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

Pseudotumor, Intracranial
- 90% of intracranial pseudotumors occur without orbital disease
- Tolosa-Hunt syndrome (painful ophthalmoplegia) when CS involved
  - Uni- > bilateral
  - Look for associated meningeal thickening (can be extensive)
  - Bone invasion, destruction may occur
Leukemia
- Paranasal sinus/orbit involvement typical
- Bilateral CS involvement rare
Extramedullary Hematopoiesis
- CS involvement rare
- Look for associated dural-based masses (calvarium, spine)
Germ Cell Neoplasms
- Rare; typically involve pituitary gland/stalk
Erdheim-Chester Disease
- Rare non-Langerhans cell histiocytosis
- Disseminated xanthogranulomatous infiltrative disease of unknown origin
  
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