PMC3669473_01
CT of cranio-cervical junction, (a) Axial cut shows the mass attached to right posterior rim of atlas, (b) Sagittal reformation shows the relation of the mass to the bony structures of the cranio-cervical junction, (c) Axial bone window shows the relation of the mass to the atlanto-occipital joint and the vertebral artery
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F1
With and without contrast, head and cranio-cervical junction computed tomography demonstrated a calcified mass, measuring 4.3 x 2.5 cm in the axial cuts [Figure 1a], and its height was 3.5 cm in sagittal reconstruction [Figure 1b].
CTA of cranio-cervical junction. Right and middle compartment in this figure is a coronal reformation of the vertebral artery pathway in the cranio-cervical junction. The right and middle arrows point to the vertebral artery passing inside the calcified mass. Left arrow points to the vertebral artery in axial insight encased within the anterior pole of the tumor with the PICA running inside the mass
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F2
CTA demonstrated that the anterior portion of the mass engulfing the right vertebral artery [Figure 2], hence transcondylar approach was planned for surgery.
Intraoperative microscopic picture showing the free dissection of vertebral artery, PICA loop, and the spinal accessory nerve at the anterior pole of the rock like tumor after drilling of the occipital condyle
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F3
Intraoperatively, the tumor was a rock-like mass with scanty soft tissue at its periphery; it was engulfing the vertebral artery, posterior inferior cerebellar artery, and rootlets of lower cranial nerves in its substance [Figure 3].
Histopathologic slides of the specimen, (a) Low magnification of the growth pattern of the non calcified portion of the lesion. Note the sheet-like growth interrupted by scattered nodules or nests (H and E, x20), (b) High magnification of the cytology of the meningothelial tumor cells; note the eosionophilic inclusions in the cytoplasm of the tumor cells (H and E, x60), (c) Calcified portions of the specimen showing the lamellated vaguely psammomatous concretions. Note that in the meningioma between calcified areas, the morphology (black arrow) remains rhabdoid (H and E, x20), (d) Vimentin immunohistochemistry showing the strong cytoplasmic labeling characteristic of rhabdoid meningioma (x60)
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F4
A vimentin immunostain was strongly positive and highlighted the cytoplasmic inclusions [Figure 4].
Immunohistochemical staining for Ki-67 antigen, (a) x60, MIB-1 proliferation index was quantitated at 12.9%, (b) Shows detail of the prominent nucleoli in the MIB-1 immunostained section
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F5
An MIB-1 proliferation index was quantitated at 12.9% (32/247) [Figure 5].
Post-contrast axial view MRI follow-up done after 14 months shows no recurrence in the tumor bed
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F6
Her follow-up images after 14 months of surgery showed no recurrence in the tumor bed [Figure 6].