Wk 8, Case 3 - Review

Patient History
31-year-old female with a history of a clival mass undergoing preoperative evaluation

Findings
MRI brain and orbits:

Evidence of a mildly heterogenous, markedly T2 hyperintense lesion arising from the midline and right paramedian aspect of the dorsum sellae demonstrating mild heterogenous enhancement. This lesion is mildly hyperintense on the FLAIR images and demonstrates restriction of diffusion, bulging posteriorly into the prepontine cistern, posteriorly displacing the basilar artery and indenting the ventral aspect of the pons. Anteriorly, there is destruction of the posterior wall of the sphenoid sinus with enhancing tumor that projects into the sinus lumen. There is involvement of the right posterior and superior portion of the cavernous sinus by this mass with no obvious involvement of the petroclival fissure. There is extension of enhancing tissue into the superior portion of the right Meckel's cave however. The cavernous sinus portion of the lesion appears to enter laterally displacing the 3rd cranial nerve. There is extension of enhancing tissue into the right side of the sella with left anterolateral displacement of the pituitary parenchyma and deviation of the pituitary stalk to the left. A small T2 hyperintense hypoenhancing lesion is present in the anterior portion of the sella in the midline of uncertain etiology. There is mild elevation of the optic chiasm and impression upon the medial aspect of the right temporal lobe. The mass measures approximately 2.8 cm in the craniocaudal dimension, 2 cm in the AP dimension, and approximately 2.9 cm in the transverse dimension.

The brainstem shows no convincing focal abnormality or signal change. Cerebellum and fourth ventricle are within normal limits. Supratentorial brain shows asymmetric size of the lateral ventricles, with minimal deviation of the septum pellucidum to the left. Otherwise, ventricular system is normal with normal appearance of the third ventricle and the temporal horns. No focal signal abnormalities are present within the supratentorial brain. There is no evidence of restricted diffusion in the brain. No evidence of abnormal susceptibility identified on the gradient echo images.

Orbital structures are within normal limits. No abnormality of the orbital segments of the optic nerves. Paranasal sinuses and mastoids are clear.

Impressions
1. Expansile, focally destructive mass arising from the superior portion of the clivus, with a mild erosive change along the superior aspect of the petrous apex with focal bone destruction and extension of tumor into the sphenoid sinus lumen. This T2 hyperintense mildly enhancing lesion demonstrates restricted diffusion and morphology and location are most concerning for a chordoma. There is extension of the tumor into the posterior superior portion of the right cavernous sinus and extension of the tumor into the suprasellar cistern and into the right posterolateral sella.