Real role of MRI in ORL diagnosis protocol in hearing loss and vertiginous syndrome: A daily challenge for the clinician and the radiologist

Transcription

1 Real role of MRI in ORL diagnosis protocol in hearing loss and vertiginous syndrome: A daily challenge for the clinician and the radiologist Poster No.: C-0848 Congress: ECR 2012 Type: Scientific Exhibit Authors: M. A. Martin Perez, I. Martín García, B. R. Arenas García, R. Blanco Hernández, J. Marín Balbín, M. T. Escudero Caro; Zamora/ ES Keywords: Head and neck, Ear / Nose / Throat, Vascular, MR, Diagnostic procedure, Comparative studies, Efficacy studies, Inflammation, Ischemia / Infarction, Neoplasia DOI: /ecr2012/C-0848 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 126

2 Purpose 1. To illustrate the pathological findings and normal avriants in MRI. 2. Determine the usefulness of MRI in the battery of additional tests Fig. 1: Coverpage References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Images for this section: Page 2 of 126

3 Fig. 1: Coverpage Page 3 of 126

4 Fig. 2: Index Page 4 of 126

5 Methods and Materials Description of technique and pathological findings in image from the retrospective analysis of 456 studies collected between September 2006 and July 2009, made in 1.5 T MR equipe (fig 3). We used T1-weighted sequences, T2W, DWI, and 3D FIESTA of both inner ears. Were admitted in the review and classified patients into two symptom clusters: hearing loss-tinnitus, and central or peripheral vertigo (including instability). We divide and illustrate the pathological findings-78 (17%) of the total, broken down into vascular anomalies, loops and other variants 46 cases (10%), tumoral pathology in context or not NF, typical and atypical tumors of the cerebellopontine angle, metastases in the posterior fossa, and intracranial or medium ear processes impact on the membranous labyrinth, a total of 25 cases (5.5%), and malformation or inflammatory labyrinthine disease 7 cases (1.5%). (Fig 4). The remaining 378 cases (83%) were normal or showed no alterations related to the consultation process. Fig. 3: Fig.3. Graphic 1 References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 5 of 126

6 Fig. 4: Fig.4. Graphic 2 References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Images for this section: Fig. 3: Fig.3. Graphic 1 Page 6 of 126

7 Fig. 4: Fig.4. Graphic 2 Page 7 of 126

8 Results Patients admitted to the study: Sensorineural hearing loss, tinnitus: Peripheral or central vertigo, including other nonspecific symptoms of posterior fossa, as instability or dizziness: 245 Study: posterior fossa MRI protocol - T1WI,T2WI, 3DFIESTA focuses in the inner ear - Brain MRI: FLAIR and T2WI Pathologic findings: 78 cases Vascular disorders, loops and other variants: 46 Tumours: 25 Malformative-inflammatory disease: 7 No alterations related to initial consultation process: 378 cases View Graphics 1 & 2 (Fig 3,4). ANATOMY: A BRIEF REMINDER Figs 5 (virtualmedicalcentre.com/anatomy/ear/), 6 (Nervous System & Special Senses Home Page) & 7 Page 8 of 126

9 Fig. 5: Fig.5. Ear anatomy. Graphic References: virtualmedicalcentre.com/anatomy/ear/ Page 9 of 126

10 Fig. 6: Fig.6. Inner ear model. 1.Cochlea. 2.Cochlear Branch of Vestibular Cochlear Nerve VIII 3.Vestibular Branch of Vestibular Cochlear Nerve VIII 4.Scala Tympani (Perilymph) 5.Cochlear Duct (Endolymph) 6.Scala Vestibuli (Perilymph) 7.Vestibular Membrane 8.Basilar Membrane 9.Semicircular Canals 10.Semicircular Ducts 11.Ampulla of Semicircular Duct 12.Utricle 13.Saccule 14.Oval Window References: Nervous System & Special Senses Home Page 1. Cochlea Cochlear Branch of 9. Vestibular Cochlear Nerve VIII Semicircular Canals 3. Vestibular Branch of 10. Vestibular Cochlear Nerve VIII Semicircular Ducts 4. Scala Tympani 11. (Perilymph) Ampulla of Semicircular Duct 5. Cochlear (Endolymph) Utricle Duct 12. Basilar Membrane Page 10 of 126

