Fibrous dysplasia of the clivus

Fibrous Dysplasia of the Clivus: Case Report and Literature Review

Fibrous dysplasia is a benign, developmental bone disorder that causes fibrous replacement of normal skeletal tissue. This may lead to weakness, distortion, and tissue expansion. Fibrous dysplasia can occur anywhere in the body, including the craniofacial area. The clivus is a central skull bone formed by the bases of the sphenoid and occiput, respectively. The clivus is a rare, usually unrecognized, and seldom reported location for the development of fibrous dysplasia. Although fibrous dysplasia of the clivus (FDC) is usually discovered by incidental findings, it can sometimes present with clinical symptoms. In this case, we discuss a 30-year-old male who presents to the emergency room with headaches, altered mental status, and a prior presentation of location-related symptomatic epilepsy. Magnetic resonance imaging depicted a mass in the clivus, low in signal on T1 and mildly hypointense on T2 imaging. Follow-up computed tomography (CT) imaging, as recommended, revealed the classic presentation of FDC. In this paper, we discuss the significance of this condition and the importance of thorough investigation to rule out differential diagnoses that may present with similar acute symptoms as this patient.

Endoscopic Endonasal Surgery for Uncommon Pathologies of the Sellar and Parasellar Regions

Endoscopic skull base surgery has become an integral part of the present neurosurgical armamentarium. The pioneering efforts in which the purely endoscopic transsphenoidal approach was introduced have triggered a growing tide of using the endoscopic endonasal procedures for a large variety of skull base lesions. Because of their anatomical peculiarities, lesions of the sellar and parasellar regions lend themselves very well to the endoscopic endonasal approaches. Apart from the common pathological entities, many other less frequent pathologies are encountered in the sellar and parasellar area. In this chapter, we review the surgical technique of the endoscopic endonasal transsphenoidal approach and its extensions applied to a variety of rare and uncommon pathological entities involving the sella turcica and clivus. An overview of these pathological entities is also presented and exemplified.

A Rare Case of a Primary Leiomyoma of the Clivus in an Immunocompetent Patient and a Review of the Literature Regarding Clival Lesions

Leiomyomas are common lesions that are usually located in the genitourinary and gastrointestinal tracts. Primary leiomyomas at the skull base are uncommon. They are composed of well-differentiated smooth muscle cells without cellular atypia. The diagnosis of a leiomyoma has to be confirmed by immunohistochemistry. The tumor tissue is immunoreactive for SMA, S100 and cytokeratin. Leiomyomas mainly occur in immunocompromised patients. Most tumor tissues are positive for EBV. The presented case is that of a 56-year-old immunocompetent woman with a tumor on the clivus. The radiological images suggested chordoma or fibrous dysplasia. Transnasal transsphenoidal surgery was performed. The tumor tissue consisted of well-differentiated smooth muscle cells with elongated nuclei. Immunohistochemistry revealed a positive reaction for desmin, SMA and h-Caldesmon and a negative reaction for S100, beta-catenin, PGR and Ki67. The leiomyoma diagnosis was subsequently established. To the best of our knowledge, the case of a primary leiomyoma on the clivus of an immunocompetent patient is the first to be described. We also extensively reviewed the literature on the immunohistopathological and radiological differential diagnosis of clival lesions.

Cranial fibrous dysplasia: An institutional experience and review of the literature

Background:

Cranial or craniofacial fibrous dysplasia (CFD) is a rare entity which most often presents with either incidental finding or with pain/cosmetic disfigurement or visual/hearing problems. Multidisciplinary treatment with close follow-up or medical management/surgery is options. Management of these lesions can often give satisfying results. There is a dearth of neurosurgical literature on this subject matter. Our objective was to review the clinical symptomatology and outcome of CFD patients managed in our institution.

Methods:

This is a retrospective observational study of CFD patients managed in our institution over a period of 5 years. Clinical and radiological data were collected from departmental database. Outcomes were evaluated immediately and on 1–4 years follow-up.

