Head and Neck #11

43-year-old female:
– Known with M. Ollier (multiple enchondromas)
– Long-standing headache
– Recent ophthalmoplegia right side
– MRI was made

What is the most likely diagnosis?

Large, lobulated T2 hyperintese mass centered in the petrous apex, off-midline.
More specific: on the petroclival synchondrosis (bonus point!).
Extension in clivus, sphenoid bone, and cavernous sinus and extracranial to the neck trhough hypoglossal canal and jugular foramen. Not extending to or from the internal acoustic canal.
Very high T2 signal with some T2 hypointense serpiginous lines, possible flow voids or calcifications.
Isointense on T1, intense enhancing after contrast.

Do you need additional CT?

CT shows central arc and ring calcifications in the lesion, suggesting chondromatous origin. Bony margins are lytic, not well-defined margins. Non-sclerotic margins. No hyperostosis.

Differential Diagnosis

– Intraosseous extension and pattern atypical for most common CPA lesions meningioma and schwannoma (of 12th hypoglossal nerve considering mass in this canal also)
– Does not fit with cholesterol granuloma (sclerotic margins)
– High T2 signal does not fit lymphoma or plasmacytoma
– Growth into foramina does not fit metastasis and unknown with primary tumor
– No mucosal space origin (so no nasophayryngeal carcinoma)
– Could be a jugular paraganglioma but, however, not centred at jugular foramen, and no flow voids on additional MRA TOF
– Age and location and also history of M. Ollier, could fit well with chondrosarcoma

Bonus points for those who see the mass multicystic lesion low in the neck on the left with trachea deviation. Unfortunately, no further imaging was done in this hospital. This could be a lot of things, including extensive multinodular struma, lymphangioma, neurofibroma, or paraganglioma.

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