11 6. Scala Vestibuli 13. (Perilymph) Saccule 7. Vestibular Membrane Oval Window 14. (Figure 6: Nervous System & Special Senses Home Page) Fig. 7: Fig.7. Inner anatomy. MRI correlation References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN POSTERIOR FOSSA PATHOLOGY IN MRI - Cerebellopontine lesions: Figures 8,9 - Radiological findings: Figures 10,11,12. Essential semiology of MRI in pontocerebellous angle pathology: Key Points Page 11 of 126

12 Fig. 8: Fig.8. Pontocerebellous angle lesions. MRI findings References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 12 of 126

13 Fig. 9: Fig.9. Location of pontocerebellous angle lesions References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 13 of 126

14 Fig. 10: Fig.10. INTRAAXIAL & INTRAVENTRICULAR LESIONS INVADING PCA: MRI ROLE References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 14 of 126

15 Fig. 11: Fig.11. CEREBELLOPONTINE CISTERN LESIONS: MRI FINDINGS References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 15 of 126

16 Fig. 12: Fig.12. MRI IN CEREBELLOPONTINE LESIONS DERIVED FROM THE SKULL BASE References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Modified tables from Imaging of cerebellopontine angle lesions: an update. Part 1: enhancing extra-axial lesions. Eur Radiol (2007) MRI FINDINGS: DESCRIPTION OF CASES 1. VASCULAR DISORDERS, LOOPS and OTHER VARIANTS AICA Vascular Loop. (Fig. 13). Basilar Vascular Loop. (Fig. 14). High dilated Jugular Bulb. (Fig. 15). Glomus Jugulare Tumour (Fig. 16 and 17). Jugular Bulb Diverticulum. (Fig. 17). Venous Angioma (Fig. 18 and 19) Cavernous Malformation (Fig. 20) Multiple Vascular Malformations (Fig. 21) Internal Carotid Artery Aneurysm (Fig. 22) Cerebellar Haematoma (Fig. 23) Page 16 of 126

17 Transversal Sinus Thrombosis (Fig 24) Vertebrobasilar Ischemic Stroke (Fig. 25) Multiple Vascular Territories Ischemia (Fig. 26) Gasser Ganglion Lobulation (Fig. 27) Subarachnoid Fat Drops (Fig. 28) Fig. 13: Fig.13. AICA Vascular loop References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 17 of 126

18 Fig. 14: Fig.14. BASILAR VASCULAR LOOP. 3D TOF MIP and T2FSE weighted image References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Fig. 15: Fig.15. HIGH DILATED JUGULAR BULB T1WI and after gadolinium contrast administration. Shows high dilated jugular bulb in a patient with tinnitus. Page 18 of 126

19 References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Fig. 16: Fig.16. GLOMUS JUGULARE TUMOUR T1 and T2WI and after gadolinium contrast administration. Note the intense homegenously enhancement with hypointense foci. References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 19 of 126

20 Fig. 17: Fig.17. JUGULAR BULB DIVERTICULUM (Left) GLOMUS JUGULARE TUMOUR (Right) T2WI shows a mass surrounding the jugular bulb, slightly hyperintense, and with absence of signal foci related vascular nature, in a patient with left-tinnitus sense. Salt and pepper appearance References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 20 of 126

21 Fig. 18: Fig.18. VENOUS ANGIOMA References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 21 of 126

22 Fig. 19: Fig.19. VENOUS ANGIOMA References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 22 of 126

23 Fig. 20: Fig.20. CAVERNOMAS Several cases of multiple cavernomatosis in cerebellum and brainstem. Hyposignal spotlights flowering significantly in T2 * GRE sequences. It should be a differential diagnosis with other entities such as chronic bleeding focus in the context of hypertension, as in Example 4. References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 23 of 126

