PMC5609397_01
(a and b) (Lateral and AP views of skull) and (c and d) (axial and coronal CT) show a heavily calcified lesion in the left frontotemporal region with its origin from the temporal bone immediately behind the pterion. The mass is non-homogeneous with sharply defined margins. The arrow indicates where the lesion may have become intradural
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F1
Initial work up consisted of X-ray of the skull, which demonstrated a dense calcified lesion in the left frontotemporal region [Figure 1]. At this time, an otolaryngologist ordered a computed tomography (CT) scan, which demonstrated growth of the mass [Figure 1].
MR images (a and b) are from 2014; (c and d) are from 2016, just prior to surgical resection. These demonstrate growth of this lesion over a two-year period. Axial FLAIR images (a and c) demonstrate adjacent vasogenic edema extending in the left temporal lobe and optic radiation. These images reveal the extensive nature of this mass, occupying a large part of the left middle cranial fossa with resultant shift of the uncus medially deforming the suprasellar cistern and shifting the midbrain. On coronal images upward displacement of left MCA is seen
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F2
This was verified by MRI, which also showed an increase in surrounding edema with transtentorial herniation and mass effect on the midbrain [Figure 2].
CT through middle cranial fossa shows the mass and its relations with the left petrous bone. Note close relations of the mass to the left cochlea and geniculate ganglion
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F3
While his hearing was intact and face symmetric, there was an unclear relationship of the mass to the geniculate ganglion and cochlea on immediate preoperative imaging studies [Figure 3].
Postoperative CT (a) and MR (b and c) obtained on postoperative day one, demonstrate complete resection of the large calcified lesion with stable residual vasogenic edema and uncal shift
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F4
Postoperative imaging showed a complete resection [Figure 4] and he was discharged in excellent condition on the second postoperative day.
Permanent pathology obtained after surgical resection of the lesion. Panel (a and b) represent H&E stained sections demonstrating curvilinear trabeculae of woven bone surrounded by moderately cellular fibrous stroma. Negative epithelial membrane antigen stain and negative somatostatin receptor 2 staining are represented in Panel (c and d), respectively
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F5
Despite analysis of the frozen section raising a concern for meningioma, permanent analysis showed FD [Figure 5].