Traditional Approach. Pathways for Skull Base Pathology. Special Pathways Approach. 1. Traditional Approach. Central Skull Base. Anterior Skull Base
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1 Traditional Approach Pathways for Skull Base Pathology Anatomy Local Pathology Wade Wong DO FACR Professor of Radiology University of California, San Diego Special Pathways Approach Perineural Perivascular Pterygopalatine Fossa Eustachian Tube Transorbital Fascial Highways 1. Traditional Approach Anatomy Anterior Skull Base Central Skull Base Posterior Skull Base Local Pathology Anterior Skull Base Orbital Plates (Frontal bone) Cribiform Plate (Ethmoid & Sphenoid bones) Upper Clivus Sella Cavernous Sinus Sphenoid Central Skull Base
2 Posterior Skull Base Posterior Clivus Occipital Bone (For. Magnum) Temporal Bone Anterior Skull Base Pathology Common *Sino-Nasal (Malignant & Inflammatory) *Metastasis *Meningioma Inverted Papilloma Papilloma Neoplasm HP Virus Exposure 15 % Chance Malignant degen; Types: *Fungiform *Inverted *Cylindrical Fungiform Papilloma Meningioma Anterior Skull Base Pathology Mucocele 2 Polyp Less Common *Mucocele *Osteoma *Polyps *Lymphoma *Esthesioneuroblastoma *Granuloma *Other Mucoceles 2 NHL Mucocele: Obstructed sinus Mucus Retension cyst: Obstructed gland Polyp: B9; Inflam. or Allergic mucosal hypertrophy
3 Very dense bone Frontal/ethmoid Remodeling Obstruction & Mucocele Osteoma Esthesioneuroblastoma Destructive Lesion: Anterior Skull Base Cribiform Plate: Olfactory Groove Malignant Small Blue Cells PNET Esthesioneuroblastoma Rhabdomyosarcoma 4 y/o M Destructive Ant/Mid Skull Base Mass Malig. Pleuripotential Rhabdoid Cells H&N #2 MC site Juvenile Nasoangiofibroma 19 y/o M Nasal Stuffiness & Profuse Nasal Bleeding Congenital neural tube closure defect Types *Encephalocele *Meningocele Cephaloceles
4 44 y/o F: Nasal Suffiness Endoscopic Sinus Surgery Meningocele Aspergillus Midline Granuloma Central Skull Base Pathology NP Malignancy NP Inflammatory Sellar Pathology Cavernous Sinus Pathology Clival Lesions NP Sq Cell Ca Cavernous Sinus Lesions NF2 ( MISSME) Mets, Lymphoma Meningioma Schwannoma Vascular: Aneurysm, Fistula, Thrombosis Other Lymphoma 29 y/o F Can see; can t hear too well HAs Few Café Au Lait spots?dx
5 M: Multiple Intracranial & Spinal Schwannomas Meningiomas Ependymomas MISSME Cavernous ICA Aneurysm 79 y/o M Sudden onset HA. Severe MS change: Coma Dx? Sellar Masses S: Sella Pituatary Adenoma A: Aneurysm, Abscess T: T.B. Tuberculum Meningioma C: Craniopharyngioma H: Hypothalamic Glioma M: Meningioma O: Optic Nerve Glioma
6 39 y/o F: R. Visual Loss 44 y/o F: Bitemporal Hemianopsia Dx: Pituatary Adenoma? Aneurysm Dx: Pit. Adnoma 44 y/o M: Bitemporal Hemianopsia Dx: LIC Aneurysm Pituitary Hyperplasia Physiologic enlargement >10-15 mm May be related to hypothyroidism or other end organ failure Diffusely enlarged gland with superior margin convex upward Prominent Invagination of arachnoid & CSF into sella Normal Pituitary gland may be flattened against the sella floor Empty Sella Pituitary Hemorrhage Apoplexy: if sudden and mass effect significant Signal bright t1 t2 Ddx Rathkes cleft cyst, Craniopharyngioma
7 Pituitary Apoplexy Hypophysitis Acute HA, vis defects,opthalmopl egia, endocrine difficiencies, mental changes Post Acute hemorrhage or infarction 24 y/o F: Galactorea DDX Hypophysitis Meningioma Leukemia Sarcoid TB Dural Thickening & C+ Idiopathic inflammation of ant pituitary Thick non tapered stalk Uniform C+ Adj dural thickening & sphenoid sinusits Hypophysitis Sarcoid Cystic Microadenoma Cystic changes poss DDX sellar cyst Adenoma Rathkes Cranioph. Arachnoid Cyst Aneurysm
8 Thrombosed Aneurysm Rathkes Cleft Cyst x Arachnoid Cyst Sharply follows CSF Dx w/ Cisternography 60% middle Cr Fossa 10% Suprasellar No restricted diffusion Suprasellar Abnormalities May extend superiorly and laterally Sx: (Common) Bitemporal Hemianopsia Macroadenoma Sellar/Suprasellar Masses Vascular Chiasmatic Lesions