24 Fig. 21: Fig.21. MULTIPLE VASCULAR MALFORMATIONS Uncertaint dizzyness in patient with multiple vascular malformations consisting on pontine cavernoma, venous angioma in parasagittal region of the right cerebellar hemisphere, and large dilated veins in the subcutaneous tissue, which connect to the sigmoid sinus with dural fistula. References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 24 of 126

25 Fig. 22: Fig.22. ICA ANEURYSM Aneurysm of right internal carotid artery, almost entirely thrombosed. Right Tinnitus in evolution. T1weighted sequences and after Gadolinium administration. Flair and gradient echo T2 *. References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 25 of 126

26 Fig. 23: Fig.23. CEREBELLAR HAEMATOMA Old right hemispheric haematoma in cerebellum, with hypointense central area, longstanding hematic deposits of degeneration in all pulse sequences, and full hemosiderotic ring, relating its long evolution. References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 26 of 126

27 Fig. 24: Fig.24. TRANSVERSAL SINUS THROMBOSIS T1-weighted images, T2WI, and gradient echo T2 *. Axial and coronal reconstructions of venous 2D FIESTA which reveals the large filling defect of left transverse sinus, and hemorrhagic transformation associated with temporal lobe ischemia. References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 27 of 126

28 Fig. 25: Fig.25. VERTEBROBASILAR ISCHEMIC STROKE Extensive vertebrobasilar stroke, affecting the posterior and medial right cerebellar hemisphere, and branches of PICA (not shown), with ipsilateral vertebral artery thrombosis. T2-weighted sequences, and coronal reconstruction of 3D TOF Images. View DWI hypersignal, with restricted ADC. References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 28 of 126

29 Fig. 26: Fig.26. MULTIPLE VASCULAR TERRITORIES ISCHEMIA 42 year old patient, with instability and vertigo of sudden onset. Tumor emboli of cardiac origin, which determine patchy areas of ischemia in different vascular territories. Lung carcinoma with invasion of left atrium. References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 29 of 126

30 Fig. 27: Fig.27. INTRAPETROUS LOBULATION OF GASSER GANGLION Patient 67 years. Instability. T1-weighted images without and after gadolinium contrast media agent, 3DFIESTA and T2WI of both IAC. Prominent Gasser ganglion bulging the cranial portion of PCA and base of the left IAC. References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 30 of 126

31 Fig. 28: Fig.28. SUBARACHNOID FAT DROPS CT and MRI Correlation (T1WI). There are markedly hypodense foci, with a range of densitometry of fat in the subarachnoid space; hyperintense on T1-weighted images. References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN 2. TUMOURS Subependymoma (Fig. 29) Medulloblastoma (Fig. 30) Arachnoid Cyst (Fig. 31) Dermoid tumor (Fig. 32) Brainstem Glioma (Fig. 33) Page 31 of 126

32 Cholesterol Granuloma (Fig. 34) Epidermoid Cyst (Figs ) Cholesteatoma (Fig. 37) VIII CN Schwannoma associated (Figs 43 & 45) or not with neurofibromatosis (Figs ) Meningioma (Figs ) Schwannoma of other cranial nerves (Fig. 50) Lymphoma (Fig.51) Metastasis (Fig ) Cerebellar hemangioblastoma (Fig. 55) Squamous cell carcinoma (Fig. 56) Tuberous sclerosis complex (Fig. 57) Leptomeningeal melanoma (Figs 58 & 59) Fig. 29: Fig.29. SUBEPENDYMOMA References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 32 of 126

33 Fig. 30: Fig.30. MEDULLOBLASTOMA References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 33 of 126

34 Fig. 31: Fig.31. ARACHNOID CYST References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 34 of 126

35 Page 35 of 126

36 Fig. 32: Fig.32. DERMOID TUMOR References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 36 of 126

37 Page 37 of 126

38 Fig. 33: Fig.33. BRAINSTEM GLIOMA References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 38 of 126

39 Page 39 of 126

40 Fig. 34: Fig.34. CHOLESTEROL GRANULOMA References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Fig. 35: Fig.35. EPIDERMOID CYST References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 40 of 126