Results:

A total of 21 patients were managed over a period of 5 years with age ranging from 12 to 55 years and symptoms of cosmetic issues or visual disturbance. Preoperative computed tomography scan with 3D reconstruction with bone window was done in all patients. In most of the patients (16/20), immediate reconstruction was done following excision. Five patients were managed conservatively. Follow-up was obtained over a period ranging from 1 to 4 years and all (except one) patients are doing well. Only one patient had permanent visual impairment in spite of early intervention.

Conclusion:

Craniofacial dysplasia has various modalities of management. Careful selection of patients for surgical or conservative management is feasible with good results both in short and long term.

Fibrous dysplasia of the clivus - A case study and literature review

Fibrous dysplasia is a benign, congenital skeletal disorder which leads to the formation of fibro-osseous intramedullary bone lesions. Clival fibrous dysplasia is a rare variant which commonly presents asymptomatically with no findings on examination and is often picked up incidentally on radiological investigation. A 39-year-old female presented with a sudden onset headache of 3 days’ duration alongside diplopia and right lower limb weakness upon examination. Computerized tomography head scan revealed an expansile clivus with a ground-glass appearance, magnetic resonance imaging brain scan revealed a predominantly hypointense signal on T1- and T2-weighted images and subsequent whole-body bone imaging confirmed the diagnosis of monostotic clival fibrous dysplasia. This case highlights the importance of considering monostotic clival fibrous dysplasia as a differential diagnosis in patients presenting with sudden onset symptoms of headache alongside cranial and peripheral nerve involvement, when other more sinister causes have been excluded.

Pediatric Orbital Roof Intradiploic Meningioma Operated by Eyebrow Incision

INTRODUCTION

Primary intradiploic meningiomas account for <1% of all osseous calvarial lesions and are categorized as bone tumors. They are frequently observed in the frontotemporal region of the calvarium, anterior cranial fossa, and orbit. We present a case of intradiploic meningioma of the orbital roof, which is rarely observed in the pediatric age-group; it was surgically treated with a unique minimally invasive approach.

CASE PRESENTATION

A 16-year-old male with chief complaints of headache on the right side for approximately 1 year was presented to our clinic. Cranial MRI revealed an intradiploic mass with homogeneous, hypointense contrast patterns on the T1W and T2W images of the right orbital roof. A skin incision was made through the right eyebrow, and the frontal sinus anterior wall was opened by craniotomy. Gross total resection was achieved by reaching the tumor present in the orbital roof. The mass was characterized as psammomatous meningioma by a pathological examination.

DISCUSSION/CONCLUSION

In cranial oncologic surgery, lesion localization and possible pathological diagnosis are essential for the determination of the correct surgical technique. In particular, in pediatric cases, selecting a method that will reduce the need for transfusion, shorten the surgical time, minimize the chances of facial deformity, and facilitate postoperative care will ensure compliance with the correct and appropriate treatment process.

Magnetic resonance imaging features of craniofacial fibrous dysplasia

Purpose

To assess the value of magnetic resonance imaging (MRI) in detecting craniofacial fibrous dysplasia (CFD) and diagnosing and differentiating it from intraosseous meningioma. Additionally, the MRI appearance of the typical computed tomography (CT) imaging feature, the ground glass phenomenon, was evaluated.

Material and methods

MRI datasets of 32 patients with CFD were analysed retrospectively. Detectability in MRI was assessed by analysis of 10 randomly selected patients with CFD and 10 normal controls by two blinded readers. Changes of affected bone, internal lesion structure, T1 and T2 signal intensity, and contrast enhancement of the lesion in general and ground glass areas in particular were assessed. Ten patients with intraosseous meningioma (one in each) served as differential diagnosis for CFD.

Results

All 10 CFD lesions were reliably detected in MRI. In 32 patients 36 CFD lesions were evaluated. In 66.7% CFD were iso- to hypointense in T1 and hyperintense in T2; this proportion was similar for ground glass areas (65.7%). Ground glass areas were more homogeneously structured than the whole CFD lesion in both T1 (100% vs. 56%, respectively) and T2 (91% vs. 61%, respectively). Contrast enhancement was found in 97% of complete CFD lesions and 93% of ground glass areas. The accuracy for CFD vs. intraosseous meningioma was 100% for 'no soft-tissue component' and 98% for 'bone broadening' in MRI.

