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Hassanzadeh S, Gao L, Alvarado AM, Camarata PJ, Lakis NS, Haeri M. Extra-Axial Cavernous Angioma: A Case Report and Review of the Literature. Neurol Int 2024; 16:162-185. [PMID: 38251058 PMCID: PMC10801606 DOI: 10.3390/neurolint16010010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 12/18/2023] [Accepted: 12/25/2023] [Indexed: 01/23/2024] Open
Abstract
Cavernous angiomas (CAs) are benign vascular malformations predominantly seen in the brain parenchyma and therefore referred to as intra-axial. Extra-axial dural-based cavernous angiomas, on the other hand, are rare vascular lesions found outside of the brain parenchyma. They occur in the middle fossa and may be easily misdiagnosed as meningiomas due to their extra-axial location. In addition, CAs that are located outside the middle fossa, such as in the convexity, have a better prognosis since they are more surgically accessible. Surgical resection is the main treatment of choice in CAs. However, other options, such as embolization and radiotherapy, may also be considered therapeutic choices or additive treatment options. The pathogenesis of CA and the involvement of other factors (genetics or environmental factors) are still unknown and require further investigation. We are presenting a young man who presented for evaluation of seizure-like events without any family history of neurologic conditions. The physical examination was unremarkable except for a slightly antalgic gait. Imaging studies showed an extra-axial left tentorial mass suggestive of a meningioma, hemangiopericytoma, or other extra-axial lesions. The lesion was resected where its vascular nature was mentioned initially, and the histology proved the diagnosis of cavernous angioma. Here we give an overview of the known pathogenesis, causes, clinical features, and diagnostic and therapeutic options in CA. Better knowledge about CA, its causes, clinical features, and treatment options would help clinicians in early diagnosis and patient management.
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Affiliation(s)
- Shakiba Hassanzadeh
- Department of Pathology and Laboratory Medicine, East Carolina University, Greenville, NC 27834, USA
| | - Linlin Gao
- Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Anthony M. Alvarado
- Department of Neurosurgery, University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Paul J. Camarata
- Department of Neurosurgery, University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Nelli S. Lakis
- Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Mohammad Haeri
- Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, KS 66160, USA
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Bove I, Franca RA, Ugga L, Solari D, Elefante A, De Caro MLDB, Cavallo LM. The "chameleon" sellar lesions: a case report of unexpected sellar lesions. Front Neurol 2023; 14:1149858. [PMID: 37168664 PMCID: PMC10164933 DOI: 10.3389/fneur.2023.1149858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 03/27/2023] [Indexed: 05/13/2023] Open
Abstract
Introduction The sellar region and its boundaries represent a challenging area, harboring a variety of tissues of different linings. Therefore, a variety of diseases can arise or involve in this area (i.e., neoplastic or not). A total of three challenging cases of "chameleon" sellar lesions treated via EEA were described, and the lesions mimicked radiological features of common sellar masses such as craniopharyngiomas and/or pituitary adenomas, and we also report a literature review of similar cases. Methods A retrospective analysis of three primary cases was conducted at the Università degli Studi di Napoli Federico II, Naples, Italy. Clinical information, radiological examinations, and pathology reports were illustrated. Results A total of three cases of so-called "chameleon" sellar lesions comprising two men and one woman were reported. Based on the intraoperative finding and pathological examination, we noticed that case 1 had suprasellar glioblastoma, case 2 had a primary neuroendocrine tumor, and case 3 had cavernous malformation. Conclusion Neurosurgeons should consider "unexpected" lesions of the sellar/suprasellar region in the preoperative differential diagnosis. A multidisciplinary approach with the collaboration of neurosurgeons, neuroradiologists, and pathologists plays a fundamental role. The recognition of unusual sellar lesions can help surgeons with better preoperative planning; so an endoscopic endonasal approach may represent a valid surgical technique to obtain decompression of the optic apparatus and vascular structures and finally a pathological diagnosis.
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Affiliation(s)
- Ilaria Bove
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli “Federico II”, Naples, Italy
- *Correspondence: Ilaria Bove
| | - Raduan Ahmed Franca
- Department of Advanced Biomedical Sciences, Pathology Section, University of Naples “Federico II”, Naples, Italy
| | - Lorenzo Ugga
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, Naples, Italy
| | - Domenico Solari
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli “Federico II”, Naples, Italy
| | - Andrea Elefante
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, Naples, Italy
| | | | - Luigi Maria Cavallo
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli “Federico II”, Naples, Italy
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Akammar A, Sekkat G, Kolani S, El Bouardi N, Haloua M, Boubbou M, Maâroufi M, Alaoui Lamrani MY, Alami B. Unusual cause of binocular diplopia: Cavernous sinus hemangioma. Radiol Case Rep 2021; 16:2605-2608. [PMID: 34285729 PMCID: PMC8278149 DOI: 10.1016/j.radcr.2021.06.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 06/16/2021] [Accepted: 06/16/2021] [Indexed: 11/22/2022] Open
Abstract
Cavernous hemangiomas are rare account representing 5%-13% of the intracranial vascular malformations and occur in approximately 0.5%-1% of the population. We report the case of 34-years-old woman, having a medical history of seizure, admitted for headache with binocular diplopia. The radiology investigation and operatory piece has shown an association of cavernous sinus hemangioma and frontal focal cortical dysplasia. This study highlights clinical, radiological and therapeutic features of this entity.