41 Fig. 36: Fig.36. EPIDERMOID CYST Typical features at image of epidermoid cyst with high signal on DWI. In this case presents great extra-axial extension to suprasellar cistern, floor of the third ventricle to the left cerebellopontine angle References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 41 of 126

42 Page 42 of 126

43 Fig. 37: Fig.37. CHOLESTEATOMA References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Fig. 38: Fig.38. VIII CN Schwannoma. Intracanalicular location, reaching the acoustic pore. Low signal on T2WI, and homogeneous enhancement after gadolinium contrast media administration References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 43 of 126

44 Fig. 39: Fig.39. Vestibular Schawanoma. Total occupancy of the IAC, and enhancing mass in the canaliculus. Extension with ice cream cone morphology, emerging into the left cerebellopontine angle. References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 44 of 126

45 Fig. 40: Fig.40. Vestibular Schawanoma. Note the homogeneous enhancement with small punctate nodular and cystic areas. References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 45 of 126

46 Fig. 41: Fig.41. Extracanalicular Schwannoma, occupying the right PCA and producing opening of the acoustic-facial package, reporting to the inferior vestibular branch. Typical behavior in image. References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 46 of 126

47 Fig. 42: Fig.42. Great schwannoma of CN VIII, with dilation of the right IAC and extension to the PCA. References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 47 of 126

48 Fig. 43: Fig.43. Neurofibromatosis type II: Left trigeminal and vestibular schwannomas and affecting paraspinal nerves. References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 48 of 126

49 Fig. 44: Fig.44. Enlarged, cystic degeneration and heterogeneous enhancement of CN VIII schwannoma treated with stereotactic radiotherapy (patient declined surgical treatment). Progressive loss of hearing, balance disorders and otalgia. T2WI (lower left) and after administration of gadolinium which shows heterogeneous, predominantly peripheral enhancement and central necrosis. References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 49 of 126

50 Fig. 45: Fig.45. Neurofibromatosis type II: right vestibular schwannoma (blue arrows) and bilateral trigeminal schwannomas( orange arrows). Paraspinal peripheral nerve sheath tumor (yellow arrow) and meningiomas (white arrows). References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 50 of 126

51 Fig. 46: Fig.46. Extraaxial mass that occupies right PCA, extending to the internal auditory canal. Early and homogeneous enhancement with dural tail. Meningioma. References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Fig. 47: Fig.47. Meningioma. References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 51 of 126

52 Fig. 48: Fig.48. Two examples of meningioma. Left; occupation of the PCA and mass effect on left facial-acoustic package.on the right, meningioma that infiltrates transverse sinus. References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 52 of 126

53 Fig. 49: Fig.49. Meningioma in the left PCA, T1WI without and with gadolinium contrast media administration and T2WI. View the existence of large cystic components (asterisks). References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Fig. 50: Fig.50. Right CN IX schwannoma (orange arrow) Left CN X schwannoma (white arrow) References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 53 of 126

54 Fig. 51: Fig.51. Primary cerebral lymphoma. Ring enhancement after gadolinium administration. References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 54 of 126

55 Fig. 52: Fig.52. Multiple geminal tumor metastasis. Instability. Note lesion in posterior fossa. References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 55 of 126

56 Page 56 of 126

57 Fig. 53: Fig.53. Metastases from oat-cell lung carcinoma. References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Fig. 54: Fig.54. Cystic metastasis from squamous cell lung carcinoma. References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 57 of 126

58 Fig. 55: Fig.55. Cerebellar hemangioblastoma. T1WI after gadolinium and axial 3D FIESTA. References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 58 of 126

59 Fig. 56: Fig. 56. Auricular squamous cell carcinoma with extension into the external auditory canal and with invasion of the tympanic membrane, which produces instability. References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 59 of 126