Conclusions

Distinct morphological changes of CFD are reliably detected in MRI and allow differentiation from intraosseous meningioma. Areas with ground glass phenomenon in CT show a predominantly homogenous internal structure in MRI with contrast enhancement.

Natural history of cranial fibrous dysplasia revealed during long-term follow-up: Case report and literature review

BACKGROUND

Fibrous dysplasia (FD) is a rare developmental disease characterized by the replacement of bone marrow with proliferating fibro-osseous tissue. There exist three forms of FD-monostotic, polyostotic, and that associated with McCune-Albright syndrome. The disease can present in different locations and with a variety of symptoms. One of the more common locations of FD occurrence is the craniofacial region. Treatment of asymptomatic FD often involves conservative management with serial imaging. Medical management with bisphosphonates is an option, though long-term efficacy data are lacking. Surgical resection is usually reserved for very large or symptomatic lesions.

CASE DESCRIPTION

We discuss the most unusual case of a 52-year-old male found to have a left pterional mass while being worked up for sinus headaches. The patient elected to follow this lesion conservatively, and imaging several years later showed obvious growth which accelerated in the last 4 years during an 18-year observational period. He ultimately underwent successful resection of an extradural and intradural FD.

CONCLUSIONS

The significant growth potential of these lesions was revealed in this patient, in whom conservative management had been adopted. Despite optimal surgical resection and outcome in this case, the importance of surveillance imaging and perhaps earlier intervention cannot be underestimated when managing cranial FD.

[Transpterygoid expanded endonasal approach in fibrous dysplasia of the skull base: case report and technical note]

INTRODUCTION

Expanded endonasal approaches (EEA) are becoming a first-level technique for the treatment of skull base pathologies. In some cases, the endoscopic procedures make it possible to dissect structures manipulated with greater difficulty in the classic approaches. We report a full endoscopic transpterygoid EEA for the treatment of a fibrous dysplasia (FD) of the skull base. In addition, we reviewed the English literature available on FD and transpterygoid EEA, establishing an exact surgical technique and showing our intraoperative experience.

CASE REPORT

A 42-year-old male with right sixth cranial nerve palsy. Cranial MRI and CT showed a central skull base lesion with diagnostic suspicion of FD. Patient underwent a full endoscopic transpterygoid EEA, achieving a wide skull base neurovascular decompression. Neuronavigation and the vidian canal landmark resulted mandatory during intraoperative procedure.

DISCUSSION

The transpterygoid EEA is a safe technique consistently supported in the literature. It may reduce the morbidity associated to the classic transcranial approaches, since it permits maximum resection with minimum craniofacial distortion. The vidian hole and canal are the landmarks used to locate and avoid injury to the lacerum segment of the carotid injury. The surgical treatment indication in FD cases must be established in symptomatic patients.

CONCLUSION

Transpterygoid EEA for treatment of FD of the skull base is a safe and effective procedure, thanks to the guide that the vidian canal provides in finding the lacerum segment of the carotid artery.

Clival fibrous dysplasia: Case series and review of the literature

Slightly more than 30 cases of fibrous dysplasia involving the clivus have been reported in the international literature, primarily in the neurosurgery and radiology literature. In this article we present a series of 4 cases involving patients with clival fibrous dysplasia. In a retrospective chart review, 4 patients presenting to tertiary care centers from January 1, 2006, to January 31, 2008, were identified and their presenting symptoms and radiologic findings reviewed. Based on our literature review, we describe the presenting symptoms of patients with clival fibrous dysplasia and characterize the findings of imaging studies associated with this disorder. All patients in this series had a presenting complaint of headache or cranial nerve deficits, which is consistent with previous reports found in our literature review. Additional presenting symptoms that have been reported include dysphagia and a nontender occipital mass; there was also an incidental asymptomatic finding. Magnetic resonance imaging findings are consistent with those associated with fibrous dysplasia at other sites of the body. We conclude that clival involvement in monostotic fibrous dysplasia may not be as rare as previously perceived.