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Affiliation(s)
- Amal Akammar
- Radiology department of Hassan II university hospital of Fez, Sidi Mohammed Ben Abdallah University, Fez Morroco
| | - Ghita Sekkat
- Radiology department of Hassan II university hospital of Fez, Sidi Mohammed Ben Abdallah University, Fez Morroco
| | - Sylvie Kolani
- Radiology department of Hassan II university hospital of Fez, Sidi Mohammed Ben Abdallah University, Fez Morroco
| | - Nizar El Bouardi
- Radiology department of Hassan II university hospital of Fez, Sidi Mohammed Ben Abdallah University, Fez Morroco
| | - Meriem Haloua
- Radiology department of Hassan II university hospital of Fez, Sidi Mohammed Ben Abdallah University, Fez Morroco
| | - Meriem Boubbou
- Radiology department of Hassan II university hospital of Fez, Sidi Mohammed Ben Abdallah University, Fez Morroco
- Clinical Neurosciences Labortory, Sidi Mohammed Ben Abdellah University, Fez, Morroco
| | - Mustapha Maâroufi
- Radiology department of Hassan II university hospital of Fez, Sidi Mohammed Ben Abdallah University, Fez Morroco
- Clinical Neurosciences Labortory, Sidi Mohammed Ben Abdellah University, Fez, Morroco
| | - Moulay Youssef Alaoui Lamrani
- Radiology department of Hassan II university hospital of Fez, Sidi Mohammed Ben Abdallah University, Fez Morroco
- Clinical Neurosciences Labortory, Sidi Mohammed Ben Abdellah University, Fez, Morroco
| | - Badreeddine Alami
- Radiology department of Hassan II university hospital of Fez, Sidi Mohammed Ben Abdallah University, Fez Morroco
- Clinical Neurosciences Labortory, Sidi Mohammed Ben Abdellah University, Fez, Morroco
- Department of Biophysics and Clinical MRI Methods, Sidi Mohammed Ben Abdellah University , Fez, Morroco
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4
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Al-Saiari S, Al-Orabi K, Farag A, Brinji Z, Azzouz A, Mohammed T, Mushtaq D, Hamouda W. Intrasellar cavernous hemangiomas: A case report with a comprehensive review of the literature. Surg Neurol Int 2021; 12:58. [PMID: 33654561 PMCID: PMC7911136 DOI: 10.25259/sni_622_2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 01/26/2021] [Indexed: 12/03/2022] Open
Abstract
Background: Extra-axial cerebral cavernous hemangiomas particularly those found in the sellar region, are extremely rare. Their clinical manifestations and imaging characteristics can mimic those of a pituitary adenoma thus making preoperative diagnosis difficult. Few cases are reported in the literature. We present a case, along with a comprehensive review of the literature regarding specific aspects of diagnosis and management of all similarly reported rare cases. Case Description: We present the clinical, radiological, and operative data of a rare case of a large intrasellar cavernous hemangioma in a 49-year-old female patient presented with headache and diminution of vision, which was diagnosed intraoperatively during an endonasal endoscopic transsphenoidal approach. Subtotal debulking was performed with immediate postoperative clinical improvement. The patient was then referred for radiotherapy and maintained her clinical improvement since then. Conclusion: Neurosurgeons should consider this rare pathology in the preoperative differential diagnosis of sellar tumors. Bright hyperintense T2 signal with or without signal voids associated with centripetal delayed contrast enhancement in magnetic resonance imaging images might raise the suspicion which can be further confirmed intraoperatively with frozen sections. Due the reported high vascularity and intraoperative profuse bleeding leading to high operative morbidities, piecemeal subtotal resection followed by radiosurgery may be considered today as the safest and most effective strategy.
