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Skull Base Tumors Workup

  • Author: Todd C Hankinson, MD, MBA; Chief Editor: Brian H Kopell, MD  more...
 
Updated: Feb 27, 2015
 

Laboratory Studies

Preoperative laboratory studies include a complete blood cell count, electrolyte evaluation, and bleeding and coagulation parameters.

Masses located in or around the sella turcica merit serum endocrine studies.

Paragangliomas: Catecholamine secretion can be diagnosed with urine or serum studies.

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Imaging Studies

General imaging studies for assessment of skull base tumors include the following:

  • CT scan of the brain with thin cuts and sagittal and coronal reconstructions can reveal abnormalities of the bone (eg, erosion, hyperostosis) and calcification in the tumor.
  • Brain MRI with and without gadolinium is the best study to evaluate soft tissue masses and structures.
  • Cerebral angiography is beneficial if the tumor encroaches on the carotid or other major intracranial arteries or a major venous sinus. It is used to assess whether arteries and venous sinuses are patent. In the case of meningioma and other vascular tumors, angiographic embolization of appropriate feeding vessels can decrease blood loss during operative resection and contribute to the ease of tumor removal.
  • MR arteriography and venography may also be used to assess the patency of arterial and venous structures.
  • If a metastatic tumor has an unknown primary source, a systemic workup should be performed. Imaging tests include posteroanterior and lateral chest radiography; contrast-enhanced CT scan of the chest, abdomen, and pelvis; and a bone scan.

Tumor-specific and site-specific imaging techniques include the following:

