Clivus pathologies from diagnosis to surgical multidisciplinary treatment. Review of the literature

Isolated Abducens Nerve Palsy as the Sentinel Sign of Clival Metastasis in High-Grade Neuroendocrine Carcinoma: A Case Report

We report a rare case of clival metastasis from a high-grade neuroendocrine carcinoma (NEC) of unknown primary origin. A 71-year-old man, previously cured of prostate adenocarcinoma, presented with abdominal pain leading to the diagnosis of metastatic NEC (Ki67 >90%) involving the liver and bones. After three lines of chemotherapy and immunotherapy, he developed sudden diplopia and right abducens nerve palsy. A brain contrast-enhanced MRI revealed a clival mass compressing the sixth cranial nerve, which was undetectable on prior imaging. The patient received palliative radiotherapy and corticosteroids without a significant clinical response. While neuroendocrine neoplasms (NENs) frequently metastasize to visceral organs, clival involvement is exceptionally rare, particularly as a delayed complication. To our knowledge, this is the first reported case of NEC with clival metastasis, emphasizing the tumor's aggressiveness. This case underscores the critical role of advanced neuroimaging in detecting atypical presentations in patients with new neurological deficits, even under systemic therapy, and highlights the challenges of managing skull base metastases in aggressive malignancies. Radiotherapy may stabilize symptoms, but functional recovery remains limited in cases of prolonged nerve compression.

Fungal skull base lesion masquerading as malignancy: a diagnostic dilemma. Illustrative case report

Introduction

The clivus is an uncommon site for fungal infections and is typically associated with tumors or metastases. Invasive fungal sinusitis extending to the skull base is exceptionally rare and often mimics clival malignancies such as chordomas or metastases. This overlap in clinical and radiological features can lead to diagnostic delays.

Case presentation

The authors present a case of a 36-year-old immunocompetent male who presented with symptoms and imaging findings suggestive of a malignant skull base tumor, particularly clival chordoma. However, histopathological analysis revealed invasive fungal sinusitis with clival involvement.

Discussion

In skull base lesions, particularly those involving the clivus, fungal infections should remain a differential diagnosis, even in patients without immunocompromising conditions. Early diagnosis using biopsy and microbiological analysis is essential for appropriate surgical management and antifungal therapy.

Conclusion

This case highlights the importance of considering the fungal etiology in clival lesions, especially in high-risk patients. Prompt diagnosis and a multidisciplinary approach can significantly improve the outcomes in rare and complex presentations.

Craniovertebral Junction Tuberculosis, a Rare Presentation With Hypoglossal and Facial Nerve Palsy: A Case Report

CASE

A 47-year-old man presented with neck pain, restricted neck movements, along with involvement of facial and hypoglossal nerve. On the basis of clinico-radiological correlation, the patient was diagnosed with craniovertebral junction tuberculosis and was started on antitubercular therapy (ATT). Failing the conservative trial, the patient was operated and occipitocervical fusion was done with bone grafting. After 12 months of ATT intake, he showed complete recovery of the facial and hypoglossal nerve, with complete resolution of instability pain.

CONCLUSION

Craniovertebral junction tuberculosis is uncommon, and its manifestation with cranial nerves involvement is even more rare. Meticulous clinico-radiological assessment should be done to diagnose and plan the treatment. Early recognition and prompt initiation of ATT, along with timely surgical intervention, when necessary, are crucial for optimal management and outcomes.

Case report: Unilateral paralysis of the hypoglossal nerve as the only clinical sign of clivus meningioma - a case report and literature review

Introduction

Clivus meningiomas are benign tumors that occur at the skull base in the posterior cranial fossa. Symptoms usually progress several months or years before diagnosis and may include: headache, vertigo, hearing impairment, ataxia with gait disturbances, sensory problems. In the neurological findings, paralysis of the lower cranial nerves is most often seen, which in the later course can be accompanied by cerebellar and pyramidal signs until the development of a consciousness impairment.

Case presentation

We presented the case of a patient who at the time of diagnosis had only unilateral hypoglossal nerve paralysis with dysarthria and mild dysphagia. After the neurosurgical procedure, pathohistological analysis confirmed meningothelial meningioma.

