Orginal Research
2022 June
Volume : 10 Issue : 2


Clinical and imaging features in surgically verified patients over 11 years and literature review

Vedula RR, Kummary Y, Gurram SR, Gudipati A, Ponnaganti S, Panigrahi MK

Pdf Page Numbers :- 47-59

Rajanikanth Rao Vedula1,*, Yadagiri Kummary1, Sunil Reddy Gurram1, Anantram Gudipati1, Sandeep Ponnaganti1, and Manas Kumar Panigrahi2

 

1Department of Radiololgy, Krishna Institute of Medical Sciences, Minister Road, Secunderabad-500003, Telangana, India

2Department of Neurosurgery, Krishna Institute of Medical Sciences, Minister Road, Secunderabad-500003, Telangana, India

 

*Corresponding author: Rao RK Vedula, MD, DMRD, FRCP (Glasgow), Emeritus Professor, Krishna Institute of Medical Sciences, Minister Road, Secunderabad-500003, Telangana, India. Mobile: +91 9989773473; Email: vedula@gmail.com

 

Received 25 January 2022; Revised 14 March 2022; Accepted 22 March 2022; Published 30 March 2022

 

Citation: Vedula RR, Kummary Y, Gurram SR, Gudipati A, Ponnaganti S, Panigrahi MK. Clinical and imaging features in surgically verified patients over 11 years and literature review. J Med Sci Res. 2022; 10(2):47-59. DOI: http://dx.doi.org/10.17727/JMSR.2022/10-11

 

Copyright: © 2022 Vedula RR et al. Published by KIMS Foundation and Research Center. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.



Abstract

Background: Controversy continues in the treatment decisions despite advanced imaging techniques. Though specific diagnosis by imaging is not precise. Diffusion weighted imaging is useful in a small proportion of patients. We evaluated the features of magnetic resonance imaging (MRI) with histopathological findings in patients with lesions of the cavernous sinus (CS).

Materials and methods: Retrospective analysis of clinical, imaging and histopathological findings of lesions involving cavernous sinus (CS) in 27 consecutive patients was done.

Results: The average age of the study population was 41.12 ± 14.49 (13-63) years; with 16 (59.2%) males. Visual disturbances were the most common complaints, reported in 62.0% and cranial nerve involvement was observed in 55 % of the patients. Complete excision was done in nine (33.3%) patients. Post-operative histopathology revealed meningiomas and hemangiomas in six (22.2%) patients each. While, five (18.5%) patients had schwannoma; fungal granuloma was observed in three (11.1%). Imaging based diagnosis showed concordance with histopathology in five (85.0%) patients with hemangioma. Among fungal granuloma, schwannoma and meningiomas, the concordance was 66.6%, 40.0% and 33.3% respectively. In the entire study population, concordance was 44.4%.

Conclusions: MR signal intensities are similar in neoplasms, infections, vascular lesions and inflammatory lesions. Cavernous hemangiomas are most often mistaken for other lesions but may be characterized by intense contrast enhancement and absence of restriction of DWI and blooming on GRE sequence. In lesions of cavernous sinus, accuracy of diagnosis on MRI is less than 50%. Diagnosis on MRI is more accurate in hemangiomas and fungal granulomas. Non-invasive diagnosis of granulomatous lesions may help plan appropriate management strategy.

 

Keywords: cavernous sinus; magnetic resonance imaging; diffusion weighted imaging

Full Text

Keymessage

While other benign neoplastic lesions in cavernous sinus exhibit non-specific appearances, hemangiomas demonstrate consistent features on imaging. MRI has a valuable role in the follow-up of granulomatous and inflammatory lesions.