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Affiliation(s)
- Sultan Al-Saiari
- Department of Neurosurgery, King Abdullah Medical City, Mecca, Western Province, Saudi Arabia
| | - Khalid Al-Orabi
- Department of Neurosurgery, King Abdullah Medical City, Mecca, Western Province, Saudi Arabia
| | - Ahmed Farag
- Department of Neurosurgery, King Abdullah Medical City, Mecca, Western Province, Saudi Arabia
| | - Zaina Brinji
- Department of Radiology, King Abdullah Medical City, Mecca, Western Province, Saudi Arabia
| | - Azza Azzouz
- Department of Radiology, King Abdullah Medical City, Mecca, Western Province, Saudi Arabia
| | - Tahira Mohammed
- Department of Pathology, King Abdullah Medical City, Mecca, Western Province, Saudi Arabia
| | - Deepa Mushtaq
- Department of Pathology, King Abdullah Medical City, Mecca, Western Province, Saudi Arabia
| | - Waeel Hamouda
- Department of Neurosurgery, Cairo University School of Medicine and Teaching Hospitals, Manial, Cairo, Egypt
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Abstract
RATIONALE Intrasellar cavernous hemangiomas (ICHs) are rare vascular lesions that arise in the sellar region. ICHs are usually misdiagnosed and treated as pituitary adenomas. Therefore, a preoperative diagnosis is particularly important, especially when the goal is complete resection. PATIENT CONCERNS A 55-year-old woman presented with a 1-month history of intermittent dizziness. Magnetic resonance imaging (MRI) revealed a well-demarcated abnormal ellipsoid signal in the sellar region (size: 2.7 cm × 1.7 cm), with a mulberry-like enhancement after gadolinium injection. Computed tomography revealed an intrasellar mass without calcification that extended into the left cavernous sinus and was faintly contrast-enhanced. Angiography revealed a tumor with mildly delayed staining fed by the C5 segment of the right internal carotid artery. DIAGNOSIS An intrasellar cavernous hemangioma based on neuroradiological examinations. INTERVENTIONS The patient underwent surgery with an endoscopic endonasal transsphenoidal approach to debulk the lesion and obtain tissue for the pathological diagnosis. OUTCOMES Blood spurting was observed after puncture, and the capsule was stained blue. Lesion removal was stopped, and the patient underwent gamma knife surgery 1 week later. She remained in good condition during the follow-up. LESSONS Sponge-like or mulberry-like lesions can be identified on MRI after gadolinium injection and can facilitate a preoperative diagnosis of ICH. Currently, surgical debulking with cranial nerve decompression during the acute stage and subsequent gamma knife radiosurgery are considered to be a safe and effective treatment.
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Affiliation(s)
| | | | | | - Haiyan Lou
- Department of Radiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang, China
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Abushamat LA, Kerr JM, Lopes MBS, Kleinschmidt-DeMasters BK. Very Unusual Sellar/Suprasellar Region Masses: A Review. J Neuropathol Exp Neurol 2019; 78:673-684. [PMID: 31233145 DOI: 10.1093/jnen/nlz044] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 04/15/2019] [Accepted: 05/10/2019] [Indexed: 12/18/2022] Open
Abstract
The cause of sellar region masses in large retrospective series is overwhelmingly pituitary adenomas (84.6%), followed by craniopharyngiomas (3.2%), cystic nonneoplastic lesions (2.8%), inflammatory lesions (1.1%), meningiomas (0.94%), metastases (0.6%), and chordomas (0.5%) (1). While other rare lesions were also identified (collectively 6.0%), single unusual entities in the above-cited series numbered <1-2 examples each out of the 4122 cases, underscoring their rarity. We searched our joint files for rare, often singular, sellar/suprasellar masses that we had encountered over the past several decades in our own specialty, tertiary care specialty pituitary center practices. Cases for this review were subjectively selected for their challenging clinical and/or histological features as well as teaching value based on the senior authors' (MBSL, BKD) collective experience with over 7000 examples. We excluded entities deemed to be already well-appreciated by neuropathologists such as mixed adenoma-gangliocytoma, posterior pituitary tumors, metastases, and hypophysitis. We identified examples that, in our judgment, were sufficiently unusual enough to warrant further reporting. Herein, we present 3 diffuse large cell B cell pituitary lymphomas confined to the sellar region with first presentation at that site, 2 sarcomas primary to sella in nonirradiated patients, and 1 case each of granulomatosis with polyangiitis and neurosarcoidosis with first presentations as a sellar/suprasellar mass. Other cases included 1 of chronic lymphocytic leukemia within a gonadotroph adenoma and 1 of ectopic nerve fascicles embedded within a somatotroph adenoma, neither of which impacted patient care. Our objective was to share these examples and review the relevant literature.
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Affiliation(s)
- Layla A Abushamat
- Department of Endocrinology, University of Colorado Health Sciences Center, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Janice M Kerr
- Department of Endocrinology, University of Colorado Health Sciences Center, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - M Beatriz S Lopes
- Department of Pathology (Neuropathology) and Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Bette K Kleinschmidt-DeMasters
- Department of Pathology
- Department of Neurology
- Department of Neurosurgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
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Khattar NK, Adams SW, Schaber AS, White AC, Al Ghamdi M, Hruska RT, Savage JJ, Downs RK, Hattab EM, Williams BJ. Endoscopic Endonasal Surgery for the Resection of a Cavernous Hemangioma with a Sellar Extension. Cureus 2018; 10:e3663. [PMID: 30740283 PMCID: PMC6355302 DOI: 10.7759/cureus.3663] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Cavernous hemangiomas with an intrasellar extension are very rare, generally benign lesions that manifest by the compression of nearby structures. The presenting symptoms usually range from visual disturbances to an endocrine imbalance. Occasional extension into the cavernous sinus has been reported, which can cause cranial nerve compression. We present the case of a 69-year-old man presenting with facial pain and decreased libido. On investigation, a lesion was identified and the parasellar region was homogeneously hyper-intense on gadolinium-enhanced magnetic resonance imaging (MRI). Endoscopic endonasal surgery remains one of the favored approaches for the resection of sellar lesions. Such pathology needs to remain on the neurosurgeon’s differential diagnosis, making an intraoperative frozen section of these lesions a useful tool in the surgeon's armamentarium, to guide further surgical resection.
