Meckel cave/cavernous sinus meningioma with perineural spread

Case contributed by Henry Knipe
Diagnosis probable


Right lip twitching. Right eye fullness. Headache.

Patient Data

Age: 55 years
Gender: Female

Right Meckel's cave /cavernous sinus enhancing mass measures 27 x 13 x 25 mm (AP x ML x SI) with extension into the orbital apex surrounding the orbital nerve; through foramen rotundum into the pterygopalatine fossa, and through an expanded foramen ovale into the suprahyoid neck where there is ill-defined enhancement that extends posterior to the right mandibular ramus to the superficial parotid space. An enhancing component abuts the stylomastoid foramen. Mild right proptosis. 

T1/T2 isointense (to grey matter) mass lesion centered in the right Meckel's cave with approximate dimensions of 3 x 1.4 x 2.8 cm (AP x ML x SI) with vivid post contrast enhancement and increased diffusion restriction.

There is extension along inferior and lateral aspect of the right cavernous sinus and through superior orbital fissure into the right orbital apex where the optic nerve is encased. Linear enhancement within optic canal is not as bulky. There is also enhancement and enlargement of the right maxillary division (V2) expanding foramen rotundum with tumor completely occupying the pterygopalatine fossa and contiguous via the petromaxillary fissure with the infratemporal fossa component of the tumor. Inferiorly there is spread along the right mandibular division (V3) with expansion of the foramen ovale.

Enhancing tumor extends along the mandibular nerve, including inferior alveolar nerve at least as far as the mandibular foramen, and the auriculotemporal nerve as it wraps around the back of the mandibular ramus. From here, abnormal tumor extending in an anteroposterior direction is likely involving facial nerve branches. Abnormal enhancing tumor is present at stylomastoid foramen and facial canal. Further enhancement involves right facial canal at geniculate ganglion. The enhancement in infratemporal fossa region and within parotid also encases the right internal maxillary and external carotid arteries.

Thin dural thickening and enhancement along the floor of the right middle cranial fossa extending around the cerebral convexity. There is enhancement and fatty marrow replacement of greater wing of sphenoid and petrous apex on the right.

Case Discussion

Mass centered in the right Meckel's cave/cavernous sinus with extracranial extension including extensive perineural spread involving V2/pterygopalatine fossa, V3 and mandibular nerve, and the facial nerve on the right, as well as spread through the right superior orbital fissure into the right orbital apex compressing the optic nerve. There is thin but extensive right dural thickening and bony hyperostosis, which favors meningioma. The patient proceeded to biopsy, which was unfortunately non-diagnostic. 

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