Malignant lymphomatous invasion of Meckel's cave: pathoanatomical considerations of the petrous apex

Abstract

Secondary central nervous system lymphoma is rare, occurring in up to 10% of non-Hodgkin's lymphoma patients and in 5% of diffuse large B-cell lymphoma patients. The prognosis is poor, even rarer is metastasis of large B-cell lymphomas into Meckel's cave and the trigeminal nerve roots. We describe a relapsing case of a large B-cell lymphoma that migrated into Meckel's cave, the mandibular branch of the trigeminal nerve and the adjacent cavernous sinus. We review petrous apex anatomy, review the literature of metastatic spread into Meckel's cave and analyse existing pathoanatomical studies that explain the conduits and barriers of tumour spread. Understanding this pathoanatomical relationship is critical for neurologists and neurosurgeons alike to effectively correlate patient signs and symptoms to intracranial pathology and identify origins and sites of metastatic dispersion in similar rare clinical scenarios.

Keywords: malignant and benign haematology; neuroimaging.

Figure 1

Failure of abduction of the right eye (red arrow) and normal adduction of the left eye (green arrow) are consistent with a right abducens nerve palsy.

Figure 2

(A) T1-weighted fluid-attenuation inverse recovery MRI reveals isointense lesion in the vicinity of the cavernous sinus, which extends into Meckel’s cave (red arrow). (B) T1-weighted gadolinium-enhanced MRI reveals a homogenous enhancing lesion in the vicinity of the cavernous sinus which extends into Meckel’s cave (yellow arrow).

Figure 3

T1-weighted MRI revealed a slit-like right cavernous sinus invaded by tumour (red arrow) and a normal left cavernous sinus (yellow arrow).

Figure 4

(A) Partial removal of lateral dura of the right cavernous sinus exposes the cavernous sinus and Meckel’s cave. (B) Complete removal of encasing dura. (C) Removal of the anterior clinoid process further exposes the cavernous sinus. (D) Overview of adjacent anatomy of the cavernous sinus and Meckel’s cave. (Image provided courtesy of The Neurosurgical Atlas by Aaron Cohen-Gadol, MD.). ACP, anterior clinoid process; CN, cranial nerve; GSPN, greater superficial petrosal nerve; IAM, internal auditory meatus; PCA, posterior cerebral artery.