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Affiliation(s)
- Nicolas K Khattar
- Neurological Surgery, University of Louisville School of Medicine, Louisville, USA
| | - Shawn Wc Adams
- Neurological Surgery, University of Louisville School of Medicine, Louisville, USA
| | - Alexandra S Schaber
- Neurological Surgery, University of Louisville School of Medicine, Louisville, USA
| | - Andrew C White
- Radiology, University of Louisville School of Medicine, Louisville, USA
| | | | - Rob T Hruska
- Neurological Surgery, University of Louisville School of Medicine, Louisville, USA
| | - Jesse J Savage
- Neurological Surgery, Goodman Campbell Brain and Spine / Indiana University, Bloomington, USA
| | - Richard K Downs
- Radiology, University of Louisville School of Medicine, Louisville, USA
| | - Eyas M Hattab
- Pathology, University of Louisville School of Medicine, Louisville, USA
| | - Brian J Williams
- Neurological Surgery, University of Louisville School of Medicine, Louisville, USA
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Lan Z, Richard SA, Li J, Xu J, You C. A giant solid cavernous hemangioma mimicking sphenoid wing meningioma in an adolescent: A case report. Medicine (Baltimore) 2018; 97:e13098. [PMID: 30383694 PMCID: PMC6221700 DOI: 10.1097/md.0000000000013098] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
RATIONALE Central nervous system (CNS) solid cavernous hemangiomas are rare extra-axial anomalies that may sometimes resemble meningiomas. Due to their complex vascular nature, accurate preoperative diagnosis is important to avoid disastrous hemorrhage during operation. To the best of our knowledge this is the first case in an adolescent since all middle cranial fossa hemangioma cases reported in literature are adults in their 40s or 50s and all the pediatric cases are cystic. PATIENT CONCERNS We present a case of a 14-year-old girl with headache and dizziness for 3 months. She occasionally experienced nausea and vomiting but denied visual disturbances and loss of smell. DIAGNOSES MRI revealed a lesion that extends to the greater wing of the sphenoid bone as well as the pituitary fossa. Our initial diagnosis was a sphenoid wing meningioma but interestingly, histopathology revealed solid cavernous hemangioma. INTERVENTIONS The residual tumor was completely removed with 2 sessions of Gamma Knife radiotherapy after surgery. OUTCOMES We were confronted with excessive bleeding during surgery so we attained subtotal resection. However, the patient recovered well with no recurrence of the tumor. LESSONS Our case shows that space occupying lesions involving the cavernous sinus and sphenoid ridged could be easily misdiagnosed as sphenoid wing meningiomas in children and adolescents and even adults therefore great care must be exercised when confronted with this kind of presentation.
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Affiliation(s)
- Zhigang Lan
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan PR China
| | - Seidu A. Richard
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan PR China
- Department of Surgery, Volta Regional Hospital, Ghana, West Africa
| | - Jin Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan PR China
| | - Jianguo Xu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan PR China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan PR China
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Al-Sharydah AM, Al-Suhibani SS, Al-Jubran SA, Al-Abdulwahhab AH, Al-Bar M, Al-Jehani HM, Al-Issawi WM. Endoscopic management of Atypical sellar cavernous hemangioma: A case report and review of the literature. Int J Surg Case Rep 2017; 42:161-164. [PMID: 29248833 PMCID: PMC5985255 DOI: 10.1016/j.ijscr.2017.12.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 11/29/2017] [Accepted: 12/02/2017] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION supratentorial cavernous hemangiomas, particularly those found in the sellar region, are extremely rare. We present a case of sellar cavernous hemangioma with radiological characteristics that have never been reported. Due to the difficulty diagnosing these lesions, misdiagnosis might occur. Thus, briefing surgeons about the clinico-radiological features of such rare lesions is crucial for better understanding the enigmatic features of such rare lesions and to develop early management approaches that could result in better surgical excision with a lower tendency for complications. PRESENTATION OF CASE A 43-year-old male presented with headache, blurred vision, and impotence for the last 2 years. Brain magnetic resonance imaging showed an atypical sellar mass displaying signals of heterogeneous intensity on T1- and T2-weighted imaging. The mass exhibited heterogeneous enhancement after gadolinium injection. Endoscopic endonasal surgery was subsequently performed, during which an uneventful subtotal resection of the mass was achieved. Histopathological analysis confirmed the diagnosis of intrasellar cavernous hemangioma. DISCUSSION Many questions regarding how best to manage such lesions remain unanswered. Hence, we summarize the relevant surgical techniques and discuss misconceptions. CONCLUSION Seller cavernous hemangioma (SCH) is an extremely rare lesion that can be misdiagnosed. It is characterized by clinico-radiological features similar to those of other lesions such as pituitary macroadenoma and should be included in the differential diagnosis. The endoscopic endonasal transsphenoidal (EET) approach with subtotal/total resection appears to be a feasible option for debulking, with less surgical complications. Nonetheless, combining stereotactic radiosurgery will reduce postsurgical morbidities.
