PMC4672581_01
(a) Postcontrast head computed tomography scan revealing an enhanced mass in the clivus. (b) Postcontrast sagittal computed tomography showing clival erosion (arrowheads). T1-weighted (c) and T2-weighted (d) magnetic resonance images showing an iso- and hypo-intense mass, respectively. (e) Postcontrast sagittal T1-weighted magnetic resonance images revealing a homogeneously enhanced tumor. (f) Three-dimensional angiography showing both meningohypophyseal trunks (arrows)
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F1
Computed tomography (CT) demonstrated a homogeneously enhanced mass (5.1 cm x 3.1 cm x 4.9 cm) in the clivus [Figure 1a and b]. The mass was isointense and hypointense on T1- and T2-weighted magnetic resonance imaging (MRI), respectively [Figure 1c and d]. Gadolinium-enhanced MRI revealed a homogeneously enhanced tumor extending into the brainstem [Figure 1e]. Three-dimensional (3D) CT angiography showed feeder arteries arising from the bilateral meningohypophyseal trunks (MHTs) [Figure 1f].
The first operation via an endoscopic endonasal transsphenoidal approach. An intraoperative image showing a yellowish gray tumor of the clivus (a), and profuse bleeding in the tumor (b). (c) A histological specimen showing numerous multinucleated giant cells with dense eosinophilic cytoplasm, scattered against a background of uniform mononuclear cells. Bar 50 mum. (d) Postcontrast sagittal T1-weighted magnetic resonance images revealing a partially resected tumor via the endoscopic endonasal transsphenoidal approach. Regrowth of the tumor after radiation (e) and showing an increase in recurrent tumor size (f)
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F2
The tumor was yellowish gray and bled profusely [Figure 2a and b]. Partial resection was performed because of massive intraoperative bleeding from the feeding artery (850 mL; [Figure 2b]). Histopathological analysis revealed a cellular tumor comprised of osteoclastic giant cells and stromal cells [Figure 2c]. Postoperative MRI showed partial resection [Figure 2d]. Two months after the initial surgery, MRI confirmed gradual postradiation tumor regrowth [Figure 2e]. The tumor gradually increased in size and eventually invaded the brainstem, leading to brainstem edema [Figure 2f].
Angiography showing weak tumor staining from meningohypophyseal trunks (arrows). Right side (a), and left side is (b). The second (c) and the third operations (d): An intraoperative image showing a fibrous tumor via the endoscopic endonasal transsphenoidal approach (c), and the anterior transpetrosal approach (d), respectively. (e) Postcontrast sagittal T1-weighted magnetic resonance images revealing partial resection after surgery. (f) A histological specimen showing spindle cell proliferation, with scattered giant cells, pigmentation, and hyalinization. Bar 50 mum
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F3
Angiography revealed weak tumor staining, which may have been caused by radiotherapy [Figure 3a and b]. The tumor was fibrotic and there was slight intraoperative bleeding [Figure 3c]. Thereafter, 1 month after the second surgery, we performed the anterior transpetrosal approach (ATPA) for the subdural lesion [Figure 3d]. Although blood control was good owing to MHT interruption by this approach, the tumor was tightly adhered to the brainstem, and we performed a partial resection [Figure 3e]. Histopathological analysis revealed mitotic spindle cell proliferation [Figure 3f].