Solitary lesions of the clivus: what else besides chordomas? An extensive clinical outlook on rare pathologies

BACKGROUND

Solitary non-chordomatous lesions of the clivus are rare pathologies, which represent a diagnostic challenge. This study provides an overview of the clinical, radiological and prognostic characteristics of non-chordomatous clival lesions, highlighting current therapeutic options.

METHODS

Twenty-two non-chordomatous lesions of the clivus were collected. A retrospective analysis of clinical and radiological patterns as well as survival data was conducted.

RESULTS

Clinical presentation was a result of local mass effect. Imaging features, although mainly specific, were not always diagnostic. Extent of surgery was gross total in 45.5 % of cases. Depending on the histology, biological behaviour and presence of seeding, adjuvant treatment was performed, tailoring the treatment strategy to the single patient.

CONCLUSIONS

Solitary non-chordomatous lesions of the clival bone are more prevalent than expected. They should be approached with a correct differential diagnosis, considering specific epidemiological, radiological, and histopathological characteristics, to minimise diagnostic bias and allow the planning of the best treatment strategy.

Surgical approaches to central skull base and postsurgical imaging

The close proximity to or intricate involvement of critical neurovascular structures in the central skull base region or both present unique surgical challenges. Varied surgical approaches may be used to remove tumors in this region, including open craniotomies and minimally invasive transnasal or transfacial endoscopic approaches. The ideal surgical technique is chosen based on multiple factors including the aggressiveness, histopathology, and location of the tumor with respect to regional neurovascular elements. Postsurgical image analysis of the central skull base requires an intimate understanding of preoperative and expected postoperative appearance in relation to the nature of the excision and surgical materials used.

Clinical, radiological, and pathological features of 26 intracranial and intraspinal malignant peripheral nerve sheath tumors

Object

Intracranial and intraspinal malignant peripheral nerve sheath tumors (MPNSTs) are rarely reported because of their extremely low incidence. Knowledge about these tumors is poor. In this study the authors aimed to analyze the incidence and clinical, radiological, and pathological features of intracranial and intraspinal MPNSTs.

Methods

Among 4000 cases of intracranial and intraspinal PNSTs surgically treated between 2004 and 2011 at Beijing Tiantan Hospital, cases of MPNST were chosen for analysis and were retrospectively reviewed. To determine which parameters were associated with longer progression-free survival (PFS) and overall survival (OS), statistical analysis was performed.

Results

Malignant PNSTs accounted for 0.65% of the entire series of intracranial and intraspinal PNSTs. Twenty-four (92.3%) of these 26 MPNSTs were primary. Radiologically, 26.9% (7 of 26) of the MPNSTs were misdiagnosed as nonschwannoma diseases. Twenty-one patients were followed up for 1.5 to 102 months after surgery. Twelve patients experienced tumor recurrence, and median PFS was 15.0 months. The 2- and 3-year PFS rates were 47.7% and 32.7%, respectively. Five patients died of tumor recurrence, and median OS was not available. The 2- and 3-year OS rates were 74.7% and 64.0%, respectively. Univariate analysis revealed that female sex, total tumor removal, and primary MPNSTs were significantly associated with a better prognosis. Multivariate analysis revealed that only total removal was an independent prognostic factor for both PFS and OS.

Conclusions

Malignant PNST within the skull or spinal canal is a rare neoplasm and is seldom caused by benign schwannomas. Radiologically, intracranial or intraspinal MPNST should be differentiated from meningioma, chordoma, fibrous dysplasia of bone, and ear cancer. Total resection whenever possible is necessary for the prolonged survival of patients, especially males.

Fibrous dysplasia of the maxilla: diagnostic reliability of the study image. Literature review

Objective Fibrous dysplasia (FD) is a benign bone disorder in facial bones. This study evaluates the possibility of diagnosing fibrous dysplasia on imaging alone, without biopsy of the lesion, which is often burdensome for the patient. Materials and Methods The authors bring their experience of four cases of bone lesions of the maxillofacial region and present a review of published studies. The imaging techniques evaluated are computed tomography (CT) and magnetic resonance imaging (MRI) with and without contrast. Results The literature review demonstrates that it is impossible to make diagnosis of fibrous dysplasia exclusively by imaging. Radiographic images often show a ground-glass appearance, which is characteristic but not pathognomonic of fibrous dysplasia. Conclusion Although CT and MRI images may in many cases suggest a diagnosis of fibrous dysplasia, histological examination or follow-up imaging should follow.