 

Introduction

The cavernous sinus (CS) is an intracranial dural venous sinus extending from the orbital apex and superior orbital fissure anteriorly, to the Meckel’s cave posteriorly. It is composed of a network of small venous channels that may arbitrarily be divided into different compartments. The main venous influx into the CS is the superior and inferior ophthalmic veins, pterygoid plexus, and sylvian vein and posteriorly into the superior and inferior petrosal sinuses. The internal carotid artery (ICA) is the most medial structure within the CS located in the carotid trigone. Cranial nerves III and IV and the first and second divisions of the cranial nerve V (from superior to inferior) are situated in the lateral dural wall of the CS (Figures 1 & 2). Sixth cranial nerve courses in the central part of the CS inferolateral to the ICA. These structures are involved by neoplastic, vascular, infective and infiltrative lesions. Neurogenic tumors, meningiomas, epidermoids, dermoids and cavernous hemangiomas commonly involve the cavernous sinus [1]. Patients present with oculomotor paresis, diplopia, sensory motor disturbances of facial muscles and rarely with symptoms and signs of cavernous sinus thrombosis by spread through the skull base and foramina (Figure 3). The two classifications based on anatomical location by Ishikawa and Jefferson demonstrated inflammatory lesions more in the anterior type and tumors were occupying mainly the posterior and the whole types. T2 hypointense signal pattern is noted in chronic inflammatory lesions, granulomas and lymphomas while cavernomas and hemangiomas demonstrate hyperintensisty on T2 sequence. T1 hyperintensity is typically observed in dermoids, adenomas, melanomas and hemorrhagic lesions (Figure 4). Extradural transcavernous or intradural surgical approaches are decided depending on the plane of the lesion and its extent of location. Though primary radiation is offered as an option, many lesions require biopsy for specific treatment. We retrospectively reviewed the medical records for clinical, imaging and histological diagnostic findings of lesions involving CS. The tumor site, size, morphology or signal characteristics and post intravenous (I.V) gadodiamide enhancement pattern were assessed. The present case series of twenty seven patients describes the clinical presentation and MRI features correlating with histopathology that helped selection of treatment modality.

 

Figure 1: Diagram of a coronal section through the cavernous sinuses and the sella turcica. Note that the medial wall of the cavernous sinus (CS) is constituted by only a single layer of the dura mater. ACA = anterior cerebral artery, ICA = cavernous segment of the ICA, III = oculomotor nerve, IV = trochlear nerve, MCA = middle cerebral artery, OC = optic chiasm, PIT = pituitary gland, SS = sphenoid sinus, VI = abducens nerve, V1 = ophthalmic nerve, V2 = maxillary nerve, black arrowhead = inner periosteal layer of the dura, white arrowhead = outer meningeal layer of the dura, * = subarachnoid.

 

Figure 2: Diagram of the segments and major branches of the cavernous segment of the ICA. Light blue structure represents the cavernous sinus (CS). The segments of the cavernous carotid artery from proximal to distal are the posterior vertical (PV), the posterior genu (PG), the horizontal (HORZ), the anterior genu (AG), and the anterior vertical (AV). ACP = anterior clinoid process, DDR = distal dural ring, OA = ophthalmic artery, PDR = proximal dural ring, PLL = petrolingual ligament.

 

Figure 3: Anatomic pathways related to the cavernous sinuses and the regional bone anatomy. Blue areas represent the position of the cavernous sinuses in the floor of the middle cranial fossa. Yellow lines outline the anatomic region set in boldface in each label. ACP = anterior clinoid process, OC = optic canal, PCP = posterior clinoid process, PPF = pterygopalatine fossa (outlined in orange on image at far left).

 

Figure 4: Etiologic classification of cavernous sinus lesions. IgG4 = immunoglobulin G4.

 

Materials and methods

This retrospective study of data was approved by the hospital internal review board. Of the total 27 patients presenting with lesions in the cavernous sinus, 26 consecutive patients with CS lesions underwent MRI examination between 2008 and 2019 (age range, 13-63 years; mean age 41.12, SD ± 14.49; 16 males, 11 females with female to male ratio of 0.60). Both 1.5-T and 3-T systems were used for MR imaging. The imaging technique included conventional spin-echo, echo-planar diffusion-weighted imaging (DWI) and FLAIR sequence. DW images in 21 patients and GRE sequence in 24 were available. Axial T1- weighted (T1-W) contrast enhancement with Omniscan (Gadodiamide, GE Healthcare, Oslo, Norway) was supplemented with and without fat suppression pulse in addition to post contrast SPGR sequence.

