Intrafrontal sinus primary meningioma

I

Neuroradiology (1991) 33:251-252

leuro--

radiology 9 Springer-Verlag 1991

Case reports

Intrafrontal sinus primary meningioma P. M. Som 1' 2, V. P. Sachdev 3, M. M. Sacher 1, A. L. StoHman 1, and W. Lawson 2 Departments of 1 Radiology, 20tolaryngology, and 3 Neurosurgery of the Mount Sinai School of Medicine of CUNY, New York, USA

This 45-year-old w o m a n presented with (a) one m o n t h ' s history of severe bifrontal headaches which radiated to the vertex and occipital regions, and (b) v a g u e right frontal fullness of u n k n o w n duration. C h i l d h o o d seizures had started at age six years, for which she received Dilantin 300 mg q.d. and Valium 10 m g h . s . q . d , for m a n y years. Physical examination, neurological examination and multiple E E G s have b e e n normal. She has b e e n seizurefree for the last 8 years. Plain radiographs revealed a right frontal sinus mass with s m o o t h remodelling of b o n e along the medial and caudal aspects of the lesion and p e r m e a t i v e b o n e destruction along the right lateral m a r g i n of the lesion (Fig. 1 a). N o n - c o n t r a s t G E 9800 CTs revealed a h o m o g e n e o u s nearly isodense mass that e r o d e d portions of the posterior table of the right frontal sinus. T h e lateral margins of the b o n e defect were displaced posteriorly into the cranial

cavity. T h e intersinus s e p t u m s h o w e d s m o o t h remodelling and displacement a r o u n d the left lateral aspect of the lesion. T h e mass could not be clearly separated f r o m the right frontal lobe (Fig. i b). 0.3 T F o n a r M R scan revealed a nearly h o m o g e n e o u s right frontal sinus mass and that was hypointense to brain on T l - w e i g h t e d sequences (Fig. 1 c) and hyperintense to brain on T2-weighted sequences (Fig. 1 d). A crescent of increased signal circumscribed most of the posterior margin of the lesion, and was interpreted as edema. However, at several points the posterior margin of the mass could not be clearly separated f r o m the frontal lobe or meninges. Biopsy o b t a i n e d t h r o u g h the lower anterior frontal sinus wall was interpreted as meningioma. Frontal cran i e c t o m y was then p e r f o r m e d for exenteration of the frontal sinuses. The posterior sinus table was f o u n d to be

Fig. 1. a Cauldwell view reveals a right frontal sinus mass that has remodelled the bone along its left lateral and caudal aspects and demonstrates permeative destruction on its right lateral and cranial margins. b Axial non contrast CT scan reveals a soft tissue mass filling the right frontal sinus. There is focal destruction of the right anterior sinus table (thin arrow) and destruction of most of the posterior sinus table. The remaining portions of the posterior sinus wall are displaced backwards into the intracranial cavity (arrows) indicating that the primary growth of the process originated in the frontal sinus.

There is no clear margin along the posterior aspect of the process which separates it from the meninges and frontal lobe. e, d Sagittal spin echo Tl-weighted (e) and T2-weighted (d) MR scans reveal a frontal sinus mass that has a fairly homogeneous signal and which is slightly hypointense compared to brain on Tl-weighted images and hyperintense to brain on T2-weighted scans. There is faintly seen a zone of low intensity that separates the posterior aspect of the mass from the frontal lobe. 0.3 T Fonar scanner T1 = TR 611 ms, TE 28 ms; T2 = TR 2100 ms, TE 84 ms

252 eroded and displaced posteriorly into the cranial vault. The tumor was removed and a temporalis muscle and fascia graft was placed. The patient has done well since the surgery and no longer has frontal headache.

Discussion

Meningiomas only rarely involve the paranasal sinuses [1-11]. When they do, the involvement more commonly results from invasion of the sinus by a primary intracranial lesion [12-16]. Rare primary intraparanasal sinus meningiomas reported in the frontal, ethmoid, maxillary and sphenoid sinuses are believed to arise from embryonal arachnoid nests which b e c o m e pinched off during embryonic development and remain behind in the region of the future sinuses [3, 17-22]. Thus far, primary meningiomas have been observed most frequently in the frontal sinuses (59%), then the ethmoid sinuses (23%), sphenoid sinuses (9%) and maxillary sinuses (9%). Although one can be definite about the primary intrasinus origin of a meningioma only if the posterior sinus table is intact, the literature supports the contention that the primary center of the process and the direction of bone remodelling can be used to ascertain the presumed site of origin [8]. In this case, the posterior intracranial displacement of the residual posterior table of the sinus strongly suggests that the tumor grew from the frontal sinus into the cranial cavity, rather than visa versa. Patients with frontal sinus meningiomas may present with a mass either in the forehead or in the upper orbit, often resulting in exophthalmos. Other c o m m o n complaints include headaches, dizziness and seizures.

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RM.Som, M.D. Department of Radiology Mount Sinai Hospital One Gustave Levy Place New York, NY 10029 USA