Fibrous dysplasia of the clivus

Fibrous dysplasia (FD) of craniofacial structures is well documented, however, its involvement of the clivus is seldom described. We report a case of clival FD in a young man who presented with headache localized to the occipital area. The radiological studies revealed a monostotic disease confined to the clivus, with typical findings of hypointensity on magnetic resonance images and ground-glass density on computed tomography. The diagnosis of FD was confirmed on pathological examination of specimens taken through transsphenoidal surgery. The patient showed reduction of symptoms and no change of residual lesion on follow-up imaging taken 2.5 years later after surgery. This study includes clinical aspect, radiographic appearance, differential diagnosis and treatment strategy of this rare skull base lesion.

Lymphangioma of the skull base bones leading to cerebrospinal fluid rhinorrhea

Lymphangioma localized to the bones of the skull base is rare. The authors report herein the case of a 5-year-old boy who presented with lymphangioma of the bone, localized to the skull base and leading to cerebrospinal fluid (CSF) rhinorrhea with meningitis. Neuroimaging demonstrated lytic destruction with a cyst in the right middle skull base. The patient was successfully treated with resection of the tumor and prevention of CSF leakage. Histopathological examination revealed a lymphangioma. An enlarging lymphangioma can lead to bone destruction. A differential diagnosis of a lytic lesion for a cyst at the skull base is important for proper case management.

Craniovertebral junction neoplasms in the pediatric population

INTRODUCTION

The incidence of tumors at the craniovertebral junction in the pediatric population is low. Because of the variable pathology and the rarity of these tumors, ideal therapies are only now being defined.

MATERIALS AND METHODS

Thirty-eight children with tumors affecting the craniocervical junction were encountered between 1991 and 2006. These comprised neoplasms of osseous origin and neural extramedullary tumors.

RESULTS AND DISCUSSION

Chordomas of the clivus and foramen magnum were seen in eight, fibrous dysplasia in four, aneurysmal bone cysts in four, eosinophilic granuloma affecting the atlas and axis vertebra in four, Ewing's sarcoma involving the atlas in two, osteoblastoma in two, neurenteric cysts in four, meningioma in five, schwannoma in two, and plexiform neurofibromas in three. The location of these tumors was predominantly ventral, and a very small number had a lateral or dorsal location. The ventral tumors included chordoma, meningioma, fibrous dysplasia, aneurysmal bone cyst, and osteoblastoma. Plexiform neurofibroma affecting the craniocervical junction was ventral to the clivus and upper cervical spine causing severe kyphosis of the craniocervical region. Pain in the head and neck occurred in 70%. Paresthesias and dysesthesias in the hands were seen in 40% and spastic weakness of extremities in 22%. Cranial nerve palsies were seen in 33%. Twenty-eight percent of children showed dysphagia or dysarthria. The cranial nerves affected were the vagus followed by hypoglossal and glossopharyngeal nerves. This led to dysphagia, slurred speech, repeated aspiration pneumonia, and weight loss. The most common findings for chordomas at the craniocervical junction were isolated hypoglossal nerve palsy. All individuals underwent magnetic resonance imaging, computed tomography, and 3D computed tomography and angiography. Vertebral angiography was used to understand the dynamics of collateral circulation and tumor vascularity. Tumor embolization was performed in chordoma and aneurysmal bone cysts. Our experience and results are presented here.

Surgical treatment of skull fibrous dysplasia

BACKGROUND

Fibrous dysplasia of the skull is difficult to manage when the cranial nerves, skull base, and face are involved. The procedure for the surgical treatment of this lesion needs to be studied clinically because of the low incidence rate and its operative complicacy. Faced with this, combined with our clinical experience, we explore the surgical strategy and operative procedures of the skull fibrous dysplasia.

