Presentation
Patient referred for a cervical spine MRI to evaluate the possibility of injury related to a fall in the bath. Pins and needles in both hands.
Patient Data
On the superior aspects of the sagittal images a soft tissue mass is identified arising from the dorsal surface of the left aspect of the clivus, measuring 16 x 8 mm, with a minor indentation of the medulla. The appearance is suggestive of a meningioma.
Straightening of the normal lordosis.
Ununited dens fracture versus developmental ununited ossicle. This could be further assessed with CT.
Cord indentation and localized signal at C3/4.
Multilevel foraminal stenosis.
MRI brain shows an extra-axial enhancing lesion arising from the left dorsal clivus, measuring 15 x 20 x 8.5 millimeters. There is indentation of the cervico medullary junction and the left vertebral artery indents the left posterior aspect of the mass.
There is a second larger extra-axial lesion arising in the floor of the anterior cranial fossa in the region of the olfactory groove measuring 30 x 38 x 39 mm. Internal flow voids are noted in the mass.
Conclusion:
Dorsal clival meningioma indenting the cervicomedullary junction.
Large olfactory groove meningioma.
Findings: No significant fibromuscular disease, stenosis or dissection is seen in either carotid artery or the left vertebral artery. The anterior cranial fossa skull base tumor is markedly hypervascular, with a parenchymal staining pattern typical of a meningioma. The supply comes almost exclusively from ethmoidal meningeal branches from each ophthalmic artery. A small pial supply from the frontopolar branch is suspected. There was no significant supply from either middle meningeal artery, or other external carotid artery feeders. On this basis no embolization was performed. Groin sheath removed and manual compression applied.
Conclusion: Meningioma supply predominantly from ophthalmic artery ethmoidal branches.
MICROSCOPIC DESCRIPTION: Paraffin sections show a moderately hypercellular meningioma. This has a well-developed syncytial architecture. Tumor cells have uniform nuclear features. An occasional mitotic figure is identified. No necrosis is seen. A small focus of invasion of underlying brain parenchyma is identified.
DIAGNOSIS: Brain tumor: Meningioma with focal brain invasion (WHO Grade II)
Case Discussion
This case illustrates an incidental finding observed during cervical spine investigations related to trauma.
Meningiomas are generally benign and slow growing CNS tumors which, with a large use of diagnostic imaging, can be incidentally found while still asymptomatic 1.
Multiple meningiomas like in this case are found in less than 10% of patients with meningiomas and it can occur sporadically or as part of a familial syndromes 1.
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