9 Chiasmatic: Bitemporal Hemianopsia Pituitary Adenoma Lobulated, rounded Resembles CSF but could be hyperintense because of hi protein, hemorrhage, saponification Epidermoid Cyst y/o Epidermoid 3 rd m/c cp angle mass (%0%)/ parasellar (15%) Insinuates, invaginates, lobulated Epidermoid Epidermoid: Restricted Diffusion Rathkes Cleft Cyst Defective dev of Rathkes pouch B9 cyst Usu Asx Usu no C+ No Ca++ No solid components
10 Mean age 45 F>M Some cysts spontaneously shrink Conservative Rx Rathkes Cleft Cyst Rathkes Cleft Cyst May ext suprasellar Craniopharyngioma Rathke s pouch origin y/o (50-60) 90% suprasellar 10% sellar 70% both Ca++ Multicystic Nodules in cyst wall Craniopharyngioma Commonly>5 cm May be multicystic Periph nodules DDx Rathkes Arachnoid cyst Pit Adenoma Epidermoid Thrombosed An Craniopharyngioma Peripheral enhancing nodules Crank case oil : hemorrhage, protein, cholesterol Peds: Adamatinomatous Adult: papillary Craniopharyngioma m/c pediatric nonglial IC tumor
11 54 y/o F: Bitemporal Hemianopsia 19 y/o M: Nasal Stuffiness Dx: Meningioma Dx: Craniopharyngioma Clival Lesions NP/Sphenoid Sinus Sq. Cell Ca Chordoma Mets Infection Other: Chondrosarc, Lymphoma, Plasmacytoma Dx: Chordoma Pituatary Adenoma Lung Ca Met
12 Posterior Skull Base Posterior Clivus Occipital Bone (For. Magnum) Temporal Bone Foramen Magnum Lesions Meningioma Posterior Clival Lesions Vascular Other 64 y/o F: Mult. Cranial N Deficits 58 y/o M: Mult. Cranial N. Deficits Dx: Chondrosarcoma Dx: Meningioma 9 y/o F: Mult Cranial N. Deficits 49 y/o M: Mult. Cranial N Deficits Dx: Juvenile Pilocytic Astrocytoma Dx: Fusiform Basilar Aneurysm
13 Temporal Bone: CP angle Masses 8 th Nerve Schwannoma 8 th N Schwannoma (75%) Meningioma (10%) Epidermoid (5%) 7 th N Schwannoma (<5%) Other Erosive Otitis Media with Epidural Abscess 49 y/o F: R. Hearing Loss Dx: Meningioma 7 th Nerve Schwannoma 4 th m/c CP angle mass Note anatomical course of 7 th nerve 7 up! Geniculate ganglion m/c site
14 Jugular Foramen Lesions Common *High Jug. Bulb *Thrombosis *Paraganglioma Less Common *Schwannoma *Mets Paraganglioma (Glomus Jug.) Neural crest cell origin Highly vascular T2: salt & pepper Poss. multiple Pre vs Post 200 u PVA 44 y/o F: Pulsatile Tinnitus Dx: Paraganglioma
15 54 y/o F: Hoarseness Cholesterol Granuloma Post inflammatory cystic petrous apex Smooth margins Hemorrhagic signal DDx: Aneurysm Dx: Schwannoma Diffuse Skull Base Lesions Fibrous Dysplasia Pagets Myeloma Other Dx: Fibrous Dysplasia 62 y/o M: Hearing Loss Fibrous Dysplasia vs Pagets Ds Dx: Pagets Dx: Pagets Adoles. & Young Adults Skull & Face Ground glass, cystic, expansile Cr. N. Deficits B9 Elderly Early destrucive, lytic/ Late sclerotic Bony overgrowth Basilar Invagination Cr. N. Deficits Poss Malig. degen
16 9 y/o B. Male: MS Changes 74 y/o F: Head Pain Dx: Myeloma Dx: Sickel Cell 69 y/o F: R. Hearing Loss Classic Approach Local Invasion/Direct Destruction Dx: Fibrosarcoma Dx: Breast Met 2. Special Pathways Approach Perineural Pathways Perineural Perivascular Pterygopalatine Fossa Eustachian Tube Transorbital Fascial Highways V3 V2 7 th Other Dx: Adenocystic Ca>V3
17 Foramen Ovale Dx: Rhabdomyosarcoma 56 y/o F: Numbness L Cheek PMH: Adenoidcystic Ca 12 yrs ago Dx: Perineural Metastasis V2 Foramen Rotundum (V2) Pterygopalatine Fossa:
18 Palatine Nerves 5 th, 7 th N. Dx: Perineural Metastasis to 5th N Perivascular Pathways Carotid Artery Jugular Vein Dx: Perineural Metastasis to 7th N Dx: Perivascular Metastasis to Cavernous Sinus 27 y/o B F: Numbness R Lower Face Perivascular Metastasis to Jugular Foramen: Extranodal
19 Pterygopalatine Fossa Dx: Sarcoid Perivascular Extension Dx: Sq Cell Ca Extension up Pterygopalaine Fossa to Orbital Apex Dx: Hypopharyngeal Sq. Cell Ca Along Eustachian Tube Meningioma Optic N. Glioma Mets Infection Vascular Other Transorbital
20 Dx: Optic N. Glioma (NF1) 56 y/o F: decreased vision OD Granulomatous Pseudotumor 58 y/o F c/o dereased vision OS?Dx
21 Dx: Meningioma optic N Sheath Sagital Oblique? Intracranial Extension Meningioma Extra to Intracranial s,.w. 62 y/o F c/o visual loss OD Dx: Plasma Cell Granuloma Met from Lung Ca Transorbital Trauma Dx: Leukemia
