Radiological Imaging of the Visual Pathways: A Patient with a Planum Sphenoidale Meningioma

Michael Tibbetts, Harvard Medical School Year IVGillian Lieberman, MD

Michael Tibbetts, 2008Gillian Lieberman, MD

September, 2008

Descartes, 1604•Lavidor M, Walsh V. The nature of foveal representation. Nature Reviews Neuroscience 2004; 5, 729-735.

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Agenda

1. Case Presentation of Patient RR2. Anatomy of the Visual Pathways3. Menu of Tests for Imaging of the Visual

Pathways4. Review of Patient RR’s Imaging Studies5. Discussion of Findings

Michael Tibbetts, 2008Gillian Lieberman, MD

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Patient RR: PresentationHistory:

75 year-old woman who noticed progressive decreased vision in her left eye starting ~2 years ago with no visual changes in right eye– PMH: Hypertension– Ocular history: unremarkable

Exam: 20/25 OD 20/400+1 OS no improvement w/pinholeColor vision 16.5/17 OD, unable to see plates OSRelative afferent pupillary defect OSNo other focal neurological deficits

Michael Tibbetts, 2008Gillian Lieberman, MD

Next step: Direct visualization of the retina and optic nerve head

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Fundus ExaminationMichael Tibbetts, 2008Gillian Lieberman, MD

www.revophth.com/publish/images/1_13156_0.jpg

Clinical Features of Optic Nerve Disease:

1. Afferent pupillary defect2. Optic disc changes3. Poor color vision ?

Patient RR has 2 features suggestive of optic nerve disease (color vision unable to be assessed to do poor vision and field loss not formally evaluated)

http://faculty.washington.edu/alexbert/MEDEX/Fall/eye-fundus.jpg

Optic disc pallor

4. Field loss ?

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Anatomy of the Visual Pathways

Michael Tibbetts, 2008Gillian Lieberman, MD

http://www.iupucanatomy.com/images/Picture%201465.jpg

•Visual information processed by rods and cones of retina

•Transmitted via optic nerves (CNII)

•Nasal fibers cross at the optic chiasm

•Fibers synapse at the lateral geniculate nucleus

•Geniculocalcarine tract forms the optic radiation that fans into optic radiations to occipital cortex

Lesions here cause:Unilateralfield defects

Lesions here cause:Bilateralfield defects*

*Exception: temporal 60-90 degrees of vision (temporal crescent) has monocular representation in the most anterior part of the striate cortex.

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Differential Diagnosis of Unilateral Optic Neuropathy

Inflammation/Infection• Idiopathic demyelinating

optic neuritis

Vascular (infarction)• Anterior ischemic optic

neuropathy• Posterior ischemic optic

neuropathy

Michael Tibbetts, 2008Gillian Lieberman, MD

Trauma •Isolated optic nerve trauma is possible, but very unlikely

Tumor•Optic nerve compression

- Intracranial meningiomas, primary optic nerve sheath tumors

Optic nerve infiltration - Leukemia, lymphoma or disseminated

carcinoma•Chiasmal compression

- Pituitary tumors, craniopharyngioma

Next: Review the Menu of Tests for Imaging the Visual Pathways

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Menu of Tests for Imaging of the Visual Pathways

Michael Tibbetts, 2008Gillian Lieberman, MD

CT+better for osseous detail of

orbits and calcifications+better for assessing orbital

fractures

MRI+better for imaging optic

nerve and tumors+better for evaluation of

cerebral perfusion and post-chiasmal lesions

http://www.djo.harvard.edu/files/2918_349.jpg T1 PACS, BIDM C, 2007

Globe

Maxillarysinus

Inferior Turbinates

Orbital Floor

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Michael Tibbetts, 2008Gillian Lieberman, MD

Ultrasound+used for imaging globe when

no view to posterior pole +used for imaging of foreign

bodies in the orbit-poor penetration and resolution

Angiography+used to assess for vascular

malformations, stenosis or vascularized tumors

-invasive

www.ophthalmicultrasonography.com/CD%20BScan.htm www.urmc.rochester.edu/smd/Rad/diagneuro.htm

Menu of Tests for Imaging of the Visual Pathways

Detached Retina

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MRI Imaging of the Visual PathwaysMichael Tibbetts, 2008Gillian Lieberman, MD

T2 with Fat Saturation – improved visualization of optic nerves

1. Optic canal2. Globe3. Dorsum sellae4. Sphenoid sinus5. Macula6. Medial rectus muscle7. Lateral rectus muscle8. Optic nerve9. Ophthalmic artery10. Temporal lobe

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2

8

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3

OpticNerve

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4 79

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•Wichmann W, Muller-Forell W. Anatomy of the visual system. Eur J Radiology 2004; 49, 8-30.

T1

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T2 MRI Imaging of the Visual PathwaysMichael Tibbetts, 2008Gillian Lieberman, MD

Optic tract

Archcortex

Optic nerveAmygdolo- claustral area

Optic tract

Archcortex

Optic radiation

www.e-anatomy.org

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Patient RR: Head MRI 6/2007

“No evidence of acute infarct, mass effect, or hydrocephalus.”