  • Osteoma: Diagnosis is based on the radiographic appearance. The most sensitive test is CT scanning, in which the lesion appears as a circumscribed homogeneous bony density (see the image below).
    Osteoma. CT scan with axial bone windows and coronOsteoma. CT scan with axial bone windows and coronal plane reconstruction that demonstrates a fibrous osteoma that involves the right orbit and the floor of the anterior cranial fossa.
  • Chondroma: Radiographically, chondromas are best characterized by CT scanning; these tumors appear as lytic lesions with sharp margins and erosion of surrounding bone. Stippled calcification within the lesion helps distinguish it from a metastasis or chordoma.
  • Hemangioma: Skull radiographs may demonstrate a circular lucency with trabeculations. CT scanning demonstrates a nonenhancing hypodense lesion. Flow voids may be visualized on MRI.
  • Dermoid and epidermoid tumors of the skull: Radiographs demonstrate rounded or ovoid lytic lesions with sharp sclerotic margins. On CT scans, these lesions are nonenhancing and hypodense and involve all 3 bone layers. MRI demonstrates a low-intensity lesion on T1 and a high-intensity lesion on T2.
  • Paragangliomas: MRI and magnetic resonance (MR) angiography best characterize paragangliomas because these modalities usually reveal their extensive vascularity, meriting preoperative embolization in many cases (see the images below).
    Paraganglioma. Contrast-enhanced MRI scan of the aParaganglioma. Contrast-enhanced MRI scan of the axial (left) and coronal (right) planes that demonstrates a paraganglioma (glomus jugulare) at the right cerebellopontine angle. Extension out of the jugular foramen into the extracranial soft tissue is visible (right).
    Paraganglioma. Arterial phase external carotid artParaganglioma. Arterial phase external carotid artery angiograms. Pre-embolization imaging (left) demonstrates the rich vascularity of the tumor. Postembolization imaging (right) demonstrates that the arterial feeding vessels have been significantly reduced.
  • Metastasis to the skull base: MRI scans can reveal even small skull base metastases. Almost all tumors can be visualized, especially if they lie within the cavernous sinus.
  • Direct extension of malignant tumors to the skull base: Imaging demonstrates erosion of the skull base and the presence of a soft tissue mass.
  • Osteogenic sarcoma and fibrous sarcoma: Fibrous sarcoma is a soft tissue tumor that arises from bone, periosteum, scalp, or dura. It is often accompanied by bony destruction, showing a regular but discrete lytic radiographic picture.
  • Vestibular schwannoma: MRI is the best modality for the diagnosis of a vestibular schwannoma. The tumor enhances vigorously, and its origin in the internal auditory canal distinguishes it from a meningioma. CT scanning with contrast demonstrates most tumors larger than 1.5 cm.
  • Trigeminal schwannoma: Diagnosis is best established with MRI.
  • Meningioma
    • Imaging of skull base meningiomas includes CT scanning, MRI, and sometimes angiography, which can be obtained in conjunction with embolization of feeding arteries. On nonenhanced CT scans, the tumor is isodense or slightly hyperdense compared with the brain. The mass is generally smooth and sometimes lobulated, and calcifications are often appreciated. Contrast enhancement is strong and homogeneous; margins are distinct, and the tumor’s dural base can usually be appreciated, as in the first image below. Hyperostosis of the underlying bone is common and can be appreciated radiographically. Hyperostosis of the immediately adjacent bone is seen in 25% of patients, as in the second and third images below.
      Meningioma of the tuberculum sella. Contrast-enhanMeningioma of the tuberculum sella. Contrast-enhanced T1-weighted MRI scan that demonstrates a meningioma in a patient who presented with headaches and slowly progressive visual loss. Note the broad dural base, best appreciated on the sagittal image (right). This lesion was completely removed using a frontotemporal craniotomy with orbital osteotomy.
      Right sphenoid wing meningioma with intraorbital iRight sphenoid wing meningioma with intraorbital involvement. Contrast-enhanced T1-weighted sagittal MRI scan. This tumor manifested as slowly progressive unilateral vision loss and mild proptosis on the right. It was resected using a frontotemporal craniotomy with orbitozygomatic osteotomy. Note the right sphenoid hyperostosis, which is best seen on the axial image.
      Right sphenoid wing meningioma with intraorbital iRight sphenoid wing meningioma with intraorbital involvement. Contrast-enhanced T1-weighted axial MRI scan. This tumor manifested as slowly progressive unilateral vision loss and mild proptosis on the right side. It was resected using a frontotemporal craniotomy with orbitozygomatic osteotomy. Note the right sphenoid hyperostosis.
    • On MRI, the tumor is isointense (65%) or hypointense (35%) when compared with normal brain on both T1-weighted and T2-weighted imaging. Intense and homogeneous gadolinium enhancement is visible, and the dural tail is often evident. MRI is the best modality to define the relationship between the tumor and surrounding structures.
    • Atypical radiographic features such as cysts, hemorrhage, and central necrosis, which can mimic features of glioma, are visible in about 15% of meningiomas. Malignant meningiomas commonly demonstrate bone destruction, necrosis, irregular enhancement, and extensive edema. MRI demonstrates the rare cases of direct brain invasion by tumor. The differential diagnosis of radiographically atypical meningiomas includes dural metastasis, other primary meningeal tumors (eg, sarcoma), granuloma, or aneurysm. Metastases are commonly associated with abundant surrounding edema and bone destruction; in contrast, hyperostosis and moderate edema suggest meningioma.
    • On angiograms, skull base meningiomas are hypervascular, generally with feeding vessels from the external carotid artery. Encased or compromised arteries and venous sinus involvement can be assessed using MR or CT angiography, which greatly contributes to operative planning. Catheter angiography is reserved for cases in which balloon test occlusion (BTO) or arterial embolization is planned.
  • Hemangiopericytoma: Gadolinium-enhanced MRI best characterizes these lesions (see the image below). CT scanning may help differentiate hemangiopericytoma from a meningioma by demonstrating local osteolysis, rather than the hyperostosis that may be seen with meningioma. Angiography can demonstrate the tumor’s vascularity, and embolization can be a helpful adjunct prior to surgical intervention.
    Hemangiopericytoma. Contrast enhanced T1-weighted Hemangiopericytoma. Contrast enhanced T1-weighted MRI scans that demonstrates a large hemangiopericytoma originating from the floor of the anterior fossa in a young man with progressive headaches, blurred vision, and papilledema. This tumor was subtotally resected through a frontotemporal craniotomy with orbital osteotomy.
  • Tumors of the posterior cranial fossa: MRI usually differentiates a meningioma from a vestibular schwannoma because the latter begins within the internal auditory canal.
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Other Tests

In the appropriate clinical setting, additional tests are used to formally evaluate cranial nerve function. Tests may include a formal visual field evaluation, audiography, or swallowing study.

