Cavernous Sinus Meningioma

This patient is a 46 year old woman from Portugal who was admitted to the Massachusetts General Hospital in September 1986 with ophthalmoplegia of the left eye (OS) and signs of aberrant reinnervation of the third nerve. She presented, in August 1985, with an episode of diplopia. The diplopia was sudden in onset, and on awakening in the morning she had diplopia in all directions of gaze for approximately 15 minutes. When the diplopia resolved in primary gaze, she noted persistent vertical diplopia looking up. By July 1986, she had diplopia in all directions of gaze and drooping of the left eyelid. She consulted an ophthalmologist and was referred to the Neurovisual Clinic at the Massachusetts General Hospital and admitted. Past History: Negative for additional episodes of diplopia, transient ptosis, or strabismus as a child. No headaches, face or eye pain, seizures, syncope or vertigo. Neuro-ophthalmological examination: Visual acuity 20/20, J1OU. Visual fields, color vision and fundoscopic examination normal. Pupils anisocoria. OD 3 mm brisk to light and near OS 4 mm sluggish to light and near Eyelid OS: Subtle signs of aberrant reinnervation of the left third nerve present with changes in the position of the ptotic eyelid on abduction and adduction. Partial ptosis in primary gaze Palpebral fissure OD 9 mm, OS 7 mm Complete ptosis on abduction Elevation of the ptotic lid on adduction No constriction of the pupil OS on adduction No exophthalmos Normal orbital resilience Normal corneal reflex No ocular pulsation or bruit Sense of smell intact Ocular motility OS: The pattern of weakness of the ocular muscles innervated by the third nerve was characteristic of a partial paresis of the trunk of the third nerve with paresis of the: Levator superioris Superior rectus (SR) Inferior oblique (IO) Mild weakness of the medial rectus and inferior rectus Superior oblique (cranial nerve 4) normal Abduction weakness (cranial nerve 6) Absent Bell's OS (elevation of the eye under closed lids) Diagnosis: Compressive lesion of the left third nerve trunk within the cavernous sinus Primary aberrant reinnervation of the third nerve. Primary aberrant reinnervation of the third nerve is a well recognized sign of long standing compression of the nerve from a cavernous sinus meningioma or an aneurysm of the internal carotid artery (ICA). It has also been reported with a compressive lesion of the third nerve due to a basilar artery aneurysm. Brain MRI Pre-contrast axial T1 W1 sequence shows a mass expanding the left cavernous sinus (Figure 1). Post-contrast axial T1 W1 showed the mass enhanced strongly and uniformly. A dural tail extended posteriorly along the tentorium. The left ICA was occluded. (Figure 2) Coronal post-contrast T1 W1 showed the mass expanded the cavernous sinus and completely obliterated Meckel's cave. (Figure 3) MRA study showed: 1.No flow related enhancement in the left intracranial ICA. 2.Cross filling of the left middle cerebral artery via the anterior communicating artery. 3.A retrograde left posterior communicating artery providing inflow from the vertebral basilar system. 2-D time of flight MRA through the neck revealed flow related enhancement in the left ICA which tapered to a pointed stump just above the bulb. This finding was thought to reflect greatly slowed flow or frank occlusion of the cervical ICA related to distal encasement. The right common carotid, bifurcation and cervical ICA were normal. Diagnosis: Left cavernous sinus meningioma Partial third nerve (trunk) palsy involving the pupil Primary aberrant reinnervation of the third nerve Partial cavernous sinus syndrome Partial 6th nerve palsy Neurosurgical Consultation: Conservative management without a biopsy was recommended. Treatment: Patient elected conservative management. In 1990, with the onset of dull retro-orbital pain OS, the patient returned for focal radiation therapy. Brain MRI showed no significant change at that time. Follow-Up: The patient was last seen in 2003 with no significant change in her clinical findings. See also: http://content.lib.utah.edu/cdm/ref/collection/ehsl-shw/id/101