Presentation
Left lower cranial nerve palsy, left trigeminal neuralgia, disequilibrium, and chronic headache.
Patient Data
There is a left-sided petroclival meningioma with long enhancing dural tail and midline cross associated with extension and involvement of adjacent structures as followed:
- invasion with effacement of left Meckel cave and cavernous sinus with extension to the contralateral cavernous sinus
- encasement of left ICA cavernosal segment with no evidence of occlusion and encasement of right ICA cavernosal segment with no evidence of narrowing and occlusion
- invasion to sella tursica and dorsum sella with marked pressure effect on pituitary gland with right-sided deviation as well as a suprasellar extension with invasion to pituitary stalk and diencephalon structures
- invasion to clivus with posterior extension and close contact with basilar artery
- posterior extension: causing to marked pressure effect on brain stem with a right-sided deviation of midbrain as well as notable pressure effect on left brachium pontis and cerebral peduncle associated with surrounding vasogenic edematous changes
- superior and medial extension with marked pressure on left temporal lobe and adhesion to optic chiasma on the left side
- anterior extension into the left optic canal and superior orbital fissure and adhesion to the left optic nerve
Ventriculomegaly with transependymal spillage is seen in the background of pressure effect of the mass on 3rd and 4th ventricles
VP shunt is present at the right lateral ventricle
High signal foci in T2 and flair sequences at subcortical and periventricular white matter of both cerebral hemispheres depict microvascular ischemic events
Mucocele at sphenoidal sinuses.
Case Discussion
Petroclival meningioma arises in the upper two-thirds of the clivus at the petroclival junction, medial to the fifth cranial nerve. The tumor can displace the brain stem and the basilar artery to the contralateral side. Petroclival meningiomas had a considerable high postoperative morbidity and mortality because of tumor proximity to cranial nerves, major blood vessels, and the brainstem.
Clinical symptoms initially start with an insidious onset of headache and then progress to lower cranial neuropathy with unilateral hearing loss or facial sensory disturbances and trigeminal neuralgia. Brainstem and cerebellar compression signs e.g. gait disturbance are not uncommon.