- Email: [email protected]
Middle Cranial Fossa Meningioma*
NOTES, CASES, INSTRUMENTS
798
contrast media reached the subdural space. Both patients suffered intense pain, nausea and vomiting, but these acute initial symp toms slowly diminished and disappeared after a few hours, without after-effects. Manchester 3 reported a different compli cation following orbitography with 3 5 % Diodrast: a patient lost all light perception in the eye on the side of the injection, the im mediate fundus picture being that of an oc clusion of the central retinal artery. H o w ever, 26 hours later, vision had returned to 2 0 / 2 0 and the fundus was normal except for slight retinal edema. Orbitography with water-soluble contrast material is relatively frequent in E u r o p e and South America, judging from the de scriptions of its advantages and harmlessness. 4 " 9 T h e complications listed are con sidered rare and, to our knowledge, no per manent damage has been reported. Since the approach and technique for or bitography are identical to that used in retrobulbar anesthesia, occasional poor akinesia might be explained by rapid diffusion of the injected material into the subdural space. SUMMARY
A case is reported in which, as a result of diagnostic orbitography, radiopaque materi al entered the subdural space at the base of the midbrain and descended to the subdural space at the level of the lumbar spine. N o transient or permanent clinical damage re sulted from this complication. Room 261 /irmed Forces Institute of Pathology (20025). REFERENCES
1. Gifford, H., Jr. : Motor block of extraocular muscles by deep orbital injection. Arch. Ophth., 41 :S, 1949. 2. Lombardi, G. : Orbitography with water-sol uble contrast media. Acta radiol. (Stockh.), 47:417,1957. 3. Manchester, P. T., Jr., and Bonmati, J. : Iodopyracet (diodrast) injection for orbital tumors. Arch. Ophth., 54:591, 1955.
4. Montresor, D. : Orbitografia con mezzi di contrasta. A. Hi. Soc. oft. Lomb, 2:258, 1952 5. Pettinati, S. : La localizzazione radiologica dei corpi estrangi orbtiari con I'auslio dei mezzi di contrasta radio-opachi idrosolubih. Riv. otoneuro-oftal., Rass. ital. Ottal., 22:587, 1953. 6. Montresor, D. : Ulteriore contribute all'indagine orbitografica con mezzi di contrasta iodici idrosolubili. Riv. oto-neuro-oftal., 29:258, 1954. 7. Chinaglia, V., and Santelli, F . : Impiego di mezzi di contrasta nella diagnostica delle affezioni dellOrbita. Riv. oto-neuro-oftal., 29:24, 1954. 8. Cowie, J. W., and Groves, J. S. : Preliminary report on the use of contrast media in orbital ra diography. Brit. J. Ophth., 39:283,1955. 9. Ananos, V. A.: Orbitography with sodium diatrizoate (hypaque). Sem. med. (B. Aires), 22:165, 1963. 10. Lombardi, G. : Personal communication.
MIDDLE CRANIAL FOSSA MENINGIOMA* CAUSING
UNILATERAL
LOSS
OF
VISUAL
ACUITY GILBERT S M O L I N ,
M.D.
Columbus, Ohio Middle cranial fossa meningiomas and the chondromatous type of meningioma are both relatively rare entities. T h e patient here presented had both of these conditions. In addition, the large size of the tumor mass resulted in diverse ophthalmologic and neu rologic symptomatology. C A S E REPORT
M. M. S., a 46-year-old white woman, was ad mitted on November 13, 1964, for the first time to Ohio State University Hospitals. About eight years prior to admission, the patient noted the onset of left esotropia, dysphagia, lagophthalmos of the left eye, staggering gait to the right and left occipital headaches. Diplopia was present in certain fields of gaze and clonic twitching was noted around both eyes. She was seen at the Cleveland Clinic Hospital from August 4 to 12, 1957, and demonstrated pa resis of the left VI, VII, X and XI cranial nerves. A spinal fluid examination was within * From the Department of Ophthalmology, The Ohio State University.