Student Name, yearGillian Lieberman, MD

T1 Transverse BIDMC, PACS, 2007 T1 Sagittal BIDMC, PACS, 2007

Optic Nerve

Optic Chiasm

Requisition: “loss of vision left eye”

Occipital cortex

Optic chiasm

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Patient RR: MR Angiogram 6/2007

Michael Tibbetts, 2008Gillian Lieberman, MD

“No evidence of vascular occlusion or stenosis” BIDMC, PACS, 2007

Basilar artery

Internal carotid artery

Vertebral artery

Anterior cerebral artery

Next: Further Testing for Evaluation of Vision Loss

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Further Testing: Visual Fields and Optical Coherence Tomography (OCT)

Michael Tibbetts, 2008Gillian Lieberman, MD

• Significant superior and temporal field loss OS

• Optical coherence tomography (OCT) of the optic nerves demonstrated definite nerve fiber layer losses OS and questionable thinning of optic nerve OD

• Findings suggestive of “compressive lesion” by neuro- ophthalmologist despite initial negative imaging

OS OD

Courtesy of Nurhan Torun, M.D., 2007

Next: Further Imaging of the Visual Pathways in Patient RR

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Patient RR: C+ MRI of Orbit and Head 12/2007

Michael Tibbetts, 2008Gillian Lieberman, MD

T1 Transverse Pre-contrast T1 Transverse Post-contrast BIDMC, PACS, 2007

Enhancing lesion w/ well-circumscribed marginsDDx: meningioma, pituitary macroadenoma, hemangiopericytoma

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Planum Sphenoidale Meningioma

Michael Tibbetts, 2008Gillian Lieberman, MD

• Meningioma of the dura of the planum sphenoidale: lying on the midline posterior to the olfactory nerve meningiomas and anterior to the tuberculum sella meningiomas

• Planum sphenoidale forms the roof of the sigmoid sinus

• Peak incidence at age 45, 2:1 female• Isointense or hypointense on T1 MRI, intense

enhancement w/ contrast• Small lesions and those isointense may be

difficult to pick up on MRI• Focal areas of nonenhancement within the

tumors may be present representing areas of hemorrhage, scar, cyst, or necrosis.

T1 Sagital Post-Contrast BIDMC, PACS, 2007

Mass extends from sella/suprasellar region w/ involvement of cavernous sinuses, but normal cartoid flow

Patient RR: C+ T1 Head MRI 12/2007

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Was the lesion missed in the original head MRI?

Michael Tibbetts, 2008Gillian Lieberman, MD

T2 Transverse BIDMC, PACS, 2007

Incorrect imaging study was ordered for “Vision loss left eye”.

Orbital cuts and contrast enhanced images not evaluated.

Lesion evident on original MRI, but did not enhance without contrast

Patient RR: T2 Head MRI 6/2007

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Treatment of Planum Sphenoidale Meningioma

Michael Tibbetts, 2008Gillian Lieberman, MD

Surgical resectionTransphenoidal or transcranial approaches10-40% have worsening of vision25-80% have improvement in visual function

Radiation therapyMay halt growth of tumorLess ideal than surgery because radiation does not remove pressure on optic nerve or chiasmProton beam radiotherapy – less scatterCyberknife

No treatment – follow with imagingNot recommended given visual deficit, but Patient RR opted for no intervention

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Role of Imaging in Following TumorMichael Tibbetts, 2008Gillian Lieberman, MD

OS OD

Courtesy of Nurhan Torun, M.D., 2008

9/2007

5/2008

Tumor unchanged in volume by MRI, but increased visual field loss in superotemporal right eyeBIDMC, PACS, 2008

Patient RR: C+ T1 Head MRI 9/2008

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Summary• Patient RR diagnosed w/ planum sphenoidale

meningioma after presenting with vision loss in left eye

• Lesion not detected initially because correct study not ordered.

• Order physician must select imaging of visual pathways based on possible location of lesion.

Vision loss in only one eye -> pre-chiasmalVision loss in both eyes -> chiasmal, post-chiasmal

Michael Tibbetts, 2008Gillian Lieberman, MD

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References• Lavidor M, Walsh V. The nature of foveal representation. Nature Reviews

Neuroscience 2004; 5, 729-735. • Riordan-Eva P, Whitcher JP. Vaughan and Asbury’s General Ophthalmology 2004,

pages 259-280. • Wichmann W, Muller-Forell W. Anatomy of the visual system. Eur J Radiology 2004;

49, 8-30.• Riordan-Eva P. Clinical assessment of optic nerve disorders. Eye 2004; 18, 1161-1168.• Nozaka K et al. Effect of early optic canal unroofing on the outcome of visual functions

in surgery for meningiomas of the tuberculum sellae and planum sphenoidale. Neurosurgery 2008; 62, 839-846.

• Mohit A et al. A large planum sphenoidale meningioma with sinonasal extension in a child. Case report and review of the literature. Pediatric Neurosurgery 2003; 39, 270- 274.

• Digital Journal of Ophthalmology. www.djo.harvard.edu. Accessed on 9/21/2008. • Interactive Atlas of Anatomy. www.e-anatomy.org. Accessed on 9/21/2008.

Michael Tibbetts, 2008Gillian Lieberman, MD

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Acknowledgements

• Nurhan Torun, MD• Aarti Sekhar, MD• Gillian Lieberman, MD• Maria Levantakis• Larry Barbaras

Michael Tibbetts, 2008Gillian Lieberman, MD