrous and cavernous portion of the right ICA. 4 - Heterogeneous T 2 signal with dark areas related to hemorrhagic changes or calcification in the mass. 5 - Enhancement of the dura of the right optic nerve. 6 - Right anterior middle cranial fossa arachnoid cyst. DDx • • • Cavernous sinus meningioma Craniopharyngioma Pituitary adenoma with suprasellar extension Metastasis Hypothalamic, chiasmatic glioma Dermoid, teratoma

Discussion: Cavernous meningioma Suprasellar Meningioma (Cavernous meningioma) Incidence: 10% of all intracranial meningiomas Origin: from arachnoid + dura along tuberculum sellae / clinoids / diaphragma sellae / cavernous sinus with secondary extension into sella; NOT from within pituitary fossa Imaging features üHypothalamic / pituitary dysfunction (rare); üIrregular hyperostosis = blistering adjacent to sinus (HALLMARK of meningiomas at planum sphenoidale / tuberculum sellae); üPneumatosis sphenoidale = increased pneumatization of sphenoid in area of anterior clinoids + dorsum sellae (DDx: normal variant); üBroad base of attachment; üIntense homogeneous enhancement (may be impossible to differentiate from supraclinoid carotid aneurysm on CT) Blood supply: posterior ethmoidal branches of ophthalmic artery, branches of meningohypophyseal trunk MR: Large mass, isointense to gray matter on T 1 WI + T 2 WI Hyperintense flattened pituitary gland within floor of sella Marked homogeneous enhancement on T 1 WI DDx: metastasis, glioma, lymphoma References: 1. Dahnert's Radiology Review Manual, Fourth Edition.

Diagnosis Cavernous meningioma