NOTES, CASES, INSTRUMENTS normal limits. A pneumoencephalogram per formed on August 5, 1957, was similarly inter preted as being normal. The tentative diagnosis of posterior fossa tumor was made and explora tion recommended. The patient refused surgery. The symptoms progressed slightly until 1960 when excessive fatigability arose, concomitant with a 10-lb weight loss, brown discoloration of her skin, decreased blood pressure and syncopal attacks. A diagnosis of Addison's disease was made and the patient was placed on cortisone and digitoxin. She had suffered 12 syncopal attacks since 1960 and required two hospitalizations. Within the last five or six weeks she had noted increasing severity of her left-sided occipital headache, increased fatigability and pronounced myokymia. The dysphagia and syncope had wor sened. A boring intermittent pain arose behind her left eye and her visual acuity became worse. The patient had been wearing a frosted lens over her left eye for the past seven years because of intolerable diplopia. However, light perception and movements were noted with the left eye in the past; most recently only light could be per ceived. Physical examination revealed a thin white woman with tan skin. Her vital signs were with in normal limits. The woman was 4 ft, 11.5 in. tall and weighted 80 lb. Examination of the cranial nerves revealed the following: (I) no ab normalities were noted; (II) the visual acuity was 20/25 O.D., and no light perception, O S . ; ( I l l ) no abnormalities were noted; (IV) weakness of the left superior oblique muscle existed; (V) the corneal reflex was absent in the left eye; (VI) the left lateral rectus muscle was paretic and end-point nystagmus was present on lateral gaze to either side, more marked on the right; (VII) there was weakness of the left orbicularis muscle, lack of facial expression, and no salt taste on the left side of the tongue (anterior two thirds) ; (VIII) hearing loss was present on the left side; (IX) a decreased gag reflex was present. The pal ate was elevated on the left side; (X) dysphagia was present; (XI) no abnormalities were noted; (XII) atrophy and fasiculations of the muscles on the left side of the tongue were noted. Position sense was normal. The Babinski sign was negative and no ankle clonus was present. The finger to nose and the heel to shin tests were poorly executed. Sensation was diminished to the following: the left side of the face, the left ear, the left side of the palate and the left side of the tongue. The left forehead had normal sensation, indicating central facial nerve involvement. The patient staggered to the right upon walk ing and fell to the left during the Romberg test. Deep tendon reflexes were symmetrical (either l-f or 2 + ) . The abdominal reflex was gone. On November 19, 1964, roentgenologic exami nation revealed a radiolucent defect in the poste rior midportion of the petrous bone. The sella
799
turcica was enlarged and only one anterior clinoid process was seen (right side). The diagnosis was that of a lesion in the region of the middle crani al fossa on the left On November 20, an eye consultation was ob tained. In addition to the neurologic findings al ready listed, several other findings were noted. The exophthalmometer reading was 24, O.D., and 28, O.S. External examination revealed a left esotropia of 70 prism diopters in the primary po sition, and the lower third (exposed portion) of the cornea showed punctate staining with fluorescein. The pupil responded very sluggishly to direct light, O.S. Fundus and slitlamp examination re vealed no further abnormalities (the optic discs showed no evidence of pathology). Tangent screen examination was a 3-mm white test ob ject demonstrated an enlarged blindspot 24/22 cm but otherwise normal field, O.D. No field was present, O.S. The impression was that the patient had a large cerebellopontine angle tumor. An electroencephalogram performed on the following day showed localization to the lower central area of the left cerebrum. A pneumoen cephalogram was cancelled when the patient had a Jacksonian convulsive seizure. On November 24, 1964, angiography demonstrated a mass with a 5 cm diameter in the area of the left cerebello pontine angle elevating the left middle cerebral and posterior communicating arteries. On Novem ber 29, 1964, the maintenance dose of steroids was increased and the patient received 1,500 cc of whole blood over a 24-hour period. On November 30, 1964, a left fronto-parieto-temporal craniotomy was performed. The temporal dura was in cised and a firm pink encapsulated mass was noted beneath the temporal lobe lying intradurally and extending into the anterior, temporal and posterior fossae (with left cerebellar hemisphere involvement). It also extended into the sella and posteriorly into the petrous portion of the tempo ral bone. The III, V, VII, VIII, IX and X cranial nerves were thinned and markedly dis placed. The pituitary gland could not be iden tified. The impression was that this was a large middle cranial fossa meningioma. The pathologic examination of the tumor re vealed that the lesion was an interweaving pat tern of immature chondroid cells (figs. 1 and 2) and blood vessels in a pattern which is fairly typ ical of a meningioma. The unusual feature of this case was that the total differentiation of the mesenchymal cells present was toward immature cartilage rather than the usual fibroblastic tissue. The tumor was a chondromatous meningioma. The patient had a stormy postoperative course for several days. On December 16, 1964, a lateral tarsorrhaphy was performed (Elschnig tech nique), O.S., under local anesthesia. The patient was discharged the next day on the following medications: Dilantin, cortisone acetate, probanthine and trionine. Her neurologic examination on discharge remained unchanged.