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Affiliation(s)
- A M Al-Sharydah
- Radiology Department, Imam Abdulrahman Bin Faisal University, King Fahd Hospital of the University, Saudi Arabia
| | - S S Al-Suhibani
- Radiology Department, Imam Abdulrahman Bin Faisal University, King Fahd Hospital of the University, Saudi Arabia.
| | - S A Al-Jubran
- Radiology Department, Imam Abdulrahman Bin Faisal University, King Fahd Hospital of the University, Saudi Arabia.
| | - A H Al-Abdulwahhab
- Radiology Department, Imam Abdulrahman Bin Faisal University, King Fahd Hospital of the University, Saudi Arabia.
| | - M Al-Bar
- Otolaryngology Department, Imam Abdulrahman Bin Faisal University, King Fahd Hospital of the University, Saudi Arabia.
| | - H M Al-Jehani
- Neurosurgery Department, Imam Abdulrahman Bin Faisal University, King Fahd Hospital of the University, Saudi Arabia.
| | - W M Al-Issawi
- Neurosurgery Department, Imam Abdulrahman Bin Faisal University, King Fahd Hospital of the University, Saudi Arabia.
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Patrona A, Patel KS, Bander ED, Mehta A, Tsiouris AJ, Anand VK, Schwartz TH. Endoscopic endonasal surgery for nonadenomatous, nonmeningeal pathology involving the cavernous sinus. J Neurosurg 2016; 126:880-888. [PMID: 27128582 DOI: 10.3171/2015.8.jns15275] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Surgery within the cavernous sinus (CS) remains a controversial topic because of the delicate and complex anatomy. The risk also varies with tumor consistency. Softer tumors such as pituitary adenomas are more likely to be surgically treated, while firm tumors such as meningiomas are often treated with radiosurgery. However, a wide range of pathologies that can involve the CS are amenable to surgery. The authors describe and analyze their results using endonasal endoscopic "medial-to-lateral" approaches for nonadenomatous, nonmeningeal tumors, in relation to the degree of invasion within the CS. METHODS A prospectively acquired database of consecutive endoscopic approaches for tumors with verified intraoperative CS invasion was reviewed. Pituitary adenomas and meningiomas were excluded. Degree of invasion of the CS was classified using the Knosp-Steiner (KS) grading system as well as the percentage of cavernous carotid artery (CCA) encasement. Extent of resection of the entire tumor and of the CS component was assessed by independent neuroradiologists using volumetric measurements of the pre- and postoperative MRI studies. Demographic data and complications were noted. RESULTS Fifteen patients (mean age 51.1 years who received endoscopic surgery between 2007 and 2013 met the selection criteria. There were 11 malignant tumors, including chordoma, chondrosarcoma, hemangiopericytoma, lymphoma, and metastatic cancer, and 4 benign tumors, including 3 cavernous hemangiomas and 1 dermoid. All cases were discussed before treatment in a tumor board. Adjuvant treatment options included chemotherapy and radiotherapy. The mean pre- and postoperative tumor volumes were 12.74 ml and 3.86 ml. Gross-total resection (GTR; ie, resection greater than 95%) was the goal in 13 cases and was achieved in 6 patients (46%) while in addition 5 patients had a greater than 80% resection. Gross-total resection in the CS was accomplished in 55% of the tumors with KS Grades 1-2 and in 16.6% of the tumors with KS grades 3-4, respectively. Likewise, GTR was accomplished in 55% of the tumors with CCA encasement under 75% and in 14.3% of the lesions with CCA encasement over 75%, irrespective of tumor volume and underlying pathology. There were 18 preexisting cranial neuropathies involving cranial nerves III-VI, of which 9 fully resolved, 4 improved, and 3 remained unchanged; 2 of these worsened with tumor recurrence. Surgical complications included 1 transient new cranial nerve VI palsy associated with Horner's syndrome and 1 case of panhypopituitarism. There were no postoperative CSF leaks and no infections. The mean extended follow-up was 34.4 months. CONCLUSIONS Endonasal endoscopic approaches can play a role in the management of nonmeningeal, nonadenomatous tumors invading the CS, either through biopsy, debulking, or GTR. An advantage of this method is the relief of preexisting cranial neuropathies with low risk for new neurological deficit. Extent of resection within the CS varies with KS grade and degree of carotid encasement irrespective of the underlying pathology. The goals of surgery should be clearly established preoperatively in consultation with radiation and medical oncologists.
