PMC9830093_01
(a) Patient showing large retroauricular mass with
(arrow mark) black dot suggestive of puncture site for glue, (b) CT head
Axial view showing large herniating mass with the destruction of,
jugular foramen, mastoid, and lateral suboccipital region, (c) T1
Sequence MRI (Axial) showing large hypointense mass occupying both
middle and posterior cranial fossa abutting internal carotid artery, (d)
T 2 sequence (Axial) showing large hyperintense mass with multiple flow
voids (Arrow mark showing internal carotid artery), (e) T1 contrast
sequence (Axial) showing large homogenously enhancing mass at
retromastoid region extending anteromedially up to ventral brain stem
(arrow mark), (f) T1 contrast sequence (coronal) showing large
homogenously enhancing mass at retromastoid region (arrow mark) with
preserved plane from the brain stem.
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CT brain revealed complete disappearance of bony landmarks from the left suboccipital bone, mastoid, and foramen magnum (Figure 1 a-f).
(a) Left ECA injection oblique view, showing
hypervascular tumor with large intense tumor blush and multiple enlarged
sinusoidal spaces within the tumor core, (b) LVA injection, AP view
showing the core of the lesion which is made up of large communicating
sinusoidal spaces, (c) LAT view, fluorospot image, direct needle
puncture done under roadmap with an attempt to access the deep-seated
sinusoidal spaces first, (d & e) Glue cast, Occipital artery
angiogram, Lat view, showing no further filling and LVA angiogram, AP
view, after Second percutaneous injection of nBCA, shows no further
filling from LVA injection, and <10% filling from occipital artery
injection (oval); the LVA is no more filling on the occipital artery
injection as the muscular collaterals have been retrogradely filled with
glue (thin arrow), (f) Final check angiogram ECA injection AP view,
showing near total devascularization with a small area of fine blush in
the anteromedial portion of the tumor.
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Only the anterior aspect of the tumor was showing mild blush as it had blood supply directly from ECA (Figure 2 a-f).
(a) Post-op NCCT head showing near total resection
of mass both at intracranial and extracranial region (Arrow mark), (b)
Post-op image of the patient after 2 months showing healthy scar mark
(arrow mark) and overlying skin.
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The overlying skin and incision site were healthy (Figure 3 a & b).
(a) Histopathology suggested mixed adenoid cystic
carcinoma with both solid and cribriform components, but solid
components are predominant (H&E, 100X), (b) IHC demonstrated GFAP
negative tumor cells (100X), (c) S100 positive on IHC showing ductal
component (100X), (d) p63 positive on IHC showing myoepithelial
component (100X).
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Histopathology was suggestive of mixed ACCs (Figure 4 a-d).
(a) Image of patient's postauricular region
showing radiation-induced cutaneous reaction (Pigmentation [yellow
arrow] and ulceration[green arrow]).
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However, the radiation-induced cutaneous reaction occurred over the incision site and surrounding area (both pigmentation and ulceration) (Figure 5 a).