60 Fig. 57: Fig.57. Subependymal nodules, cortical tubers, and hypothalamic-pituitary mass (subependymal giant cell astrocytoma) in tuberous sclerosis complex. Instability References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 60 of 126

61 Fig. 58: Fig.58. Mastoid region infiltrating mass, slightly hyperintense on T1WI and hyperintense on T2WI. Heterogeneous enhancement. Leptomeningeal melanoma. References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 61 of 126

62 Fig. 59: Fig.59. Leptomeningeal melanoma infiltrating and extending to posterior and lateral semicircular canals, tympanic cavity, and forming extraaxial mass. References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN 3. MALFORMATIVE-INFLAMMATORY DISEASE Nocardia abscessus (Fig. 60) Arnold-Chiari type I variant (Fig. 61) Sjögren's syndrome (Fig. 62) Meningitis (Fig. 63) Neurosarcoidosis (Fig. 64) Page 62 of 126

63 Fig. 60: Fig.60. Nocardia abscessus in posterior fossa (case 1. Up). In case 2, down, mastoid abscess and multiple in brain (temporal fossa). Mass effect on the brainstem,ventricular system and deviation from midline due to uncal herniation. Radiological emergency. Complicated mastoiditis. Impaired level of consciousness, high fever and torpid evolution. References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 63 of 126

64 Fig. 61: Fig.61. Arnold-Chiari type I malformation. Sharpening and tonsillar descent (arrow) and syringohydromyelic cavities (asterisks), which determines spinal cord disease symptoms, vertigo and undetermined instability. References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 64 of 126

65 Fig. 62: Fig 62. Sjögren's syndrome. Diffuse dural thickening as hypertrophic focal pachymeningitis in rightcerebellopontine angle and petrous apex. Multiple hyperintense cortical and subcortical lesions in T2WI FLAIR by demyelination References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Fig. 63: Fig.63. Meningitis. Diffuse meningeal enhancement and both IAC. References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Page 65 of 126

66 Fig. 64: Fig.64. Neurosarcoidosis. Subarachnoid patched hyperintense lesions on T2WI and T2WI FLAIR in posterior fossa, enhancing after gadolinium contrast media administration. References: M. A. Martin Perez; Hospital Virgen de la Concha, Zamora, SPAIN Images for this section: Fig. 3: Fig.3. Graphic 1 Page 66 of 126

67 Fig. 4: Fig.4. Graphic 2 Page 67 of 126

68 Fig. 5: Fig.5. Ear anatomy. Graphic Page 68 of 126

69 Fig. 6: Fig.6. Inner ear model. 1.Cochlea. 2.Cochlear Branch of Vestibular Cochlear Nerve VIII 3.Vestibular Branch of Vestibular Cochlear Nerve VIII 4.Scala Tympani (Perilymph) 5.Cochlear Duct (Endolymph) 6.Scala Vestibuli (Perilymph) 7.Vestibular Membrane 8.Basilar Membrane 9.Semicircular Canals 10.Semicircular Ducts 11.Ampulla of Semicircular Duct 12.Utricle 13.Saccule 14.Oval Window Page 69 of 126

70 Fig. 7: Fig.7. Inner anatomy. MRI correlation Page 70 of 126

71 Fig. 8: Fig.8. Pontocerebellous angle lesions. MRI findings Page 71 of 126

72 Fig. 9: Fig.9. Location of pontocerebellous angle lesions Page 72 of 126

73 Fig. 10: Fig.10. INTRAAXIAL & INTRAVENTRICULAR LESIONS INVADING PCA: MRI ROLE Page 73 of 126

74 Fig. 11: Fig.11. CEREBELLOPONTINE CISTERN LESIONS: MRI FINDINGS Page 74 of 126

75 Fig. 12: Fig.12. MRI IN CEREBELLOPONTINE LESIONS DERIVED FROM THE SKULL BASE Page 75 of 126

76 Fig. 13: Fig.13. AICA Vascular loop Page 76 of 126

77 Fig. 14: Fig.14. BASILAR VASCULAR LOOP. 3D TOF MIP and T2FSE weighted image Fig. 15: Fig.15. HIGH DILATED JUGULAR BULB T1WI and after gadolinium contrast administration. Shows high dilated jugular bulb in a patient with tinnitus. Page 77 of 126