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Affiliation(s)
- Aikaterini Patrona
- Department of Neurosurgery, Medizinische Hochschule Brandenburg, Ruppiner Kliniken, Neuruppin, Germany; and
| | | | | | | | | | - Vijay K Anand
- Otolaryngology, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
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11
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Lee DM, Yu SH, Yoon HH, Lee KL, Eom YS, Lee K, Kim BJ, Kim YS, Park IB, Kim KW, Lee S. Genetic Analysis of Multiple Endocrine Neoplasia Type 1 (MEN1) Leads to Misdiagnosis of an Extremely Rare Presentation of Intrasellar Cavernous Hemangioma as MEN1. Endocrinol Metab (Seoul) 2014; 29:146-53. [PMID: 25031887 PMCID: PMC4091494 DOI: 10.3803/enm.2014.29.2.146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 10/01/2013] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Multiple endocrine neoplasia type 1 (MEN1) is a rare inherited disorder characterized by the simultaneous occurrence of endocrine tumors in target tissues (mainly the pituitary, endocrine pancreas, and parathyroid glands). MEN1 is caused by mutations in the MEN1 gene, which functions as a tumor suppressor and consists of one untranslated exon and nine exons encoding the menin protein. This condition is usually suspected when we encounter patients diagnosed with tumors in multiple endocrine organs, as mentioned above. METHODS A 65-year-old woman who underwent surgery for a pancreatic tumor (serous cystadenoma) 5 years previously was referred to our hospital due to neurologic symptoms of diplopia and left ptosis. Brain magnetic resonance imaging revealed a 3.4-cm lesion originating from the cavernous sinus wall and extending into the sellar region. It was thought to be a nonfunctioning tumor from the results of the combined pituitary function test. Incidentally, we found that she also had a pancreatic tumor, indicating the necessity of genetic analysis for MEN1. RESULTS Genomic analysis using peripheral leukocytes revealed a heterozygous c.1621G>A mutation in the MEN1 gene that was previously reported to be either a pathogenic mutation or a simple polymorphism. We pursued a stereotactic approach to the pituitary lesion, and microscopic findings of the tumor revealed it to be an intrasellar cavernous hemangioma, a rare finding in the sellar region and even rarer in relation to oculomotor palsy. The patient recovered well from surgery, but refused further evaluation for the pancreatic lesion. CONCLUSION There is great emphasis placed on genetic testing in the diagnosis of MEN1, but herein we report a case where it did not assist in diagnosis, hence, further discussion on the role of genetic testing in this disease is needed. Also, in cases of pituitary tumor with cranial nerve palsy, despite its low prevalence, intrasellar cavernous hemangioma could be suspected.
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Affiliation(s)
- Dong Min Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Gachon Univeristy School of Medicine, Incheon, Korea
| | - Seung Hee Yu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Gachon Univeristy School of Medicine, Incheon, Korea
| | - Hyun Hwa Yoon
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Gachon Univeristy School of Medicine, Incheon, Korea
| | - Kang Lock Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Gachon Univeristy School of Medicine, Incheon, Korea
| | - Young Sil Eom
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Gachon Univeristy School of Medicine, Incheon, Korea
| | - Kiyoung Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Gachon Univeristy School of Medicine, Incheon, Korea
| | - Byung-Joon Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Gachon Univeristy School of Medicine, Incheon, Korea
| | - Yeun Sun Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Gachon Univeristy School of Medicine, Incheon, Korea
| | - Ie Byung Park
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Gachon Univeristy School of Medicine, Incheon, Korea
| | - Kwang-Won Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Gachon Univeristy School of Medicine, Incheon, Korea
| | - Sihoon Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Gachon Univeristy School of Medicine, Incheon, Korea
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12
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Hasiloglu ZI, Asik M, Kizilkilic O, Albayram S, Islak C. Cavernous hemangioma of the cavernous sinus misdiagnosed as a meningioma: a case report and MR imaging findings. Clin Imaging 2013; 37:744-6. [PMID: 23453537 DOI: 10.1016/j.clinimag.2013.01.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Revised: 01/01/2013] [Accepted: 01/23/2013] [Indexed: 10/27/2022]
Abstract
Cavernous hemangioma (CH) is a benign vascular malformation. Intracranial CH is generally localized as an intracranial-intraaxial and responsible for 5-13% of all intracranial vascular malformations. Intracranial-extraaxial CHs are rare rather than intracranial-intraaxial CHs. Clinical findings, imaging characteristics, and surgical approach of extraaxial CHs are rather different than intraaxial CHs. Diagnosing cavernous sinus CH preoperatively is very important, but its radiological differential diagnosis is quite difficult. In this study, we present magnetic resonance imaging findings of a 48-year-old male who was considered preoperatively to have meningioma but was diagnosed with cavernous sinus CH during surgery by pathological examination.