 

Technical parameters

(a) Spin-echo T1- W imaging: repetition time msec/echo time msec, 2000/20; inversion time 400, flip angle 90°; and matrix 296× 205; (b) Fast spin echo T2-weighted imaging (T2-W): 3000/90; flip angle 90°; and matrix 492 × 479 for; and (c) Fluid-attenuated inversion recovery imaging: 10,000/125; 90°; and matrix, 300 × 205. Other parameters: Slice gap was 1.5-2 mm with a 5-mm section thickness, and FOV 230 × 250 mm. Echo-planar DW MR imaging was performed in the axial plane before contrast enhancement. T1-W 3 D spin-echo sequences without fat suppression and post contrast SPGR sequences were obtained using a matrix of 492 × 479; slice thickness 1mm without slice gap; flip angle, 9°; repetition time/echo time 5/10 msec and FOV 240 x 240. Intravenous dose of gadodiamide was 0.2 mL/kg (0.1 mmol/kg) body weight. T1-W, T2-FSE and FLAIR signal intensities were tabulated as hyper, hypo, iso intensities. Blooming and restriction of diffusion on the GRE and DWI sequences and intensity of contrast enhancement on T1- fat suppressed sequences were evaluated. Two patients underwent digital subtraction angiography. Histopathological diagnosis of lesion in the cavernous sinus was verified from the notes in the medical case files retrospectively.

 

Results

The study includes 27 patients and 59% were males. Visual disturbances were the predominant feature (62%) and about two thirds of the patients had no visual symptoms despite large size of the lesion. Cranial nerve involvement was observed in 55 % of the patients (Tables 1). Extra cavernous sinus involvement of Meckel’s cave, cerebral peduncles and basal cisterns were seen in all except one. Of the 26 patients who received surgery, complete excision in 9 patients was possible and subtotal excision or biopsy in the others. Trace images of DWI demonstrated facilitated diffusion in 11 and restricted (hyperintense in DWI and hypointense in ADC) in 10 patients. Mean ADC value in 17 patients was 0.09176, wherein lesions with restricted diffusion showed 0.7914 and those with facilitated demonstrated 0.776 × 10−3 mm2/s. Apart from meningioma and schwannoma, blooming on GRE sequence was observed in pituitary tumour and an epidermoid cyst. Varying patterns of enhancement of the lesions were noted following intravenous contrast enhancement (Table 2&3). Follow up MRI examination of cavernous hemangiomas after two years demonstrated total regression in one patient and significant reduction with thrombosis of the centre of the lesion in another. Homogeneous hyperintensity on T2-W sequences, lack of diffusion restriction and intense contrast enhancement were the hallmarks of cavernous hemangiomas (CSH) in contrast to the other lesions.

 

Table 1: Patient summary shows clinical spectrum in 27 patients.

 

Patient No.