78 Fig. 16: Fig.16. GLOMUS JUGULARE TUMOUR T1 and T2WI and after gadolinium contrast administration. Note the intense homegenously enhancement with hypointense foci. Fig. 17: Fig.17. JUGULAR BULB DIVERTICULUM (Left) GLOMUS JUGULARE TUMOUR (Right) T2WI shows a mass surrounding the jugular bulb, slightly hyperintense, and with absence of signal foci related vascular nature, in a patient with left-tinnitus sense. Salt and pepper appearance Page 78 of 126

79 Fig. 18: Fig.18. VENOUS ANGIOMA Page 79 of 126

80 Fig. 19: Fig.19. VENOUS ANGIOMA Page 80 of 126

81 Fig. 20: Fig.20. CAVERNOMAS Several cases of multiple cavernomatosis in cerebellum and brainstem. Hyposignal spotlights flowering significantly in T2 * GRE sequences. It should be a differential diagnosis with other entities such as chronic bleeding focus in the context of hypertension, as in Example 4. Page 81 of 126

82 Fig. 21: Fig.21. MULTIPLE VASCULAR MALFORMATIONS Uncertaint dizzyness in patient with multiple vascular malformations consisting on pontine cavernoma, venous angioma in parasagittal region of the right cerebellar hemisphere, and large dilated veins in the subcutaneous tissue, which connect to the sigmoid sinus with dural fistula. Page 82 of 126

83 Fig. 22: Fig.22. ICA ANEURYSM Aneurysm of right internal carotid artery, almost entirely thrombosed. Right Tinnitus in evolution. T1weighted sequences and after Gadolinium administration. Flair and gradient echo T2 *. Page 83 of 126

84 Fig. 23: Fig.23. CEREBELLAR HAEMATOMA Old right hemispheric haematoma in cerebellum, with hypointense central area, longstanding hematic deposits of degeneration in all pulse sequences, and full hemosiderotic ring, relating its long evolution. Page 84 of 126

85 Fig. 24: Fig.24. TRANSVERSAL SINUS THROMBOSIS T1-weighted images, T2WI, and gradient echo T2 *. Axial and coronal reconstructions of venous 2D FIESTA which reveals the large filling defect of left transverse sinus, and hemorrhagic transformation associated with temporal lobe ischemia. Page 85 of 126

86 Fig. 25: Fig.25. VERTEBROBASILAR ISCHEMIC STROKE Extensive vertebrobasilar stroke, affecting the posterior and medial right cerebellar hemisphere, and branches of PICA (not shown), with ipsilateral vertebral artery thrombosis. T2-weighted sequences, and coronal reconstruction of 3D TOF Images. View DWI hypersignal, with restricted ADC. Page 86 of 126

87 Fig. 26: Fig.26. MULTIPLE VASCULAR TERRITORIES ISCHEMIA 42 year old patient, with instability and vertigo of sudden onset. Tumor emboli of cardiac origin, which determine patchy areas of ischemia in different vascular territories. Lung carcinoma with invasion of left atrium. Page 87 of 126

88 Fig. 27: Fig.27. INTRAPETROUS LOBULATION OF GASSER GANGLION Patient 67 years. Instability. T1-weighted images without and after gadolinium contrast media agent, 3DFIESTA and T2WI of both IAC. Prominent Gasser ganglion bulging the cranial portion of PCA and base of the left IAC. Page 88 of 126

89 Fig. 28: Fig.28. SUBARACHNOID FAT DROPS CT and MRI Correlation (T1WI). There are markedly hypodense foci, with a range of densitometry of fat in the subarachnoid space; hyperintense on T1-weighted images. Page 89 of 126