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Affiliation(s)
- Zehra Isik Hasiloglu
- Division of Neuroradiology, Department of Radiology, Istanbul University Cerrahpasa Medical School, 34303, Istanbul, Turkey.
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13
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Schürch C, Birrer M, Estella I, Kappeler A, Hewer E, Vajtai I. "Leiomyomatoid angiomatous neuroendocrine tumor" (LANT) of the pituitary reflects idiosyncratic angiogenesis in adenomas of the gonadotroph cell lineage. Pathol Res Pract 2013; 209:155-60. [PMID: 23419690 DOI: 10.1016/j.prp.2013.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Revised: 12/23/2012] [Accepted: 01/10/2013] [Indexed: 11/20/2022]
Abstract
Based on a single-case observation, the descriptive label "leiomyomatoid angiomatous neuroendocrine tumor" (LANT) has been tentatively applied to what was perceived as a possible novel type of dual-lineage pituitary neoplasm with biphasic architecture. We report on two additional examples of an analogous phenomenon encountered in male patients, aged 59 years (Case 1) and 91 years (Case 2). Both tumors were intra- and suprasellar masses, measuring 5.6 cm × 4.4 cm × 3.4 cm, and 2.7 cm × 2 cm × 1.7 cm, respectively. Histologically, Case 1 was an FSH-cell adenoma interwoven by vascularized connective tissue septa that tended to exhibit incremental stages of adventitial overgrowth. The epithelial component of Case 2 corresponded to an LH-cell adenoma, and lay partitioned by a maze of paucicellular to hyalinized vascular axes. Irrespective of architectural variations, perivascular spindle cells exhibited immunopositivity for vimentin, muscular actin, and smooth muscle actin. Conversely, negative results were obtained for CD34, EMA, S100 protein, GFAP, and TTF-1. Ultrastructural study failed to reveal metaplastic cell forms involving transitional features between adenohypophyseal-epithelial and mesenchymal-contractile phenotype. We propose that LANT be regarded as a peculiar reflection of maladaptive angiogenesis in some pituitary adenomas, rather than a genuine hybrid neoplasm. While no mechanistic clue is forthcoming to account for this distinctive pattern, hemodynamic strain through direct arterial - rather than portal - supply of the adenoma's capillary bed may be one such explanatory factor. The apparent predilection of the LANT pattern for macroadenomas of the gonadotroph cell lineage remains unexplained.
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Affiliation(s)
- Christian Schürch
- Department of Clinical Pathology, Institute of Pathology, University of Bern, Switzerland
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14
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Fraser JF, Mass AY, Brown S, Anand VK, Schwartz TH. Transnasal endoscopic resection of a cavernous sinus hemangioma: technical note and review of the literature. Skull Base 2011; 18:309-15. [PMID: 19240830 DOI: 10.1055/s-0028-1086059] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
UNLABELLED Objective/Importance: Hemangiomas of the cavernous sinus are rare lesions. Complete removal through a transcranial route often causes ocular motor palsies. Because the cranial nerves in the cavernous sinus are lateral to the carotid, a medial approach to the cavernous sinus may be less traumatic to the cranial nerves. CLINICAL PRESENTATION A 50-year-old man with headaches, dizziness, diplopia, and magnetic resonance imaging that demonstrated a right cavernous sinus mass expanding into the sella and sphenoid sinus. INTERVENTION A gross total removal of a cavernous sinus hemangioma was performed through an extended endoscopic transsphenoidal approach. CONCLUSION This is the first report of a complete removal of a cavernous sinus hemangioma using an endoscopic transnasal approach. The endoscopic transnasal approach to the medial cavernous sinus may be less traumatic than the transcranial route based on the lateral location of the cranial nerves.