22 Transorbital Vascular Fascial Highways to Skull Base Carotid Space Parapharyngeal Space Masticator Space Retropharyngeal Space Prevertebral Space Carotid Space Jugular Foramen Carotid Canal Jugular Foramen Styloidmastoid Foramen Direct Destruction Parotid Space Masticator Space Foramen Ovale Pterygopalatine Fossa Foramen Rotundum Direct Destruction
23 Dx: Sq Cell Ca Extension up Pterygopalaine Fossa to Orbital Apex Retropharyngeal Space Direct destruction Foramen Magnum Direct Destruction Prevertebral Space Superior to Inferior Skull Base
24 Meningioma: Intra to Extracranial Meningioma
25 Renal cell Met 12th N. Schwannona Traditional Approach Anatomy Anterior Skull Base Central Skull Base Posterior Skull Base Local Pathology Special Pathways Approach Perineural Perivascular Pterygopalatine Fossal Eustachian Tube Transorbital Fascial Highways
26 Case Discussions 38 yo female with 2 year history of decreased hearing in right ear with facial numbness 38 yo female with 2 year history of decreased hearing in right ear with facial numbness Outside MRI- T2 38 yo female with 2 year history of decreased hearing in right ear with facial numbness Outside MRI-FLAIR 38 yo female with 2 year history of decreased hearing in right ear with facial numbness Outside MRI-T1 38 yo female with 2 year history of decreased hearing in right ear with facial numbness Outside MRI-T1 post Gd
27 38 yo female with 2 year history of decreased hearing in right ear with facial numbness Outside MRI-T1 post Gd 38 yo female with 2 year history of decreased hearing in right ear with facial numbness Noncontrast CT DDx for infratemporal lesion with extension through foramen ovale: -tumor via foramen ovale Meningioma Squamous Cell Carcinoma Schwannoma Lymphoma Neuromuscular hamartoma DDx? Adenoid cystic carcinoma Chondrosarcoma Nonneoplastic considerations -Subacute mandibular nerve denervation causing edema of the masticator space and tongue from denervation -Infection DDx for infratemporal lesion with extension through foramen ovale: 38 yo female with 2 year history of decreased hearing in right ear with facial numbness CT guided biopsy How to diagnose?
28 38 yo female with 2 year history of decreased hearing in right ear with facial numbness 38 yo female with 2 year history of decreased hearing in right ear with facial numbness Angiogram Angiogram 38 yo female with 2 year history of decreased hearing in right ear with facial numbness 38 yo female with infratemporal mass Post surgical MRI-T1 POST GD Biopsy Report FINAL PATHOLOGIC DIAGNOSIS: A: Right mass, extraaxial in infratemporal fossa -Minute fragment of meningioma. -Skeletal muscle with no pathologic diagnosis. H&E stained sections of the entirely submitted specimen disclose mostly skeletal muscle with no pathologic diagnosis. However, accompanying the skeletal muscle is a single minute fragment (less than one x400 field) of meningotheliomatous meningioma. The tumor fragment appears separately from the skeletal muscle and is not infiltrating into skeletal muscle in these sections. Aspirate Report The aspirate consists of aggregates of cohesive cells with pale uniform nuclei similar to the patient's concurrently diagnosed meningioma (HCS , right infratemporal fossa mass). These aggregates of cells are found interspersed between skeletal muscle. Anatomy of foramen ovale: Anatomy of masticator space: 1 Parapharyngeal s. 2 Masticator space. 3 Mucosal space. 4 Submandibular s. From: slide0152.htm 1 Parapharyngeal s. 2 Masticator space. 3 Carotid space. 4 Parotid space. 5 Mucosal space. 6 Perivertebral space (anterior portion). 7 Retropharyngeal space (virtual at this level).
29 Foramen ovale lesion examples: Foramen ovale lesion examples: Adenoid cystic carcinoma Squamous cell carcinoma From: FJ Laine, IF Braun, ME Jensen, L Nadel and PM Som, Perineural tumor extension through the foramen ovale: evaluation with MR imaging Radiology, Vol 174, From: FJ Laine, IF Braun, ME Jensen, L Nadel and PM Som, Perineural tumor extension through the foramen ovale: evaluation with MR imaging Radiology, Vol 174, Foramen ovale lesion examples: Lymphoma From: FJ Laine, IF Braun, ME Jensen, L Nadel and PM Som, Perineural tumor extension through the foramen ovale: evaluation with MR imaging Radiology, Vol 174,
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