Male, 87 years old, with history of a right cavernous sinus lesion and progressive dysfunction of cranial nerves III, V, VI, and VII. Since the prior examination, progression of the previously demonstrated enhancing lesion centered on the right cavernous sinus is seen. The cavernous sinus and Meckel's cave components of the lesion have become notably bulkier. In addition, the lesion appears now to extend medially, encasing but not yet occluding the right ICA, and invading the sella. New marrow replacement within the right aspect of the clivus may also reflect tumor invasion. New enhancing tissue is also evident within the right sphenoid sinus.Abnormal enhancing tissue at the level of the right orbital apex is unchanged. Enhancement within the right pterygopalatine fossa has progressed. Enhancement and thickening of V2 at the foramen rotundum and V3 at the foramen ovale appear relatively similar to prior.The component of the lesion centered on the right cisternal trigeminal nerve has significantly progressed. There is now a rim-enhancing soft tissue lesion at this location which appears to grow into the pons and extends inferiorly along the ventral surface almost to the level of the medulla. There is significant associated pontine and right middle cerebellar peduncle edema. From this lesion, new dural thickening and enhancement extends into the right IAC. Enhancement at the right geniculate ganglion and greater petrosal nerve appear similar to prior.No areas of diffusion restriction are seen within the brain. Numerous scattered small foci of FLAIR hyperintensity within the cerebral hemispheres are nonspecific and unchanged. No evidence of acute intracranial hemorrhage or any abnormal extra axial fluid collection is seen. The ventricles and sulci are mildly prominent compatible with parenchymal volume loss.
Interval progression of the enhancing infiltrative lesion centered on the right cavernous sinus is seen. The cavernous sinus component of the lesion has become notably bulkier with local extension into the sella, the right sphenoid sinus and perhaps into the bone of the clivus. The lesion has also progressed along the cisternal right trigeminal nerve with the development of rim-enhancing tissue which invades the pons and induces significant edema.The differential diagnosis remains broad and would include infiltrative malignancy such as lymphoma or perineural spread from a head and neck primary. Alternately, this could represent malignant degeneration of a peripheral nerve sheath tumor, a higher grade meningioma, or perhaps a hemangiopericytoma. The possibility of a nonneoplastic granulomatous or inflammatory condition is not excluded but considered less likely.