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Affiliation(s)
- Justin F Fraser
- Department of Neurological Surgery, Weill Medical College of Cornell University, New York-Presbyterian Hospital, New York, New York
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15
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HORI S, HAYASHI N, NOMOTO K, SATO H, HAYASHI T, NAGAI S, NISHIKATA M, ENDO S. Cavernous Sinus Cavernous Hemangioma Largely Extending Into the Sella Turcica and Mimicking Pituitary Adenoma -Case Report-. Neurol Med Chir (Tokyo) 2010; 50:330-2. [DOI: 10.2176/nmc.50.330] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Satoshi HORI
- Department of Neurosurgery, Faculty of Medicine, University of Toyama
| | - Nakamasa HAYASHI
- Department of Neurosurgery, Faculty of Medicine, University of Toyama
| | | | - Hikari SATO
- Department of Neurosurgery, Faculty of Medicine, University of Toyama
| | - Tomohide HAYASHI
- Department of Neurosurgery, Faculty of Medicine, University of Toyama
| | - Shoichi NAGAI
- Department of Neurosurgery, Faculty of Medicine, University of Toyama
| | | | - Shunro ENDO
- Department of Neurosurgery, Faculty of Medicine, University of Toyama
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16
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Menon A, Kanchan T, Lobo FD, Menezes RG. Pontine cavernous haemangioma – An incidental autopsy finding. J Forensic Leg Med 2009. [DOI: 10.1016/j.jflm.2009.04.005 epub 2009 may 1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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Menon A, Kanchan T, Lobo FD, Menezes RG. Pontine cavernous haemangioma - an incidental autopsy finding. J Forensic Leg Med 2009; 16:417-9. [PMID: 19733335 DOI: 10.1016/j.jflm.2009.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2008] [Revised: 03/16/2009] [Accepted: 04/02/2009] [Indexed: 11/30/2022]
Abstract
Cavernous haemangiomas belong to a group of vascular malformations that are developmental defects of the vascular bed. Occurrence of an asymptomatic cavernoma in the pons is uncommon and worthy of record. At autopsy, cavernomas have to be differentiated from traumatic haemorrhagic lesions in head injury cases. We hereby report a case in which a pontine cavernous haemangioma was detected at autopsy in a 25-year-old female who died due to burn injuries.
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Affiliation(s)
- Anand Menon
- Department of Forensic Medicine and Toxicology, Kasturba Medical College, Mangalore, India.
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18
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Chuang CC, Jung SM, Yang JT, Chang CN, Pai PC. Intrasellar cavernous hemangioma. J Clin Neurosci 2006; 13:672-5. [PMID: 16815022 DOI: 10.1016/j.jocn.2005.08.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2005] [Accepted: 08/08/2005] [Indexed: 11/25/2022]
Abstract
Reports of intrasellar cavernous hemangioma are rare. They are usually incidental findings at autopsy, or initially mistaken for pituitary adenoma and treated accordingly. There are no specific symptoms. Cranial nerve palsy has occasionally been reported in patients with cavernous hemangioma, with or without sellar extension. However, intrasellar cavernous hemangioma with extension into the cavernous sinus resulting in oculomotor palsy has not been reported. We present a rare case of intrasellar cavernous hemangioma and discuss the diagnosis and management. Total surgical removal is recommended. However, attempts to resect the parasellar component of the lesion may be associated with high morbidity. Therefore, surgical cranial nerve decompression in the acute stage followed by stereotactic radiosurgery for the residual lesion may be an alternative.
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Affiliation(s)
- Chi-Cheng Chuang
- Department of Neurosurgery, Chang Gung Memorial Hospital, Chang Gung University, Linkou, Taiwan, ROC
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19
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Nagai S, Shimizu C, Kimura Y, Umetsu M, Taniguchi S, Takeuchi J, Atsumi T, Yoshioka N, Kubo M, Koike T. A case of reversed pituitary dysfunction with intrasellar mass. J Endocrinol Invest 2006; 29:367-72. [PMID: 16699306 DOI: 10.1007/bf03344111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Hypopituitarism can be caused by tumor, inflammation, granuloma and injuries. Once pituitary function is disturbed, hormone replacement therapy is necessary for the remaining life span in most cases. We have experienced a rare case of a unique intrasellar mass associated with pituitary dysfunction in which both spontaneously reversed. A 61-yr-old woman developed hypoadrenalism and central diabetes insipidus (cDI). Magnetic resonance (MR) imaging revealed a lobular, strong hypointense lesion with spotty signal in the middle of the hypophysis. This spotty lesion showed isointensity on T1- and high-intensity on T2-weighted MR images. The spotty signal as well as the normal pituitary lobe were enhanced by the administration of gadolinium. As replacement therapies for hypoadrenalism and cDI, 10 mg of hydrocortisone and 2.5 microg of desmopressin acetate were prescribed. Three months later, slight shrinkage of intrasellar mass and spontaneous improvement of pituitary functions were found. Hydrocortisone was then discontinued. Furthermore, because polyuria and polydipsia were improved nine months later, desmopressin acetate was stopped. Currently, the intrasellar mass continues to shrink, and the patient shows no symptoms without medication. Based upon the unique features of MR images, we suspect that the origin of the mass is an intrasellar hemangioma.
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Affiliation(s)
- S Nagai
- Division of Endocrinology and Metabolism, Department of Medicine II, Hokkaido University Graduate School of Medicine, 060-8638 Sapporo, Japan
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20
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Abstract
Whilst pituitary adenomas are the commonest cause of a sellar mass, there are a number of other neoplastic, infectious, inflammatory, developmental and vascular aetiologies that should be considered by the radiologist. We discuss and illustrate these lesions and indicate the various magnetic resonance imaging features that are helpful in formulating an appropriate differential diagnosis.
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Affiliation(s)
- S E J Connor
- Department of Neuroradiology, King's College Hospital, London, U.K.
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