A 72-year-old woman presents with rapidly progressive horizontal and vertical diplopia as well as pain in the right forehead and right nasal region
1.Which of the following are present on these images? (Check all that apply.)
Orbital apex involvement
Mastoid air cell destruction
Sphenoid sinuscortical disruption
The lesioninvolves the lateral wall of the sphenoid sinus extending into the rightorbital apex, as demonstrated by loss of normal fat attenuation in thislocation.
The walls of thebilateral sphenoid sinuses are thickened and sclerotic, as is the intersphenoidalseptum. The sphenoid sinus is opacified.
There is noevidence of a destructive process involving the mastoid air cells on theprovided images.
Focal corticaldisruption of the lateral wall of the right sphenoid sinus is present.
2. Brain MRimages demonstrate which of the following? (Check all that apply)
Sphenoid sinus opacification
Internal carotid artery occlusion
Normal pattern of sphenoid sinus mucosal enhancement
Unilateral cavernous sinus expansion
Thecontrast-enhanced T1-weighted images show diffuse loss of normal aeration ofthe sphenoid sinus with intrinsic T1 hyperintense signal and peripheral mucosalenhancement. There is some associated left sphenoid sinus expansion, consistentwith early mucocele-like changes.
There is noevidence of internal carotid artery occlusion in these images.
At thesuperolateral margins of the bilateral sphenoid sinuses, there is loss ofmucosal enhancement pattern, and nodular soft-tissue thickening is present.
Asymmetricexpansion of the right cavernous sinus with soft-tissue attenuation and outwardconvexity of the lateral wall of the right cavernous sinus are seen.
3.Which of the following symptoms can be explained by a cavernous sinus syndrome? (Check all that apply)
Mandibular deviation with mouth opening
In the cavernoussinus, the abducens nerve runs lateral to the internal carotid artery andmedial to the oculomotor and trochlear nerves, which are contained within thelateral dural border of the cavernous sinus. Lesions affecting these cranialnerves can potentially result in diplopia.
The third division(V3) of the trigeminal nerve supplies the muscles of mastication. This branchof the trigeminal nerve exits inferiorly through the foramen ovale from Meckelcave and does not course through the cavernous sinus.
The oculomotornerve innervates the levator palpebrae superioris muscle and, when affected bya lesion of the cavernous sinus, can result in ptosis.
The ophthalmicnerve (V1), the first division of the trigeminal nerve, runs through thelateral dural border of the cavernous sinus and carries sensory informationfrom the scalp, forehead, upper eyelid, conjunctiva and cornea of the eye, andnose. When affected, this may result in paresthesias of these areas.
The optic nerve isnot located in the cavernous sinus and is not affected in a cavernous sinussyndrome.
This axialcontrast-enhanced CT of the brain in bone window shows cortical disruption ofthe lateral wall of the right sphenoid sinus (arrow) with a permeative patternof bone destruction.
This axialcontrast enhanced CT image depicts asymmetric soft-tissue attenuation withinthe right cavernous sinus and orbital apex (arrows).
This T1 coronalpostcontrast MR image shows hyperintense mucosal enhancement of the sphenoidsinus with disruption of the enhancement pattern superolaterally by a nodularmass (arrow) that is less intense than adjacent mucosal.
This T1 coronalpostcontrast image shows hyperintense mucosal enhancement of the sphenoidsinus. There is diffuse mass-like infiltration into the right cavernous sinuswith sinus expansion and convexity of the lateral wall (arrow).
This nonenhancedT1 MR image in the coronal plane shows asymmetric T1 isointense signal andexpansion of the right cavernous sinus secondary to an intracavernous mass(arrow).
This T2 coronalimage demonstrates that the T2 signal of the right cavernous sinus lesion isisointense to gray matter. The mass encases the cavernous segment of the rightinternal carotid artery without apparent luminal narrowing (arrow).
This T2 axialimage shows hyperintense material occupying the sphenoid sinus and hypointenseirregular lesions along the lateral wall of the sphenoid sinus, extending tothe posterior ethmoid cells (arrowhead). The lesion extends to the orbital apex(arrow). There is expansion of the ipsilateral cavernous sinus related to thelesion.
Bilateral non-Hodgkin lymphoma of the sphenoid sinus with extension into the right cavernous sinus and orbital apex 双侧蝶窦非何杰金氏病淋巴瘤累及右侧海绵窦及眶尖
Lymphoma is an uncommon cause of cavernous sinus syndrome and usually arises from metastatic deposits or direct infiltration.
MR findings of a T2-weighted iso- to-hypointense contrast-enhancing cavernous sinus mass with diffusion restriction, permeative bone remodeling, and dural infiltration are findings in line with lymphoma.
Approximately 50% of patients with malignant lymphoma clinically present with head and neck involvement, with the majority of cases showing nodal disease. Extranodal involvement of the head and neck is present in approximately 10% of cases and most commonly occurs in tonsillar tissue, sinonasal cavities, and the thyroid. Sinonasal lymphoma is found most commonly in the nasal fossa and maxillary sinuses with rare frontal and sphenoid sinus involvement. It may present as nodular or infiltrative enhancing mucosal masses, usually of iso- to-hypointense T2 signal compared to gray matter. Diffusion restriction may be identified. There is often disruption of the expected thin T2-bright mucosal signal and a hyperintense enhancement pattern by MRI. CT often reveals remodeling or erosion of the affected sinus wall.
The cavernous sinus contains vital neurovascular structures that may be affected by vascular, neoplastic, infectious, or infiltrative processes. Patients with cavernous sinus syndrome usually present with paresis of one or more cranial nerves (III, VI), which may be associated with painful ophthalmoplegia. The cavernous sinus rarely represents a site of primary lymphoma involvement, with most cases arising as metastatic deposits from systemic disease or from direct infiltration, as in this case. CT or MR imaging typically reveals a homogenous enhancing cavernous sinus mass, which can mimic a meningioma. Evidence of direct extension from the paranasal sinuses, dural infiltration, or osseous permeation and remodeling may be helpful in differentiating this from other processes.
Among extranodal forms of non-Hodgkin lymphoma, those involving the paranasal sinuses (most notably the sphenoid sinus) carry the poorest prognosis since the lack of specificity with regard to the presenting clinical symptoms leads to delays in diagnosis. Non-Hodgkin lymphomas are frequently treated with, and respond to, a combination of chemotherapy and radiotherapy. A review of several reports suggests that the best treatment outcomes are usually obtained with the CHOP [cyclophosphamide, Adriamycin, vincristine (Oncovin), and prednisone] regimen, given at 3-week intervals.