90 Fig. 29: Fig.29. SUBEPENDYMOMA Page 90 of 126

91 Fig. 30: Fig.30. MEDULLOBLASTOMA Fig. 31: Fig.31. ARACHNOID CYST Page 91 of 126

92 Page 92 of 126

93 Fig. 32: Fig.32. DERMOID TUMOR Page 93 of 126

94 Page 94 of 126

95 Fig. 33: Fig.33. BRAINSTEM GLIOMA Page 95 of 126

96 Page 96 of 126

97 Fig. 34: Fig.34. CHOLESTEROL GRANULOMA Fig. 35: Fig.35. EPIDERMOID CYST Page 97 of 126

98 Fig. 36: Fig.36. EPIDERMOID CYST Typical features at image of epidermoid cyst with high signal on DWI. In this case presents great extra-axial extension to suprasellar cistern, floor of the third ventricle to the left cerebellopontine angle Page 98 of 126

99 Page 99 of 126

100 Fig. 37: Fig.37. CHOLESTEATOMA Fig. 38: Fig.38. VIII CN Schwannoma. Intracanalicular location, reaching the acoustic pore. Low signal on T2WI, and homogeneous enhancement after gadolinium contrast media administration Page 100 of 126

101 Fig. 39: Fig.39. Vestibular Schawanoma. Total occupancy of the IAC, and enhancing mass in the canaliculus. Extension with ice cream cone morphology, emerging into the left cerebellopontine angle. Page 101 of 126

102 Fig. 40: Fig.40. Vestibular Schawanoma. Note the homogeneous enhancement with small punctate nodular and cystic areas. Page 102 of 126

103 Fig. 41: Fig.41. Extracanalicular Schwannoma, occupying the right PCA and producing opening of the acoustic-facial package, reporting to the inferior vestibular branch. Typical behavior in image. Page 103 of 126

104 Fig. 42: Fig.42. Great schwannoma of CN VIII, with dilation of the right IAC and extension to the PCA. Page 104 of 126

105 Fig. 43: Fig.43. Neurofibromatosis type II: Left trigeminal and vestibular schwannomas and affecting paraspinal nerves. Page 105 of 126

106 Fig. 44: Fig.44. Enlarged, cystic degeneration and heterogeneous enhancement of CN VIII schwannoma treated with stereotactic radiotherapy (patient declined surgical treatment). Progressive loss of hearing, balance disorders and otalgia. T2WI (lower left) and after administration of gadolinium which shows heterogeneous, predominantly peripheral enhancement and central necrosis. Page 106 of 126

107 Fig. 45: Fig.45. Neurofibromatosis type II: right vestibular schwannoma (blue arrows) and bilateral trigeminal schwannomas( orange arrows). Paraspinal peripheral nerve sheath tumor (yellow arrow) and meningiomas (white arrows). Page 107 of 126

108 Fig. 46: Fig.46. Extraaxial mass that occupies right PCA, extending to the internal auditory canal. Early and homogeneous enhancement with dural tail. Meningioma. Fig. 47: Fig.47. Meningioma. Page 108 of 126

109 Fig. 48: Fig.48. Two examples of meningioma. Left; occupation of the PCA and mass effect on left facial-acoustic package.on the right, meningioma that infiltrates transverse sinus. Fig. 49: Fig.49. Meningioma in the left PCA, T1WI without and with gadolinium contrast media administration and T2WI. View the existence of large cystic components (asterisks). Page 109 of 126

110 Fig. 50: Fig.50. Right CN IX schwannoma (orange arrow) Left CN X schwannoma (white arrow) Page 110 of 126

111 Fig. 51: Fig.51. Primary cerebral lymphoma. Ring enhancement after gadolinium administration. Page 111 of 126

112 Fig. 52: Fig.52. Multiple geminal tumor metastasis. Instability. Note lesion in posterior fossa. Page 112 of 126

113 Page 113 of 126

114 Fig. 53: Fig.53. Metastases from oat-cell lung carcinoma. Fig. 54: Fig.54. Cystic metastasis from squamous cell lung carcinoma. Page 114 of 126