Age

Sex

Headache

Visual disturbances

Cranial nerve involvement

Surgery

Histopathology

1

57

M

1 month

Blurring

V

Yes

Chordoma

2

34

M

No

Yes

No

Yes

Meningioma

3

17

F

2 months

Blurring

No

Excision

Fungal granuloma

4

23

M

NA

NA

NA

Excision

Dermoid

5

56

F

No

No

No

Partial excision

Pituitary hypophysitis

6

24

M

2 months

No

No

Excision

Meningioma

7

43

M

Yes

Diplopia

III, V, VI

Subtotal

Meningioma

8

40

M

12 months

No

III

Subtotal excision

Schwannoma

9

24

M

1 month

No

No

Near total excision

Schwannoma

10

43

F

NA

NA

NA

ATT

Tuberculosis

11

42

M

11 months

Diminished

V, VII

Subtotal

Schwannoma

12

52

M

1 month

Diminished

II

Subtotal excision

Schwannoma

13

57

F

1 month

Blurring

Tinnitus

Excision

Meningioma

14

34

F

No

Optic Atrophy

No

Excision

Meningioma

15

43

M

No

No

III

Excision

Epidermoid

16

17

M

1 month

No

VI

Subtotal

Cavernous Hemangioma

17

63

M

4 months

Decreased

III, VI

Excision

Meningioma

18

42

F

5 months

Blurring

V

Excision

Schwannoma

19

57

M

Yes

Decreased

No

Subtotal

Pit. Adenoma

20

41

F

NA

Decreased

NA

Excision

Pit. Adenoma

21

43

F

1 week

No

No

Biopsy

Fungal granuloma

22

51

F

12 months

Visual loss

III, IV, VI

Sub total

Hemangioma

23

26

M

2 Years

12 months

VI

Sub total

Hemangioma

24

38

F

Yes

Blurring

No

Biopsy

Hemangioma

25

51

M

4 Years

6 months

VI

Total

Hemangioma

26

13

M

Yes

No

III, VI

Excision

Hemangioma

 

 

 

 

 

 

 

 

27

32

F

Yes

Diplopia

V1,2,VI

Pain 3yrs.

Excision

Fungal granuloma

 Note: III, IV, V, VI -- Cranial nerves; NA – Not available; ATT – Antituberculous treatment.

 

Table 2: MRI features of 27 lesions and mean ADC values are shown.

 

Case No.

 

T1W

 

T2W

 

T2 FLAIR

Post-contrast

enhancement

GRE blooming

Extra cavernous sinus extension

 

Vessel encasement

 

DWI

 

Diagnosis

 

Mean ADC

1

Iso

Iso

Hyper

Homogeneous

No

Yes

No

Restricted

Tuberculosis

0.95

2

Hper

Hypo

Hypo

Rim enhancement

Yes

Yes

No

Restricted

Dermoid

0.068

3

Iso

Iso - Hypo

Iso – Hypo

Homogeneous

Yes

Yes

No

Facilitated

Chordoma

1.13

4

Hypo

Hyper

Hyper

Mild

No

Yes

No

Restricted

Pit. adenoma

0.61

5

Iso

Hypo

Hypo

Homogeneous

No

Yes

No

Restricted

Meningioma

1.64

6

Iso

Hypo

Hypo

Homogeneous

No

Yes

Yes

Facilitated

Aspergilloma

0.84

7

Iso

Iso

Iso

Homogeneous

No

Yes

No

Restricted

Pit. adenoma

1.51

8

Iso

Hyper

Hyper

Intense

Yes

Yes

No

Restricted

Meningioma

1.69

9

Hypo

Hyper

Hyper

Homogeneous

NA

Yes

No

NA

Melanotic Schwannoma

NA

10

Hypo

Hyper

Hyper

Heterogeneous

Yes

Yes

No

Facilitated

Schwannoma

NA

11

Iso

Hyper

Hyper

Homogeneous

Yes

Yes

No

Facilitated

Schwannoma

0.72

12

Hypo

Hyper

Hyper

Homogeneous

No

Yes

No

NA

Schwannoma

NA

13

Hypo

Hyper

Hyper

Heterogeneous

Yes

Yes

Yes

Restricted

Meningioma

1.031

14

Hypo

Iso

Iso

Not Done

No

Yes

Yes

Restricted

Meningioma

0.37

15

Hyper

Hyper

Hyper

Not Done

Yes

Yes

No

Facilitated

Epidermoid

0.656

16

Iso

Iso

Iso

Moderate

NA

Yes

Yes

NA

Meningioma

NA

17

Hypo

Hyper

Hyper

Heterogeneous

Yes

Yes

No

Restricted

Schwannoma

0.485

18

Mixed

Iso

Iso

Heterogeneous

Yes

No

No

Mixed

Pit. adenoma

NA

19

Iso

Iso

Hyper

Minimal

No

Intracavernous

Yes

Facilitated

Hemangioma

0.617

20

Hyper

Mild Hype r

Hyper

Homogeneous

No

Yes

Yes

Restricted

Meningioma

NA

21

Iso

Hyper

Hyper

Heterogeneou

No

Yes

 

Yes

(Arteritis)

Facilitated

 

 

Fungal granuloma