History & Physical: The patient is a 51 year-old right handed malpractice attorney with a chief complaint of intermittent right eye droop. These episodes last approximately 10-15 seconds and he has had 15 episodes over the last month. He was evaluated by a neurologist who ordered an MRI. Imaging revealed a right cerebellar cavernoma and a right sided foramen magnum mass. (Figures 1-3 Below)
Figure 4. (Below) The patient was followed with repeat imaging. MRI 3 months after the initial evaluation revealed enlargement of the foramen magnum mass. The foramen magnum meningioma was resected via a far lateral approach with the patient in the modified park-bench position. The cerebellar cavernoma was resected at the same time. Gross total resection of both lesions was accomplished (figure 4). The patient did well post-operatively with only a mild transient right XII nerve palsy.
Figure 1a: T1 axial w/ gad
Figure 1b: T1 axial with gad
Figure 2: Axial FLAIR
Figure 3: Coronal T1
1. Are any other studies warranted?
2. If so, what else would you order?
3. How would you manage the foramen magnum meningioma?
4. What about the cavernoma?
5. If you were to offer surgery for the meningioma, would you remove the cavenoma at the same time?
6. If you were to operate on the meningioma, would you use intraoperative monitoring?
7. What monitoring would you use?
8. Would you take down the condyle (all or part)?
9. Please add any suggestions or comments regarding this case:
Niether the meningioma at theforamen magnum or thecavernoma inthe cerebellar hemispherecan explain the deficit the pt., had that is intermottent 3rd paresis, however in view of the enlargement of the mass and the greater difficulties and risks for operating a much larger tumor surgery is justified upon demonsration of unequivocal evidence of tumor growth as in this case 3 months later. The approach and decision to remove the cavernoma in the same sitting which would entail no significant added morbidity is correct.
I think that radiosurgery must be considered as a therapeutic option in this case
I would consider Gamma Knife to the Meningioma and the Cavernoma at the same time. I would explain to the patient that the study of Gamma Knife for Cavernoma is entirely reserach studied. I waterproof Informed Consent will also be obtained given the profession he is in.