Presentation
Five day history of numbness to left side of face and dysphagia. Recent diagnosis of left upper lobe malignancy; untreated as per patient’s request. Decreased sensation to left trigeminal nerve, and left-sided oropharyngeal weakness on clinical examination.
Patient Data
The brain parenchyma, the sulci and ventricles are normal for age. No focal lesion is detected. There is no mass effect or hydrocephalus.
Enhancing lesion is identified expanding Meckel's cave on the left. Lesion measures 2.0 x 1.0 cm. Enhancement extends anteriorly and inferiorly through the foramen ovale in keeping with perineural spread along the mandibular branch of the trigeminal nerve. A 5 mm rim enhancing lesion is an inferior aspect of the cerebellar hemisphere. No other focal lesion identified. Ventricular size is age-appropriate. Nonspecific FLAIR hyperintensity is identified within the deep white matter in keeping with chronic small vessel ischemic changes.
Findings most in keeping up with a metastasis to the left trigeminal nerve within Meckel's cave with perineural extension tracking anteriorly along the mandibular branch of the nerve through the foramen ovale and further metastatic deposit inferiorly in the left cerebellar hemisphere.
The patient was initially treated with dexamethasone and recommended for whole brain radiotherapy. However, he refused all further proposed therapies.
Case Discussion
This case illustrates an ipsilateral trigeminal mononeuropathy resulting from presumed lung metastatic disease. Mononeuropathy of a cranial nerve resulting from metastasis is quite uncommon.
Case courtesy of Associate Professor Pramit Phal
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