115 Fig. 55: Fig.55. Cerebellar hemangioblastoma. T1WI after gadolinium and axial 3D FIESTA. Page 115 of 126

116 Fig. 56: Fig. 56. Auricular squamous cell carcinoma with extension into the external auditory canal and with invasion of the tympanic membrane, which produces instability. Page 116 of 126

117 Fig. 57: Fig.57. Subependymal nodules, cortical tubers, and hypothalamic-pituitary mass (subependymal giant cell astrocytoma) in tuberous sclerosis complex. Instability Page 117 of 126

118 Fig. 58: Fig.58. Mastoid region infiltrating mass, slightly hyperintense on T1WI and hyperintense on T2WI. Heterogeneous enhancement. Leptomeningeal melanoma. Page 118 of 126

119 Fig. 59: Fig.59. Leptomeningeal melanoma infiltrating and extending to posterior and lateral semicircular canals, tympanic cavity, and forming extraaxial mass. Page 119 of 126

120 Fig. 60: Fig.60. Nocardia abscessus in posterior fossa (case 1. Up). In case 2, down, mastoid abscess and multiple in brain (temporal fossa). Mass effect on the brainstem,ventricular system and deviation from midline due to uncal herniation. Radiological emergency. Complicated mastoiditis. Impaired level of consciousness, high fever and torpid evolution. Page 120 of 126

121 Fig. 61: Fig.61. Arnold-Chiari type I malformation. Sharpening and tonsillar descent (arrow) and syringohydromyelic cavities (asterisks), which determines spinal cord disease symptoms, vertigo and undetermined instability. Page 121 of 126

122 Fig. 62: Fig 62. Sjögren's syndrome. Diffuse dural thickening as hypertrophic focal pachymeningitis in rightcerebellopontine angle and petrous apex. Multiple hyperintense cortical and subcortical lesions in T2WI FLAIR by demyelination Fig. 63: Fig.63. Meningitis. Diffuse meningeal enhancement and both IAC. Page 122 of 126

123 Fig. 64: Fig.64. Neurosarcoidosis. Subarachnoid patched hyperintense lesions on T2WI and T2WI FLAIR in posterior fossa, enhancing after gadolinium contrast media administration. Page 123 of 126

124 Conclusion Protocol MRI study on hearing loss and vertiginous syndrome represents one of the most frequent reason of radiological consultation. Although the pathological findings are unusual and often with little involvement in the symptomatic treatment, a significant percentage of certain entities detection is key in the management (view graphics of our work), for which MRI remains an indispensable tool. Images for this section: Fig. 3: Fig.3. Graphic 1 Page 124 of 126

125 Fig. 4: Fig.4. Graphic 2 Page 125 of 126

126 References - Som PM, Curtin HD. Head and neck imaging. 4th ed. Philadelphia: Mosby-Elsevier Science; Bonneville F, et al. Unusual lesions of the cerebellopontine angle: Asegmental approach. Radiographics 2001; 21: Harnsberger R, Hudgins PA, Wiggins III RH, Christian Davidson H. Diagnostic Imaging. Head and Neck. 1 Ed Salt Lake City, UT: Amirsys Inc; Gao PY, Osborn AG, Smirniotopoulos JG, Harris CP. Radiologic-pathologic correlation: epidermoid tumor of the cerebellopontine angle. AJNR Am J Neuroradiol 1992;13: Lo WW. Tumors of the temporal bone and cerebellopontine angle. In: Som PM, Bergeron RT, editors. Head and Neck Imaging, 2nd ed. St. Louis: Mosby, 1991: Heier LA, Comunale JP, Lavyne MH. Sensorineural hearing loss and cerebellopontine angle lesions not always an acoustic neuroma-a pictorial essay. Clinical Imaging, Volume 21, Issue 3, Pages Personal Information MA Martín Pérez, I Martín García, BR Arenas García, R Blanco Hernández, JM Marín Balbín, T Escudero Caro Hospital Virgen de la Concha. Complejo Asistencial de Zamora. Spain. Mail of contact mamartin@seram.org Page 126 of 126