METHODS

Twelve patients with skull fibrous dysplasia have been studied with neuroimaging and underwent operative removal of the lesion and cranioplasty and/or reestablishment of the skull base.

RESULTS

Excellent operating outcome was obtained in 9 cases and good in 3 based on the evaluation of the lesion removal, cranioplasty, skull base reestablishment, and cranial nerve function recovery.

CONCLUSION

Surgical treatment is suitable for a patient whose lesion damages his or her cranial nerve function and/or appearance. In general, removal of the lesion, cranioplasty, and/or skull base reestablishment can be finished in 1 stage.

Lymphangioma of the clivus: case report

OBJECTIVE

Different clival lesions have been reported in the literature previously. The lymphangioma reported in the present case seems to be the first lesion localized in the clivus.

CLINICAL PRESENTATION

The patient presented with a history of diplopia and headache. Imaging studies showed a lytic lesion at the cranial base.

INTERVENTION

Transsphenoidal excision of the lesion resulted in total resolution of the patient's complaints.

CONCLUSION

Lymphangioma must be kept in mind for the differential diagnosis of lytic lesions of the cranial base. Surgical removal leads to immediate improvement of the symptoms.

Displasia fibrosa do clivus: relato de caso

Relatamos o caso de uma paciente de 43 anos com história de cefaléia crônica e diplopia. O exame neurorradiológico demonstrou aumento de volume e alteração na densidade óssea do clivus. Foi submetida a cirurgia e o exame anatomopatológico evidenciou displasia fibrosa. Foram relatados na literatura outros 14 casos de displasia fibrosa envolvendo o clivus. Discutimos essa rara apresentação da doença segundo o quadro clínico, exames de imagem, histologia e tratamento.

Craniofacial surgery in fibrous dysplasia

Cranio-orbital fibrous dysplasia usually causes proptosis, visual loss, ocular motility impairment and cosmetic deformity. The goals of cranial fibrous dysplasia management are to preserve neurological functions and improve cosmesis. Strict neurological and ophthalmological follow-up and early cranio-facial surgery enables non-aggressive treatment without significant morbidity. Furthermore, good results are achieved thanks to new techniques and materials especially in children and adolescents. The aim of the present paper is to discuss surgical indications, techniques and outcomes of cranio-facial-orbital fibrous dysplasia on the basis of personal experience of 14 patients who underwent surgery.

Fibrous dysplasia of the clivus with a second T8 bone lesion: case report

BACKGROUND

We present a rare case of a probably poliostotic fibrous dysplasia of the clivus in a young woman with a clival and vertebral involvement. We also compare our case with data reported in tables that include all cases of clival fibrous dysplasia present in literature.

CASE DESCRIPTION

Thirty-year-old women presented with headache. We reviewed radiological and clinical literature before surgery. It was possible to perform a preoperative diagnosis of fibrous dysplasia of the clivus so it was possible to adopt a minimally invasive surgical approach on the clivus. The diagnosis of fibrous dysplasia of the clivus was confirmed after the operation. As the patient was asymptomatic, we did not operate on the vertebral lesion which was stable after 1 year.

CONCLUSION

We draw the conclusion that it is possible to obtain a correct preoperative diagnosis of fibrous dysplasia based on magnetic resonance imaging and computed tomographic scans; this makes it possible to avoid major surgical operations. The reported case is particularly interesting because apart from the clival fibrous dysplasia, a vertebral involvement of the same type can be assumed; this association has never been reported in literature.

Fibrous dysplasia of the frontal sinus: an uncommon cause of frontal lobe abscess

Fibrous dysplasia of the cranial air sinuses is rarely reported in the literature. This is the first report of frontal lobe abscess (FLA) associated with fibrous dysplasia of the frontal sinus (FDFS). A 29-year-old female presented with seizures and acute confusion. Cranial computed tomography (CT) revealed fibrous dysplasia of the left frontal sinus and associated FLA. She was referred to the neurosurgical service and the abscess and dysplastic tissue were removed. Histological examination confirmed fibrous dysplasia. We review the radiological appearance of FDFS with FLA. Clinicians should be aware of the association between these two conditions.