Be sure to make the right differential considerations in this brain case

This 43-year-old female presents with neck pain. Try to work through the case looking at just the first four images, before looking at the same images with arrows indicating key findings.

Q1 – The differential diagnosis includes all of the following, except:

(a) Glomus
(b) Meningioma
(c) Epidermoid
(d) Schwannoma

Axial T2

Axial T1

Axial T1

Coronal T1

Axial T2

Axial T1

Axial T1

Coronal T1

 

A1 – (c) Epidermoid

 

Q2 –¬†Glomus jugulare may present as any of the following, except:

(a) Vernet syndrome
(b) Collet-Sicard syndrome
(c) Horner syndrome
(d) Bell’s palsy

Q3 – Glomus jugulare may demonstrate any of the following, except:

(a) Salt-and-pepper appearance on T1 MRI
(b) Salt-and-pepper appearance on T2 MRI
(c) Minimal or no enhancement on MRI
(d) Erosion of the jugular spine on CT

 

Glomus tumor is a paraganglioma of the jugular fossa which may arise from Jacobson’s nerve or Arnold’s nerve. It may result in cranial neuropathies of the skull base including those in the jugular foramen 9, 10, 11 (Vernet syndrome) or in larger lesions may also involve 12 (Collet-Sicard syndrome). Horner syndrome may also be seen secondary to involvement of autonomics closely associated with the carotid and jugular walls. Bell’s palsy involves the 7th nerve complex which is more superior in location and exits through the internal auditory canal.

Glomus tumor markedly enhances and may erode the jugular spine. The salt-and-pepper appearance due to high vascularity and multiple flow voids in a classic appearance.

It may be part of endocrine adenomatosis IIB/III syndrome and 6-8 percent are multiple.

 

A2 – (d) Bell’s palsy

A3 – (c) Minimal or no enhancement on MRI

 

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References:

1. Eldevik OP et. al. Imaging Findings in Schwannoma of the Jugular Foramen. AJNR 21(6): 1139-1144.

2. Vogl T et. al. Paragangliomas of the Jugular Bulb and Carotid Body. AJR 1989; 153(3): 583-587.