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Show Journal of Ncuro- Ophthalmologij 15( 1): 45- 47, 1995. © 1995 Raven Press, Ltd., New York Acute Bilateral Ophthalmoplegia Secondary to Metastatic Prostatic Carcinoma Demonstration on Magnetic Resonance Imaging Preeti Agarwal, M. D., Kumudini Sharma, M. S., R. K. Gupta, M. D., N. R. Dutta, M. D., Sunil Kumar, M. D., and Ratni B. Gujral, M. D. We report an unusual case of acute bilateral ophthalmoplegia secondary to bilateral cavernous sinus metastasis from prostatic adenocarcinoma. The lesion was demonstrated with magnetic resonance imaging. Key Words: Prostatic neoplasm- Diagnosis- Prostatic neoplasm- Pathology- Magnetic resonance imaging- Ophthalmoplegia. Metastatic disease of the parasellar and base of the skull region is not an uncommon cause of parasellar syndromes. The usual presentation is a unilateral, rapidly progressive painful ophthalmoplegia ( 1). Magnetic resonance imaging ( MRI) is the modality of choice for the evaluation of the lesions in this region. We report a case of prostatic adenocarcinoma with metastasis involving bilateral cavernous sinuses, sphenoid sinus, and clivus presenting as acute bilateral ophthalmoplegia. MR clearly demonstrated the pathology and provided an antemortem diagnosis. From the Departments of Radiodiagnosis ( P. A., R. K. G., S. K., R. B. G.), Neurosurgery ( Neuro- ophthalmology Division) ( K. S.), and Radiotherapy ( N. R. D.), Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India. Address correspondence and reprint requests to Dr. R. K. Gupta, Department of Radiodiagnosis ( MR Division), Sanjay Gandhi Postgraduate Institute of Medical Sciences, Rae Bareli Road, Lucknow, India 226014. CASE HISTORY A 57- year- old man had undergone bilateral orchiectomy for adenocarcinoma of prostate 1 year prior to his presentation. He remained asymptomatic for 8 months. Subsequently he developed backache with weakness of both lower limbs. 99mTc- labeled methylene diphosphonate whole-body bone scan revealed metastases in vertebral column, ribs, and upper end of left humerus. One week later he complained of double vision and drooping of his left upper eyelid. His symptoms progressed rapidly during the next 4 days leading to complete closure of both the eyes. On examination, his visual acuity was 20/ 20 corrected bilaterally. There was bilateral complete ptosis. Examination of the right eye showed complete ophthalmoplegia and that of the left eye revealed third and fourth nerve palsies with normal lateral rectus function. Pupils of both eyes were semidilated and nonreacting to light and near reflex. Corneal reflexes were intact and his facial sensation was unaffected. Fundi were normal. There was bilateral grade III paraparesis. Rest of the neurologic examination was normal. 45 46 P. AGARYJAL ET AL. Cranial MR imaging was performed on a 2.0 T superconducting system ( Magnetom, Siemens, Germany) operating at 1.5 T. Imaging was performed with a circularly polarized head coil using spin echo technique. Tl- weighted imaging was done with TR/ TE = 600/ 15 and T2- weighted parameters were TR/ TE = 2,000/ 80. Imaging was performed in sagittal and coronal planes with 5.0 mm ( sagittal) and 3.0 mm ( coronal) slice thickness, 0.5 mm ( sagittal) and 0.3 mm ( coronal) interslice gap and 256 x 256 matrix. It revealed a large mass involving the sphenoid sinus, clivus, and both cavernous sinuses causing upward displacement of the pituitary gland. The mass showed mixed intensity on Tl- weighted images and appeared hy-pointense on T2- weighted images. Radiotherapy consisting of 4,000 cGy in 20 frac- / Ncuro- Ophthalnwl, Vol. 15, No. 1, 1995 tions over a period of 4 weeks was given. Towards the completion of radiotherapy, the patient showed improvement in the ocular motor nerve palsy of the right eye, while the left eye remained the same. DISCUSSION Extra- axial intracranial metastasis are not uncommon with the usual primary malignant neoplasm being breast carcinoma, lymphoma, prostate carcinoma, and neuroblastoma ( 2). Metastasis to the cavernous sinus region usually manifests as a parasellar syndrome which consists of ocular motor nerves palsies involving third, fourth, and sixth cranial nerves as well as first and second divisions of the trigeminal nerve ( 1). This results in a unilat- FIG. 1. Metastasis to the sphenoid and both cavernous sinuses from prostatic adenocarcinoma. ( A) T l - weighted coronal image ( 600/ 15) through the cavernous sinus shows the mixed intensity lesions in both cavernous sinuses and sphenoid sinus ( arrows). Note the patent internal carotid arteries on both sides. ( B) T1- weighted sagittal image shows