Vestibular schwannoma: Hearing function can be evaluated using brainstem auditory evoked potentials, caloric stimulation with electronystagmography, and audiometry.

Tumors of the posterior cranial fossa: Abnormalities found on electronystagmography, audiography, and brainstem auditory evoked potentials testing are less common than with vestibular schwannomas, but these tests are rarely needed with current imaging techniques.

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Diagnostic Procedures

Balloon test occlusion (BTO): Large vessel compromise due to tumor involvement can be documented preoperatively with angiography to allow for adequate presurgical planning. If a large vessel requires ligation during the operative approach or tumor resection, a BTO gives the surgeon an indication of whether the patient might tolerate vessel sacrifice or if a bypass procedure is required.

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Contributor Information and Disclosures
Author

Todd C Hankinson, MD, MBA Assistant Professor of Neurosurgery, Children's Hospital Colorado, University of Colorado School of Medicine

Todd C Hankinson, MD, MBA is a member of the following medical societies: American Association of Neurological Surgeons, Congress of Neurological Surgeons, International Society of Pediatric Neurosurgery, American Society of Pediatric Neurosurgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Jeffrey N Bruce, MD Edgar M Housepian Professor of Neurological Surgery Research, Vice-Chairman and Professor of Neurological Surgery, Director of Brain Tumor Tissue Bank, Director of Bartoli Brain Tumor Laboratory, Department of Neurosurgery, Columbia University College of Physicians and Surgeons

Jeffrey N Bruce, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for the Advancement of Science, American Association of Neurological Surgeons, New York Academy of Sciences, North American Skull Base Society, Society of Neurological Surgeons, Society for Neuro-Oncology, American Society of Clinical Oncology, Congress of Neurological Surgeons, Pituitary Society

Disclosure: Received grant/research funds from NIH for other.

Leslie Robinson, MD, MBA, PharmD Resident Physician, Department of Neurosurgery, University of Colorado School of Medicine

Leslie Robinson, MD, MBA, PharmD is a member of the following medical societies: American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Brian H Kopell, MD Associate Professor, Department of Neurosurgery, Icahn School of Medicine at Mount Sinai

Brian H Kopell, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Neurological Surgeons, International Parkinson and Movement Disorder Society, Congress of Neurological Surgeons, American Society for Stereotactic and Functional Neurosurgery, North American Neuromodulation Society

Disclosure: Received consulting fee from Medtronic for consulting; Received consulting fee from St Jude Neuromodulation for consulting; Received consulting fee from MRI Interventions for consulting.

Additional Contributors

Michael G Nosko, MD, PhD Associate Professor of Surgery, Chief, Division of Neurosurgery, Medical Director, Neuroscience Unit, Medical Director, Neurosurgical Intensive Care Unit, Director, Neurovascular Surgery, Rutgers Robert Wood Johnson Medical School

Michael G Nosko, MD, PhD is a member of the following medical societies: Academy of Medicine of New Jersey, Congress of Neurological Surgeons, Canadian Neurological Sciences Federation, Alpha Omega Alpha, American Association of Neurological Surgeons, American College of Surgeons, American Heart Association, American Medical Association, New York Academy of Sciences, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Raqeeb Haque, MD Resident Physician, Department of Neurological Surgery, Columbia University Medical Center

Disclosure: Nothing to disclose.

Christopher P Kellner, MD Resident Physician, Department of Neurological Surgery, Columbia University Medical Center

Christopher P Kellner, MD is a member of the following medical societies: American Association of Neurological Surgeons, American Medical Association, and Congress of Neurological Surgeons

Disclosure: Nothing to disclose.

