Presentation
Palsy of the left complex nerves (IX, X, XI).
Patient Data
There is a small ill-defined soft tissue mass filling the left jugular foramen and compressing the neighboring jugular bulb. It elicits an iso-to low signal on T1/T2, low signal on FLAIR with heterogeneous enhancement following IV contrast with adjacent thickening and enhancement of the dura “dural tail” sign. There is a superior intracranial extension towards the ipsilateral cerebellopontine angle and an extracranial towards the retrostyloid space.
The high signal on the FLAIR sequence of the left transverse/sigmoid sinuses and the jugular vein is certainly due to the slow venous flow by compression of the jugular bulb.
The CT scan was performed after the MRI exam revealed a calcified mass centered on the left jugular foramen, filling both pars nervosa and pars vascularis and adjacent to the jugular spine and the posterior wall of the vertical portion of the carotid canal. It shows an intracranial extension towards the ipsilateral cerebellopontine angle and an extracranial extension towards the retrostyloid space.
Case Discussion
CT and MRI features of a partially calcified mass centered on the jugular foramen with intra-and extracranial extension suggestive of a foramen jugular meningioma.
On imaging, the main differential diagnosis includes:
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jugular foramen schwannomas
on CT, usually well-demarcated, iso to hypoattenuating to brain parenchyma may show expansion and remodeling of the affected jugular foramen and may have a characteristic dumbbell configuration
on MRI, typically of low signal on T1, high signal on T2 with cystic degeneration if larger tumors. On postcontrast sequences, small lesions show a homogeneous enhancement and larger tumors a heterogeneous enhancement
association with neurofibromatosis type 2 (NF2): particularly if bilateral
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paraganglioma (jugular paraganglioma), the most common tumor of the jugular foramen 1
on MRI “salt and pepper” appearance with intense enhancement and multiple small flow voids
irregular erosion of the margin of the jugular foramen, with decalcification or destruction of the surrounding bone in larger tumors
may show invasion of jugular bulb/vein with intraluminal growth
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metastatic malignant tumors (from lung, breast, and prostate) or lymphoma 1
usually destructive lesions of the adjacent bone with an irregular margin of the jugular foramen
For a full list of differentials see the article on jugular fossa masses.
Additional contributor ZE.Boudiaf, MD, CHU, Constantine, Algeria
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