Conclusion

Early recognition of clivus tumors, which include meningiomas, is necessary in order to implement an adequate therapeutic procedure and prevent further deterioration of the patient's condition.

Decision-Making in Clival Mass Lesions: Risk Factors for Malignant Disease and an Illustrative Case Example

Introduction  Clival tumors are rare and heterogeneous. Although some benign prototypical sellar lesions may present as clival tumors, the likelihood of malignant disease is higher. Here we define a novel algorithm for the workup and management of clival masses through an illustrative case of colorectal adenocarcinoma metastasis to the clivus. Methods  In this case report, the best practice guidelines for managing clival masses are described through a literature review and refined by senior author consensus. We conducted a focused systematic review to characterize the present case in the context of clival metastasis from gastrointestinal malignancy. Results  An 83-year-old woman presented with 4 weeks of headaches and blurry vision. Examination revealed partial right abducens and left oculomotor palsies. Magnetic resonance imaging (MRI) identified a large, weakly enhancing sellar and clival mass with sphenoid sinus extension. An aggressive subtotal endoscopic endonasal resection was performed with removal of all sphenoid, clival, and sellar disease without cavernous sinus wall resection. Pathology confirmed colorectal adenocarcinoma; computed tomography (CT) imaging identified an ascending colon mass with metastases to the liver and mesenteric nodes. Palliative oncologic therapies were recommended, but she elected hospice, and died 3 months after initial presentation. Gastrointestinal clival metastases are exceedingly rare among sellar and clival pathologies, with eight prior cases reported, most of which presented with diplopia from abducens nerve involvement. Conclusion  Clival masses are uncommon skull base lesions that are associated with more aggressive diseases. We present a consolidated framework for decision-making in these challenging patients, alongside an unusual case example that illustrates the importance of increased suspicion for malignant clinical entities in this setting.

Evaluation of endocrinological sequelae following particle therapy performed on anterior skull base lesions in the adult population

Background

Radiotherapy has increasingly assumed a central role in the multidisciplinary treatment of skull base lesions. Unfortunately, it is often burdened by relevant radio-induced damage to the pituitary function and the surrounding structures and systems. Patients who were treated with radiotherapy around the sellar region especially have a high risk of developing radio-induced hypopituitarism. Particle therapy has the potential advantage of delivering a higher radiation dose to the target while potentially sparing the sellar region and pituitary function. The aim of this study is to evaluate the pituitary function in adult patients who have undergone hadron therapy for anterior skull base lesions involving or surrounding the pituitary gland.

Methods

This is a retrospective, observational, and noncontrolled study. We evaluated pituitary and peripheral hormone levels in all patients referring to National Center for Oncological Hadrontherapy, Pavia, Italy for anterior skull base tumors. Furthermore, we performed a magnetic resonance imaging for every follow-up to evaluate potential tumoral growth.

Results

We evaluated 32 patients with different tumoral lesions with a mean follow-up of 27.9 months. The mean hadron therapy (HT) dose was 60 ± 14 Gray, with a mean dose per fraction of 2.3 ± 2.1 Gray. Six patients were treated with carbon ions and 26 with protons. Pituitary hormone alteration of some kind was reported for six patients. No patient experienced unexpected severe adverse events related to particle therapy.

Conclusion

Particle radiotherapy performed on anterior skull base lesions has proved to cause limited damage to pituitary function in the adult population.

Pearls & Oy-sters: Sequential Bilateral Hearing and Vision Loss With Optic Disc Swelling Due to Sphenoid Bone Craniofacial Fibrous Dysplasia

Bilateral optic disc swelling is a common finding but rarely associated with multiple cranial neuropathies. In this case, an 18-year-old man presented with subacute sequential hearing loss followed by subacute sequential visual loss. Clinical examination revealed bilateral optic disc swelling. Lumbar puncture revealed a normal opening pressure of 15 cmH₂o. This case discusses a rare but important cause of bilateral optic disc swelling in the context of hearing loss, disequilibrium, and a normal CSF opening pressure. An overview of the literature is provided, and treatment options are discussed to guide further management of similar cases.

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.