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Unraveling a cephalalgic quagmire from a cavern to a cave S Thenmozhi1, S Girija1, KN Viswanathan1, KV Karthikeyan21 Department of General Medicine, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India 2 Department of Neurosurgery, Chettinad Academy of Research and Education, Chennai, Tamil Nadu, India
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/jpgm.JPGM_809_20
Keywords: Cavernous sinus, headache, Meckel's cave, meningioma, temporal, unilateral
Meckel's cave is a dural recess located in the posteromedial part of the middle cranial fossa, acting as a passage for the trigeminal nerve. It is situated between the prepontine cistern and the cavernous sinus, housing the trigeminal ganglion, and the proximal rootlets of the trigeminal nerve.[1],[2],[3] Compression of structures around the Meckel's cave results in a classical picture which can be clinically localized.[3] We report a middle-aged lady who presented with unilateral temporal headache and was subsequently diagnosed to have Meckel's cave meningioma confirmed by imaging. We present an algorithmic approach to localize the lesion to the Meckel's cave at the bedside.
A 48-year-old lady presented with recurrent, progressive dull-aching, left-sided temporal headache for 1 year. What are the common causes for the left temporal headache? Chronic dull-aching left-sided temporal headache in women in their late forties can be primary (tension headache, cluster headache, chronic daily headache, and migraine) or secondary (glaucoma, brain tumor, raised intracranial pressure, trigeminal neuralgia, and temporal arteritis) [Figure 1].[4],[5]
Case details (continued) She also had giddiness, left-sided eye pain, and left-sided facial numbness for 1 month. She had restriction of left-sided gaze in the left eye with double vision. The double vision became single on closing the left eye (the lateral false image disappeared, leaving the medial true image intact). She had no crossing of images, diurnal variation of diplopia, tinnitus, vertigo, deafness, nausea, or vomiting. There were no neuro-cutaneous markers and her higher mental functions were normal. She had a loss of left-sided corneal and conjunctival reflexes with restricted left eye abduction. There were no other neurological deficits. What are the causes for left temporal headache with ipsilateral eye pain, facial numbness, and gaze-restriction? Our patient had unilateral headache with isolated abducent nerve palsy, with loss of corneal and conjunctival reflexes localizing the lesion to the pons. As she did not have hemiplegia, facial nerve palsy, deafness, nausea, and vomiting, a lesion in the course of nerve distal to the pontine exit becomes a possibility, further localizing it to the region of the cavernous sinus or its adjacent structures.[3],[6],[7],[8] This is explained in [Figure 2].[4],[9]
What are the structures related to the cavernous sinus? The cavernous sinus is related to the optic tract, optic chiasma, internal carotid artery superiorly, the pituitary gland inferiorly, temporal lobe with uncus laterally, superior orbital fissure, and the apex of the orbit anteriorly and apex of petrous temporal bone posteriorly. Meckel's cave is a narrow complex space measuring 4 mm × 7.5 mm, situated inferolateral to the posterior part of the cavernous sinus [Figure 3].[3],[6],[7] Structures within the lateral wall of the compartment of the cavernous sinus, from superior to inferior include the oculomotor nerve, trochlear nerve, ophthalmic, and maxillary branches of the trigeminal nerve. Structures passing through the medial wall are the abducent nerve, internal carotid artery and associated carotid plexus.[7]
What are the lesions causing cavernous sinus pathology? Thrombosis, meningioma, schwannoma, aneurysms, cavernous hemangiomas, arteriovenous malformations, infections such as neurocysticercosis, inflammation, lymphomas, dermoids, pituitary adenomas, chordomas, chondrosarcomas, craniopharyngioma, pseudotumor cerebri, Meckel's cave schwannomas or meningiomas, and secondary malignancies are the various pathological lesions in the cavernous sinus.[7] Why was this lesion localized to Meckel's cave instead of the cavernous sinus? Progressive temporal headache with isolated restricted abduction of the left eye with loss of ipsilateral corneal and conjunctival reflexes suggested that the lesion was in close proximity to the cranial V and VI nerves.[3],[8] As cranial nerves II, III, and IV were uninvolved, the lesion could probably arise from the structures adjacent to the cavernous sinus only. Cranial nerve VI is closely related to the trigeminal ganglion in the Meckel's cave. In the postero-inferior aspect of the cavernous sinus, trigeminal ganglion and VI cranial nerve are only 1.87 mm apart.[2],[7] This further localized the lesion to the Meckel's cave. Case details (continued) Magnetic resonance (MR) imaging of the brain with contrast revealed a 2 cm × 2 cm × 1.7 cm enhancing dumb-bell shaped mass lesion with mild restricted diffusion in Meckel's cave projecting into the cavernous sinus, cerebellopontine angle with dural tail [Figure 3]a. MR spectroscopy showed alanine, myoinositol [Figure 4], and glutamine peaks. A provisional diagnosis of Meckel's cave meningioma was made with a differential diagnosis of trigeminal schwannoma considering the age, gender, clinical localization, and MR findings [Figure 3]b.[3],[7],[10],[11]
What are the possible lesions that could arise from the Meckel's cave?
Meckel's cave is a dural cleft around the trigeminal nerve.[2] Meckel's cave meningiomas usually present with sensory symptoms and signs with very minimal motor involvement.[12] The presence of facial pain in the trigeminal territory with isolated sixth nerve palsy should arouse suspicion of pathology in Meckel's cave.[7] Tumors of the Meckel's cave contribute to only 0.5% of all intracranial tumors with meningiomas being the commonest.[3] Tumors with enhancing dural tail in the periphery, located along the margins of Meckel's cave are usually meningiomas.[1],[13] Case details (continued) The tumor was approached by left fronto-temporo-parietal craniotomy. Dura was incised medially close to the cavernous sinus and intracapsular debulking was done. Histopathology showed ovoid, monomorphic tumor cells arranged in whorls and syncytial pattern, with occasional intranuclear inclusions, consistent with meningothelial meningioma WHO grade 1 [Figure 5]. Her headache resolved after the surgery. The patient is currently undergoing external beam radiotherapy.
Systematically approaching this patient with unilateral temporal cephalalgia aided in clinical localization of the lesion, which was confirmed by MRI and surgical debulking resulted in cure. Declaration of patient consent The authors certify that appropriate patient consent was obtained. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
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