Male, 86 years old, with Bell's palsy, dysfunction of cranial nerves V1, V2, CN7 and CN6 on the right. Scattered foci of T2 hyperintensity are evident within the periventricular white matter and the pons. No evidence of restricted diffusion is seen. No parenchymal edema or mass effect is detected. On postcontrast images, no evidence of any pathologic parenchymal enhancement is seen.Scattered small foci of susceptibility are evident through the brain compatible with chronic microhemorrhage. No evidence of significant or acute intracranial hemorrhage. No abnormal extra-axial collections are detected. Ventricles and sulci are prominent compatible with diffuse volume loss. Prominence of the perivascular spaces is seen.There may be mild enhancement of the distal cisternal portion of the right trigeminal nerve. The other cisternal cranial nerves including the seventh nerves within the IACs are unremarkable.Very subtle asymmetric expansion of the right cavernous sinus is seen. This is felt to reflect the presence of abnormal soft tissue within the sinus which demonstrates a slightly different pattern of enhancement from the remainder of the cavernous sinus (see image 34 series 26, and image 33 series 27). This tissue can also be appreciated on precontrast T1-weighted images (image 41 series 17) and on diffusion-weighted images (image 371 series 18). This tissue occupies predominantly the upper aspect of the cavernous sinus with sparing of Meckel's cave, though it does abut the right ICA with possible mild vascular narrowing. This soft tissue thickening extends anteriorly and superiorly, nearly to the level of the orbital apex. In addition, V2 is seen to be thickened as it passes through the foramen rotundum into the pterygopalatine fossa (image 31 series 27). No specific lesions in the facial soft tissues are seen. An area of thickening or adherent secretions is seen within the left maxillary sinus, and at the left frontoethmoidal recess. No masses or cervical adenopathy are appreciated in the neck. On limited views of the cervical spine, multilevel spondylosis is appreciated most severely affecting the C5-6 level where there may be a mild spinal canal stenosis.
An abnormal soft tissue process is suspected within the upper aspect of the right cavernous sinus. This abnormality, although subtle, can be visualized on both pre- and postcontrast images and on diffusion-weighted images. The distal cisternal right trigeminal nerve enhances mildly which may be related to this process. The right V2 branch is thickened as it passes through the foramen rotundum. Meckel's cave and V3 appear to be spared.The differential diagnosis for these findings would include a cavernous sinus meningioma or nerve sheath tumor, as well as an infiltrative neoplastic process such as lymphoma or perineural tumor spread, or an infiltrative nonneoplastic inflammatory or granulomatous process.Findings compatible with chronic small vessel ischemic disease of the brain are seen. No significant or acute brain parenchymal lesions are appreciated.