Otology & Neurotology

30:681Y682 Ó 2009, Otology & Neurotology, Inc.

Imaging Case of the Month

Imaging of Vestibular Schwannoma With Prevalent
Cystic Component: Cystic Vestibular Schwannoma

*Francesco Dispenza and †Alessandro De Stefano

*Dipartimento Scienze Otorinolaringoiatriche, Università degli Studi di Palermo, Palermo; and

ÞDipartimento di Scienze Chirurgiche Sperimentali e Cliniche: Sez. di Otorinolaringoiatria, Università degli
Studi BG. d’Annunzio[ Chieti-Pescara, Italy

Cystic vestibular schwannomas (VSs) are described as
behaving in a more aggressive fashion, with shorter pe-
riods of documented symptoms, poorer responses to
radiotherapy, and worse outcomes from surgical inter-
vention (1).
These factors include higher rates of engulfment of
neurovascular structures, the association with hypervas-
cular solid components, and the absence of an adequate
subarachnoid dissection plane.
Recommendations from BNew and Modified Report-
ing Systems from the Consensus Meeting on Systems for

FIG. 1. T1-weighted image of the right cystic VS of the internal

auditory canal and cerebellopontine angle. The solid portion of
the tumor is hyperintense after Gd administration. The cyst con-
tent is hypointense as compared with the brain. Enhancement of
the cyst capsule is noticeable.

Address correspondence and reprint requests to Francesco Dispenza,

M.D., Via paolo emiliani giudici, 37, 90127 Palermo, Italia; E-mail: FIG. 2. T2-weighted image with standard TR. The cyst content
francesco-dispenza@libero.it is displayed with the same intensity as the CSF. The solid portion
Institution where work was done was Gruppo Otologico Piacenza. seems isointense as the brain.

681

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682 F. DISPENZA AND A. DE STEFANO
FIG. 3. T2-weighted image with modified TR. The cyst content
seems hypointense as compared with CSF, allowing differential
diagnosis with arachnoid cysts.
Reporting Results in Vestibular Schwannoma[ suggested
that multicystic tumors with a cystic component on the
surface of the tumor be documented to facilitate clinical
studies (2).
We report a case of right-sided cystic VS of the inter-
nal auditory canal and cerebellopontine angle with prev-
alent cystic component.
Otology & Neurotology, Vol. 30, No. 5, 2009
Copyright @ 2009 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.
Magnetic resonance imaging represents the best
choice to diagnose and visualize the VSs. Cystic VSs
consist of 2 components: 1) a solid portion and 2) a
single or multiple cysts. Intravenous administration of
gadolinium (Gd) allows visualization of tumoral solid
component.
The solid portion of the tumor seems hyperintense in
T1-weighted images with Gd (Fig. 1) and hypointense in
T2-weighted images (Fig. 2). The cystic component is
displayed hypoisointense in T1-weighted images with
Gd (Fig. 1) and hyperintense in T2-weighted images
(Fig. 2). The cyst content can be distinguished from cere-
brospinal fluid (CSF) by variation of the time of re-
petition (TR) value in T2-weighted slice. This variation
has an important effect on the control of image contrast
characteristics (Fig. 3).
Tumors with cystic component have to be differen-
tiated from CPA epidermoids and subarachnoid cysts.
These latter 2 lesions are hypointense in T1 and hyper-
intense in T2 and do not enhance after Gd administration.
Fluid-attenuated inversion recovery and echo-planar
diffusion imaging are 2 kinds of sequences that can dis-
tinguish between epidermoids and arachnoid cysts (3).
REFERENCES
1. Shirato H, Sakamoto T, Takeichi N, et al. Fractionated stereotactic
radiotherapy for vestibular schwannoma (VS): comparison between
cystic-type and solid-type VS. Int J Radiat Oncol Biol Phys
2000;48:1395Y401.
2. Kanzaki J, Tos M, Sanna M, Moffat DA, Monsell EM, Berliner KI.
New and modified reporting systems from the consensus meeting on
systems for reporting results in vestibular schwannoma. Otol Neu-
rotol 2003;24:642Y8.
3. Dutt SN, Mirza S, Chavda SV, Irving RM. Radiologic differentia-
tion of intracranial epidermoids from arachnoid cysts. Otol Neurotol
2002;23:84Y92.