Presentation
Right hearing loss in a patient on follow-up for breast cancer since 5 years, treated with surgery and chemotherapy.
Patient Data
Extra-axial dural-based mass of the right cerebellopontine angle (CPA) extending into the ipsilateral internal auditory canal. It displays an isosignal to the cortical grey matter on T1, T2, and FLAIR with vasogenic edema of the brainstem and middle cerebellar peduncle. The postcontrast sequences demonstrate a vivid heterogeneous enhancement as well as thickening with an enhancement of the adjacent margin of the tentorium cerebelli with a mass effect on the cisternal segment of the ipsilateral trigeminal nerve.
Moderate dural thickening with enhancement at the left Sylvian region that was not mentioned in the radiological report.
6 months later the patient presented with severe headache and right facial palsy.
On the follow-up MRI the right CPA mass has increased in size as well as the surrounding vasogenic edema, filling the right aspect of the prepontine cistern, invading the brainstem, the middle cerebellar peduncle, the ipsilateral hypoglossal canal, cavernous sinus, and the right aspect of the pituitary fossa with numerous enhancing cerebellar and cerebral nodules.
The dural thickening with enhancement at the left Sylvian region has also increased in size.
Case Discussion
The patient is known for breast cancer treated with surgery and chemotherapy, on follow-up for 5 years, presented with a right hearing loss. A brain MRI was performed showing a right CPA mass mistaken for meningioma and left dural thickening with enhancement at the left Sylvian region that was missed.
6 months later, the patient presented with worsening symptoms (severe headaches with right facial palsy). An MRI was performed showing an increase in the size of the right CPA mass invading the adjacent structures, compressing the vestibulocochlear/facial nerves, the cisternal segment of the trigeminal nerve with numerous cerebellar and cerebral metastatic nodules.
On the first MRI, the enhancement was not that of a meningioma, in addition, there was thickening with dural enhancement which should point towards a metastasis especially if we know that the patient has breast cancer.