NOTES, CASES, INSTRUMENTS
800
Fig. 1 (Smolin). Chondromatous meningioma under low-power magnification.
Fig. 2 (Smolin). Chondromatous meningioma under high-power magnification. DISCUSSION
Meningiomas constitute 15% of all intracranial tumors. 1 The frequency in females to males is 6 to 4 and the average age of the patient is 46.6 years of age. Meningiomas are rare in childhood and in the aged. There is an increased incidence in Negroes. The
relationship of meningioma to trauma is doubtful.2 Uihlein stated that meningiomas arise from clusters of arachnoid cells and tend to occur in specific sites.3 Cushing and Eisenhardt list three theories as to the origin. They are as follows: (1) neuroectoderm (in a sense gliomatous), (2) fibroblastic and (3) a middle ground (from primitive leptomeningeal cells from that part of the ecto derm giving origin to the cell masses of the neural groove and neural crest). 2 Meningiomas, over the course of years rarely, if ever, tend to alter in type. Cushing classifies meningiomas as nine types. The most frequent type is nonreticulin or colla gen forming tumors and the least frequent type chondroblastic and lipoblastic menin giomas. Only one case of chondroblastic me ningioma was listed by Cushing in his series of 306 meningiomas. This case occurred in the temporal fossa and it acted like a menin gioma of the more common variety. The etiology is believed to be a transition from meningeal fibroblasts to cartilage.2 The site of the meningioma in decreasing frequency is as follows: parasagittal, free convexity, sphenoidal ridge, olfactory groove, suprasellar, posterior fossa, spine, temporal fossa, falx, without durai attach ment, Gasserian, multiple, and finally in traorbital. They are more common internal to the dura.2 It must be emphasized that meningiomas may occur anywhere within the human skull and that the direction these so-called "harm less or benign" growths may take in their expansion is not predictable. (Meningiomas are considered benign because of their histol ogy.) They may attain quite a large size and may extend from one cranial fossa to another as illustrated in this case. This peculiarity of extension is common with sagittally located tumors. They may grow from one cerebral hemisphere to another be neath the falx, or from one temporal fossa to infratentorial levels, or out of the poste rior fossa into the parasellar region.4
NOTES, CASES, INSTRUMENTS Meningiomas account for the unilateral loss of vision in 4.6% of the 310 cases Uihlein studied.3 Lesions of the structures of the eyeball and glaucoma were equally fre quent and together accounted for 50% of the cases. Trauma accounted for 13%. Lesions of the optic nerve or visual pathways ac counted for 34.8%. The meningiomas were included in this last group. Sphenoidal ridge,5 inner ridge 8 and ante rior clinoid process meningiomas3 have been reported as causing unilateral loss of visual acuity. Generally speaking the visual acuity loss is much slower with tumors than with optic neuritis. Inner ridge meningiomas have associated homolateral optic atrophy and visual field defects. In the sphenoidal ridge tumors the most common ocular finding was visual loss. Proptosis was also a common finding. Anterior clinoid process meningiomas are discussed by Uihlein and Weyand in their article on unilateral visual acuity loss.8 Eisberg described meningiomas in the middle cranial fossa in 14.7% of his 767 cases,1 but Cushing found such tumors to be uncommon. Mingazzini,7 Weber 8 and Obarrio 9 have reported similar cases of middle cranial fossa meningiomas. The tumor is firm, encapsulated, and grows for ward and back as in this case. The blood supply of this tumor is the