Bilateral Cavernous Sinus Lesions



Bilateral Cavernous Sinus Lesions


Anne G. Osborn, MD, FACR



DIFFERENTIAL DIAGNOSIS


Common



  • Pituitary Macroadenoma


  • Meningioma


  • Metastasis, Skull Base


  • Lymphoma, Metastatic, Intracranial


Less Common



  • Neurofibromatosis Type 2


  • Carotid-Cavernous Fistula


  • Thrombosis, Cavernous Sinus


  • Chordoma, Clivus


  • Plasmacytoma


  • Neurosarcoid


  • Langerhans Histiocytosis, Skull Base


Rare but Important



  • Pseudotumor, Intracranial


  • Leukemia


  • Extramedullary Hematopoiesis


  • Germ Cell Neoplasms


  • Erdheim-Chester Disease


  • Benign Nonmeningothelial Tumors


ESSENTIAL INFORMATION


Key Differential Diagnosis Issues



  • Is lesion intrinsic to cavernous sinus (CS)?


  • Does it arise from skull base or extracranial tissues?


  • Is it destructive?


Helpful Clues for Common Diagnoses



  • Pituitary Macroadenoma



    • Pituitary gland indistinguishable from mass (gland IS the mass)



      • Enlarged, “figure-of-eight” mass


      • Extends laterally through thin medial dural wall into CS


      • May surround, encase ICAs but rarely occludes


      • Mass typically isointense with brain, enhances strongly/uniformly


    • Dynamic MR shows mass enhances more slowly than CS


    • If symptoms of pituitary apoplexy, hemorrhage common



      • Sphenoid sinusitis often present


  • Meningioma



    • Uni- > bilateral


    • Thick, uniformly enhancing dura along lateral walls



      • Variable extension into CS proper


    • Look for “dural tail” (thickening along tentorium, middle fossa)


    • Look for obliteration of CSF in Meckel caves


    • May extend inferiorly along clivus


  • Metastasis, Skull Base



    • Permeative, destructive mass



      • Hematogenous spread from extracranial primary common (e.g., breast)


      • Most commonly centered in central skull base (BOS), secondary extension into CS


      • May also be direct geographic extension from nasopharyngeal carcinoma


    • CS involvement can be uni-, bilateral; symmetric or asymmetric


    • Sagittal T1, coronal T1 C+ FS scans useful


  • Lymphoma, Metastatic, Intracranial



    • Primary central BOS lymphoma rare


    • Uni- > bilateral


    • Isointense, avidly enhancing


    • Associated cranial nerve, meningeal (dural) lesions common


    • Tumor often surrounds, encases but does not occlude cavernous ICAs


Helpful Clues for Less Common Diagnoses



  • Neurofibromatosis Type 2



    • Multiple schwannomas, meningiomas



      • Most common CS schwannoma = trigeminal (Meckel cave)


      • Look for meningiomas of CS, optic nerve sheath, tentorium


    • Look for bilateral vestibular schwannomas (VS, diagnostic of NF2), evidence for prior CPA/temporal bone surgery



      • One VS + other schwannoma, meningioma highly suggestive


  • Carotid-Cavernous Fistula



    • Uni- > bilateral carotid-cavernous fistulas


    • Look for CS “flow voids” in addition to ICAs


    • Look for ↑ superior ophthalmic vein(s) (SOV)



      • CTA helpful screening study


      • DSA to delineate fistula site(s)


  • Thrombosis, Cavernous Sinus



    • Can be spontaneous, sterile, or septic (thrombophlebitis)



      • Look for infection in paranasal sinuses, orbits



    • Nonenhancing areas within intensely enhancing CS



      • Lateral dural wall, CS septations enhance, thrombus does not


      • Look for ↑ SOVs


  • Chordoma, Clivus



    • Destructive T2 hyperintense mass centered in clivus


    • Large lesions may invade CS



      • Displace but rarely occlude ICAs


    • Chondrosarcoma may mimic



      • Usually unilateral, arises from petro-occipital fissure


  • Plasmacytoma



    • Solitary destructive mass of central BOS



      • Centered in sphenoid sinus, clivus


      • Isointense, strongly enhancing mass


      • Bi- > unilateral


  • Neurosarcoid



    • CS rare site


    • Look for other lesions



      • Pituitary, infundibular stalk lesion


      • Cranial nerve involvement


      • Dural-based masses


    • Infiltrating CS mass(es)



      • Lesions enhance strongly, uniformly


      • Bone destruction rare


  • Langerhans Histiocytosis, Skull Base



    • Osteolysis with sharply defined scalloped margins ± soft tissue mass


    • Varies from small punched out lesion to widespread diffuse bony involvement



      • May destroy almost entire BOS


    • Homogeneous enhancement


Helpful Clues for Rare Diagnoses

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Aug 7, 2016 | Posted by in NEUROLOGY | Comments Off on Bilateral Cavernous Sinus Lesions

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