George Timothy Reiter, MD Associate Professor, Department of Neurosurgery, Pennsylvania State University College of Medicine; Director, Department of Spinal Neurosurgery and Neurotrauma, Associate Director, Penn State Spine Center, Milton S Hershey Medical Center; Active Staff, Hershey Outpatient Surgery Center; Active Staff, Wilkes-Barre General Hospital; Hospital Appointment, Penn State Rehabilitation Hospital

George Timothy Reiter, MD is a member of the following medical societies: American Association of Neurological Surgeons and Congress of Neurological Surgeons

Disclosure: Synthes Spine Consulting fee Consulting; Integra Grant/research funds None; Integra Consulting fee Consulting

Grant P Sinson, MD Associate Professor, Department of Neurosurgery, Medical College of Wisconsin

Grant P Sinson, MD is a member of the following medical societies: American Association of Neurological Surgeons and American Medical Association

Disclosure: Nothing to disclose.

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Osteoma. CT scan with axial bone windows and coronal plane reconstruction that demonstrates a fibrous osteoma that involves the right orbit and the floor of the anterior cranial fossa.
Intracranial plasmacytoma. Sagittal and axial T1-weighted MRI with contrast enhancement demonstrate a right-sided plasmacytoma of the petrous bone. This tumor was treated through a far lateral approach and suboccipital craniotomy following a superselective embolization of feeding arteries.
Paraganglioma. Contrast-enhanced MRI scan of the axial (left) and coronal (right) planes that demonstrates a paraganglioma (glomus jugulare) at the right cerebellopontine angle. Extension out of the jugular foramen into the extracranial soft tissue is visible (right).
Paraganglioma. Arterial phase external carotid artery angiograms. Pre-embolization imaging (left) demonstrates the rich vascularity of the tumor. Postembolization imaging (right) demonstrates that the arterial feeding vessels have been significantly reduced.
Esthesioneuroblastoma. A 39-year-old man presented with 1 month of decreased vision, left facial numbness, and swelling. Physical examination demonstrated left-sided exophthalmos and blindness. He was also unable to smell. Contrast-enhanced T1-weighted MRI demonstrated a large lesion that originated in the paranasal sinuses and extended through the cribriform plate into the anterior cranial fossa. He underwent a bifrontal craniotomy for resection of this tumor.
Clival chondrosarcoma. Contrast-enhanced T1-weighted MRI in the coronal plane. This tumor involved the clivus and posterior clinoid and encroached on the optic chiasm in the suprasellar region. It was subtotally resected through a frontotemporal craniotomy with a zygomatic osteotomy.
Chordoma. T1-weighted MRI with contrast that demonstrates an enhancing mass that replaced the clivus and invaded the right cavernous sinus. This lesion was subtotally resected using a sublabial approach. The patient was then treated with gamma knife radiosurgery (GKRS).
Fibrous dysplasia. Coronal reconstruction of nonenhanced CT scan that demonstrates fibrous dysplasia of the right orbit with extension into the floor of the anterior fossa. This lesion was completely resected using a multidisciplinary team and a craniofacial approach that included a bifrontal craniotomy
Vestibular schwannoma. T1-weighted MRI scan that demonstrates a large left-sided vestibular schwannoma in a 19-year-old woman with neurofibromatosis type II. Also present on the left is a vagal (tenth nerve) schwannoma. A residual tumor from a right-sided vestibular schwannoma, which was previously operated on, is visible. These lesions were resected through a retrosigmoid approach and suboccipital craniectomy.
Hypoglossal schwannoma. Precontrast (left) and Postcontrast (right) T1-weighted MRI scans that demonstrate a right-sided schwannoma of the hypoglossal (XII) nerve. This tumor was completely resected using an extreme lateral approach and suboccipital craniectomy.
Foramen magnum meningioma. Contrast-enhanced T1-weighted MRI scans that demonstrate a ventral, left-sided meningioma at the foramen magnum. This tumor was completely resected using a far lateral approach and suboccipital craniotomy with C1 laminectomy.