the mass extending into the clivus { arrow). ( C) This mass appears hypoin-tense on T2- weighted image. MRI IN OPHTHALMOPLEGIA 47 eral ophthalmoplegia which is a frequent clinical presentation in such cases. However, bilateral involvement associated with metastatic disease is a rare phenomenon. The common causes of acute bilateral ophthalmoplegia include myasthenia gravis, dysthyroid ophthalmopathy, pituitary apoplexy, vertebrobasilar insufficiency, botulinism, Fisher syndrome, and diabetic neuropathy ( 1). We have come across only two reports of metastasis causing acute bilateral ophthalmoplegia. A 59- year- old man with total bilateral ophthalmoplegia was found to have metastatic lung carcinoma to cavernous sinuses on autopsy ( 3). Another patient d e v e l o p e d acute bilateral o p h t h a l m o p l e g i a 2 weeks after right hemicolectomy for adenocarcinoma of colon. Final diagnosis on endoscopic sphenoidal biopsy revealed poorly differentiated adenocarcinoma ( 1). In our case also the patient was already suffering from adenocarcinoma of the prostate. One year later, he developed acute onset ocular motor nerve palsies bilaterally. MRI helped in prompt localization of the lesion and institution of radiotherapy giving palliation to the patient. Multiplanar MRI is more sensitive than computed tomography ( CT) for visualizing small lesions in this region, is better able to distinguish vascular from neoplastic lesions and has the potential to delineate intradural extension of the lesion. The relationship of the tumor to carotid artery and other major blood vessels can be best delineated by MRI ( 4). Relaxation characteristics and most morphologic features are nonspecific. Tumor invasion of basisphenoid and basiocciput with replacement of fatty bone marrow by neoplastic tissue causes a lowering of signal intensity on Tl-weighted images. The usual signal on T2- weighted images is hyperintense. However, a low- signal intensity on T2- weighted images, as in our case, is occasionally encountered in markedly sclerotic metastasis ( 5). The other condition which can cause a hypoin-tense signal on T2- weighted images is fungal infection. However, extensive bone involvement, as seen in our case, is unusual in fungal lesions ( 6). Our case highlights an unusual clinical and radiological presentation of extra- axial intracranial prostatic metastasis. The prompt recognition of this rare occurrence by maintaining a high index of suspicion can enable the patient to receive treatment that may improve quality of his life. REFERENCES 1. Supler ML, Friedman WA. Acute bilateral ophthalmoplegia secondary to cavernous sinus metastasis: a case report. Neurosurgery 1992; 31: 783- 6. 2. Atlas SW. Adult supratentorial tumors. Sem'm Roentgenol 1990; 25: 130- 54. 3. Mills RP, Insalaco SJ, Joseph A. Bilateral cavernous sinus metastasis and ophthalmoplegia. / Neurosurg 1981; 55: 463- 6. 4. Hirsch W Jr, Hryshko FG, Sekhar LN, Brunberg J. Comparison of MR imaging, CT and angiography in the evaluation of the enlarged cavernous sinus. AJR 1988; 151: 1015- 23. 5. Atlas SW Jr. Magnetic resonance imaging of the brain and spine. New York: Raven Press; 1991: 945. 6. Breen DJ, Clifton AG, Wilkins P, et al. Invasive aspergillo-ma of the skull base. Neuroradiology 1993; 35: 216- 17. EDITORIAL COMMENT The paper by Dr. Agarwal and colleagues presents a very interesting and unusual presentation in a 57- year-old man with known prostate cancer for 1 year, who suddenly developed a bilateral total ophthalmoplegia. A magnetic resonance scan revealed a large mass lesion involving the clivus and both cavernous sinuses. The patient was treated with 4,000 cGy of radiotherapy over the next 4 weeks. Toward the end of that therapy, some improvement of ocular motility occurred in the right eye, but with no response on the left. It was stated that the patient had been treated with bilateral orchiectomy 1 year prior to onset of his ocular problem. However, the paper does not state whether or not the patient was treated with TACE ( chlorotrianisine) at the time of onset of his ophthalmoplegia. We have seen such dramatic responses to orbital metastases of prostate carcinoma to TACE that it was thought reasonable to add this brief editorial comment to this paper. If the patient is still alive and having problems, I would suggest that the authors administer TACE 25 mg per day by mouth for a short period and see how he responds. This therapy is also recommended to the reader who might be encountering a patient with metastatic prostate carcinoma, particularly involving the orbit and/ or cranium. J. Lawton Smith, M. D. / Neuro- Ophthalmol, Vol. 15, No. 1, 1995 |
