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Case 282

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A 52-year-old male patient sought medical attention with severe throbbing headache and vomiting, with progressive worsening during the last week. He is in treatment for hypertension with losartan 50 mg daily and has a history of unilateral left hearing loss for 8 months. Physical examination: ataxic gait, falls arising from orthostatic position, symmetrical face, hypoesthesia in the left hemiface. Magnetic resonance imaging (MRI) of the brain was requested.

Analyzing the clinical case and the images presented, what is the probable diagnosis?

a) Schwannoma

25%

b) Meningioma

25%

c) Epidermoid cyst

25%

d) Jugulotimpanic paraganglioma

25%
   

Image analysis

Image 1: Magnetic resonance imaging (MRI), weighted in T1, left paramedian sagittal cut, without intravenous contrast medium (gadolinium). Extensive formation with heterogeneous signal in cistern of the cerebellopontine angle.

 

Image 2: Magnetic resonance imaging (MRI), axial cut, T1-weighted, internal auditory meatus level, after intravenous injection of gadolinium. Extensive formation (delimited in red) occupying the left internal auditory canal, predominantly peripheral enhancement by gadolinium and delimitation of central area of necrosis.

 

Image 3 - a e b: Magnetic resonance imaging (MRI), sequential axial weights, T2-weighted, without intravenous contrast medium (gadolinium), internal auditory meatus and membranous labyrinths levels. Extensive, solid, heterogeneous formation (delimited in red), centered in the cistern of the cerebellopontine angle, occupying the left inner auditory canal.

 

Image 4 - a e b: Magnetic resonance imaging of the brain (MRI), sequential coronal sections, T2-weighted, without intravenous contrast medium (gadolinium), internal auditory meatus level. Expansion, extra-axial formation (delimited in red) causing a compressive effect on the brainstem. The cochlea (image 4a), vestibule and the semicircular canals (image 4b) were individualized with an usual appearance, without signs of lesion extension.

Highlights 

-The acoustic schwannoma corresponds to 8% of intracranial tumors in adults, being 80 to 90% of the tumors of the cerebellopontine angle and diagnosed at the age of 50 years;

-Bilateral acoustic schwannoma is characteristic of neurofibromatosis type 2;

-MRI is the examination of choice when the suspicion for a vestibular schwannoma is high, and intravenous gadolinium should be used as well as specific cuts of the internal auditory meatus;

-The acoustic schwannoma shows contrast medium uptake in MRI;

-The conduct must be individualized, since there are more or less invasive options. Observation may be employed in the elderly and small tumors, while surgery is preferred in younger and larger tumors.

References 

- Machado ABM, Haertel LC. Neuroanatomia funcional. 3. Ed. São Paulo: Editora Atheneu; 2014.

- Park JK, Vernick DM, Ramakrishna N. Vestibular schwannoma (acoustic neuroma). Eichler AF, editor. Waltham (MA): UpToDate; 2017. Disponível em: https://www.uptodate.com/contents/vestibular-schwannoma-acoustic-neuroma?source=search_result&search=schwannoma&selectedTitle=1~75

- Brasileiro Filho G. Bogliolo Patologia. 8. Ed. Belo Horizonte: Guanabara Koogan; 2011.

Authors

Ricardo Mazilão Silva, 5th year medical student at Universidade Federal de Minas Gerais
E-mail: ricardodma789[at]gmail.com 

Supervisors 

Alexandre Varella Giannetti, Neurosurgeon and Professor of the Department of Surgery at the Universidade Federal de Minas Gerais. 

Reviewers 

Arthur Melgaço, Thiago Ruiz, Ariádna Andrade, Fernanda Moura Teatini, Professor José Nelson Mendes Vieira, Professor Viviane Parisotto.

Translated by

Ricardo Mazilão Silva, 5th year medical student at Universidade Federal de Minas Gerais.

E-mail: ricardodma789[at]gmail.com

Test question

(SEAP/SES-NS, 2014) Considering the imaging investigation of sensorineural hearing loss, mark the correct alternative.

a) The negative result of computed tomography (CT) excludes the presence of retrocochlear lesions due to the high sensitivity it presents

25%

b) For the investigation of the VIII cranial nerve Schwannoma, the image examination indicated is the simple radiography

25%

c) In the suspected Schwannoma of the VIII cranial nerve, confirmation with magnetic resonance imaging is necessary, especially when the lesion is restricted to the internal auditory canal

25%

d) High resolution computed tomography (HRCT) has low specificity for the identification of foci of otosclerosis in patients with clinical suspicion

25%

e) The presence of the vestibulocochlear nerve in the internal auditory canal can only be confirmed by means of helical CT

25%
   

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