CEREBELLO PONTINE ANGLE

MASS LESIONS
Case presentation by
Dr Syed Shadan Ali Hashmi
JR1 Radiodiagnosis
 CASE 1
Chief complaints
 19 yr old female
 c/o
 B/L hearing loss since 3 years
 HEADACHE since 1 YEAR
GENERAL EXAMINATION

 Pulse-68/min
 BP-130/72mm Hg
 Temperature-afebrile
 CNS Examination : Shows decrease b/l hearing
Rest of the cranial nerves examination
WNL
Motor system appears WNL

 Rest systemic examination: WNL

DIFFERENTIALS

Acoustic Shwannoma
Meningioma
CASE 2
Chief Complaints

16 yrs old female

C/O
 tingling sensation and numbness over left
fronto temporal region x 1.5 yrs
 Headache.
 No h/o seizures, vomiting, tinnitus or vertigo
General Examination

 Pulse-86/min
 BP-128/72mm Hg
 Temperature-afebrile
 CNS Examination : No neurological deficit
noted
 Rest systemic examination: WNL
T1 T2
FLAIR
DIFFERENTIALS

Epidermoid cyst
Arachnoid cyst
 Introduction
Lesions of the cerebellopontine angle (CPA) are frequent and represent 6–10 percent of all
intracranial tumors.

Vestibular schwannomas and meningiomas are the two most frequent lesions and account
for approximately 85–90 percent of all CPA tumors.

Other lesions at CPA are:

• Epidermoid and dermoid

• Arachnoid cysts
• Facial nerve schwannomas

• CPA/internal auditory canal

lipomas
• Metastatic disease
 VESTIBULAR SCHWANNOMAS

• Vestibular schwannomas account for 70 to 80 percent of all

CPA lesions.

• Arise from the vestibular portion of CN VIII (most often from

the inferior vestibular nerve), inside the internal auditory
canal near the porus acusticus.

• Rarely arise from the cochlear portion of CN VIII.

• Peak age of presentation : 40-60 years

Vestibular schwannomas are typically benign and slow
growing.

Malignant degeneration is rare and usually associated with

NF-1.

Bilateral CN VIII schwannomas are pathognomonic for NF-2

CLINICAL HISTORY

• MC presentation is progressive unilateral sensorineural

hearing loss

• Small VSs may present initially with tinnitus.

• Enlarge one to two millimeter per year

• VS asscociated with NF2 are more aggressive.

.
IMAGING FEATURES

“Ice cream on a cone”.

• Iintracanalicular part: Cone

.

• VS passes through the porus

acusticus, expands when it enters the
CPA, forming the “ice cream” on the
cone.
IMAGING FEATURE

CT
NECT shows - mildly hyperdense

Contrast : enhances strongly

Calcification is rare

IAC enlargement
MR

T1W1: Isointense compare to cortex

T1 C+: Uniform enhancement

T2WI:Iso to heterogeneously hyperintense on T2WI

MENINGIOMAS

Meningiomas are extra-axial neoplastic lesions arising from

arachnoidal cap cells.

Approximately, 10 percent of all intracranial meningiomas arise

in the posterior fossa.

2nd most common CPA tumor, constituting approximately 10

percent of masses in this location.

Arise from the posterior petrous surface or the underside of the

tentorium
CLINICAL HISTORY

Peak occurrence is in the sixth and seventh decades.

NF2-related meningiomas occur at a younger age compared to

nonsyndromic meningiomas.

F:M ratio varies with age, peaking at 3.5-4:1 in middle-aged

patients.

Less than 10% of meningiomas become symptomatic.

MC symptom is headache
IMAGING FEATURE

CT
NECT shows - hyperdense to underlying parenchyma (75%) , it may be iso or hypodense
( 25%)

Contrast : Homogenous enhancement

Calcification in circular or radial pattern

Underlying parenchymal edema

Hyperostosis
MR

T1W1: Iso to slightly hypointense compare to cortex

T1 C+: Enhance strongly & homogensly

T2WI:Iso to moderately hyperintense compare to cortex

DSA : radial sunbust pattern of vessels

Dural “tail”
 EPIDERMOID

• Epidermoids are generally considered congenital/ developmental cyst,

arising from ectodermal heterotopia.

• lined with stratified squamous epithelium

• account for 3 to 7 percent of CPA masses.

• LOCATION:INTRADURAL (90%) $ INTRADIPLOIC (10%)

CPA cistern most common size (~50%)

EPIDERMOID IMAGING FEATURES

CT

Lobulated non enhancing lesions with CSF density

Insinuating growth pattern in CSF cisterns are characterstic

Calcification is seen in a minority of cases (10-25%)

MR 

Iso- to slightly hyperintense to CSF on T1 and T2WI but do not supress

on FLAIR
DWI: Shows restriction therefore appears as hyperintense.
ARACHNOID CYSTS

• Congenital, benign, intra-arachnoid pouch like lesions filled with

normal CSF.
• LOCATION: Superatentorial ( 90%)
Infratentorial ( 10-12 %) – mostly CPA cistern

• Majority of arachnoid cysts are asymptomatic and found incidentally

at imaging.

• Headache is most common symptom

• Most common congenital intracranial cyst.

75% are found in children and young adults .

M>F.

Hemorrhage is very rare .

 Imaging

 CT:Appear as CSF density

 MR:Isointense with CSF on T1 & T2 weighted images

 FLAIR :Shows complete suppression

 DWI:Shows no restriction
CASE 1
DIFFERENTIALS

Acoustic Shwannoma
Meningioma
ACOUSTIC SHWANNOMA MENINGIOMA
POINTS IN FAVOUR POINTS IN FAVOUR
Age and symptoms Extraxial mass lesion at CPA
IAC widening showing intense post contrast
enhancement
Intense enhancement

POINTS AGAINST

Age

Extension into the porus

acousticus
MOST PROBABLE DIAGNOSIS

ACOUSTIC SCHWANNOMA
CASE 2
DIFFERENTIALS

Epidermoid cyst
Arachnoid cyst
 EPIDERMOID CYST ARACHNOID CYST
POINTS IN FAVOUR POINTS IN FAVOUR
Age Age
Symptoms CSF density non enhancing
CT – non enhancing, hypo to cystic lesion
isoattenuating to CSF
POINTS AGAINST
Does not suppress on FLAIR
Restricts (bright) on DWI Sharply well marginated lesion

Suppress completely with

FLAIR.

Not restrict on DWI

MOST PROBABLE DIAGNOSIS

EPIDERMOID CYST
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