Multiple skull base meningiomas. Contrast-enhanced T1-weighted MRI in the coronal (above) and sagittal (below) planes demonstrates a large left-sided petroclival meningioma and a right-sided meningioma at the foramen magnum. After shunt placement to treat hydrocephalus, the petroclival tumor was resected using a presigmoid approach. The foramen magnum tumor was subsequently resected.
Right sphenoid wing meningioma with intraorbital involvement. Contrast-enhanced T1-weighted sagittal MRI scan. This tumor manifested as slowly progressive unilateral vision loss and mild proptosis on the right. It was resected using a frontotemporal craniotomy with orbitozygomatic osteotomy. Note the right sphenoid hyperostosis, which is best seen on the axial image.
Right sphenoid wing meningioma with intraorbital involvement. Contrast-enhanced T1-weighted axial MRI scan. This tumor manifested as slowly progressive unilateral vision loss and mild proptosis on the right side. It was resected using a frontotemporal craniotomy with orbitozygomatic osteotomy. Note the right sphenoid hyperostosis.
Meningioma of the tuberculum sella. Contrast-enhanced T1-weighted MRI scan that demonstrates a meningioma in a patient who presented with headaches and slowly progressive visual loss. Note the broad dural base, best appreciated on the sagittal image (right). This lesion was completely removed using a frontotemporal craniotomy with orbital osteotomy.
Hemangiopericytoma. Contrast enhanced T1-weighted MRI scans that demonstrates a large hemangiopericytoma originating from the floor of the anterior fossa in a young man with progressive headaches, blurred vision, and papilledema. This tumor was subtotally resected through a frontotemporal craniotomy with orbital osteotomy.
Adenoid cystic carcinoma. A T1-weighted image from an MRI scan that demonstrates a tumor (red arrow) that involves the ethmoid sinuses and cribriform plate.
Adenoid cystic carcinoma. Extension of the tumor into the middle fossa anterior to the temporal lobe (blue arrow).
Petroclival meningioma. Contrast-enhanced T1-weighted and a T2-weighted (upper right) MRI scan that demonstrates a large left-sided petroclival meningioma. This tumor was near totally resected using a presigmoid approach. The patient subsequently underwent gamma knife radiosurgery (GKRS) for the treatment of the residual tumor.
Skull base tumors. Sagittal enhanced T1-weighted image from an MRI scan that shows a hypointense mass (blue arrow) anterior to the brainstem.
Skull base tumors. Axial T2-weighted image from an MRI scan that demonstrates a hyperintense mass (blue arrow) anterior to and compressing the brainstem.
Squamous cell carcinoma. Venous phase of a cerebral angiogram that demonstrates filling of the right transverse sinus (red arrow) but no filling of the left transverse sinus (blue arrow).
Squamous cell carcinoma. Balloon test occlusion with the balloon inflated in the right transverse sinus (red arrow).
Squamous cell carcinoma. Venous phase of a cerebral angiogram with the balloon occluding the right transverse sinus (red arrow).
Gamma knife radiosurgery plan. This patient presented with adenoid cystic carcinoma of the right lacrimal gland. The tumor metastasized to the right middle fossa and cavernous sinus.
Radiation necrosis. This patient presented with adenoid cystic carcinoma of the right lacrimal gland. The tumor metastasized to the right middle fossa and cavernous sinus. The patient subsequently developed tumor recurrence and underwent right orbital exenteration and further gamma knife radiosurgery (GKRS). He presented 18 months later with new headaches and seizures. Contrast-enhanced T1-weighted and T2 FLAIR (center) MRI demonstrate radiation necrosis at the site of previous radiation therapy.
Giant pituitary adenoma. Contrast-enhanced MRI scan that demonstrates a very large pituitary adenoma with significant suprasellar extension. Large tumors of the sellar and suprasellar region may require a combined craniotomy and trans-sphenoidal approach to achieve complete resection.
 
 
 
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