meningeal artery; 2 however, Eisberg lists branches of the posterior cerebral and middle cerebral arteries as possible sources.1 The tumor primarily involves what is es sentially a silent region. Subjective symp toms may be slight and objective findings meager when the neoplasm is of consider able size. The reason is the slow growth and probably that the surrounding brain can ac commodate to its changing relationship. Our case revealed the slow growth of this tumor over at least an eight-year period. Convulsive seizures may precede other symptoms but usually the epileptogenic zones are not involved. Visual field changes are by no means as frequent as one would
801
expect from the location of the lesion. Homonymous field defects arose in 27% of Elsberg's cases. Enlarged blindspots and con tracted fields also occurred. Papilledema of varying degrees or secondary optic atrophy may arise in the majority of cases. Our pa tient showed neither defect. Diplopia and blurry vision may also occur.1 Sixty percent of the patients have lateral gaze nystagmus. Speech is unaffected unless the lesion is large. Other signs that are usually present are: decreased sense of smell, unsteady gait, trigeminal neuralgia, some hemiparesis, pos itive Romberg's sign, increased contralateral deep tendon reflexes, unilateral occipitalfrontal headaches, central facial nerve loss, sella turcica changes and personality changes.1·2 If the lesion expands into the posterior fossa (as it did in our case) then more ex tensive symptomatology can be expected. Cerebellopontine involvement can cause briefly the following symptoms: unilateral deafness, absent corneal reflex, trigeminal neuralgia, lagophthalmos, numbness of the face, facial palsy, loss of taste of the whole tongue, ocular muscle palsies, nystagmus, staggering gait, positive Romberg facial twitching, dysphagia, palate weakness and hemiatrophy of the tongue j 1 · 10 · 11 our patient had all of these signs. Almost no brainstem signs were present. Although headaches were present, there were no signs of in creased intracranial pressure. These neu rologic findings are compatible with the tumor location in this case. SUMMARY
A case is reported of a woman who had a huge middle cranial fossa chondromatous meningioma which extended into the poste rior fossa and up to the sella, causing uni lateral visual acuity loss (without fundus changes) associated with diverse neurologic findings. The possibility of a surgical lesion being responsible for unilateral loss of visu al acuity must be considered. 410 West Tenth Avenue (43210).
NOTES, CASES, INSTRUMENTS
802 REFERENCES
1. Eisberg, C. A. : The meningeal fibroblastomas on the undersurface of the temporal lobe and their surgical treatment. Bull, neurol. inst. N.Y., 2:95, 1932. 2. Cushing, H., and Eisenhardt, L. : Meningiomas. Springfield, 111., Thomas, 1962. 3. Uihlein, A., and Weyand, R. D. : Meningiomas of the anterior clinoid process as a cause of uni lateral loss of vision: Surgical considerations. Arch. Ophthal., 49:261, 1953. 4. Fincher, E. F. : Symposium on Neurological Surgery: Experiences with meningiomas. Surg. Clin. N. Am., 34: 1037, 1954. 5. Kearns, T. P., and Wagener, H. P. : Ophthalmological diagnosis of meningiomas of the sphenoidal ridge. Am. J. M. Sei., 226:221, 1953. 6. Walsh, F. B. : Clinical Neuro-Ophthalmology. Baltimore, Williams & Wilkins, 1957, ed. 2, pp 1934-1942. 7. Mingazzini, G. : Neue klinische und anatomopathologische Studien über Hirngeschwülste und Abszesse. Arch. Psychiat. Nervenkr., 47:1028, 1910. 8. Weber, R., and Papadaki, A. : De quelques altérations du tissu cérébral dues à la présence de tumeuras. Nouv. Icongr. Salpet., 18:140, 1905. 9. Obarrio, J. M., Orlando, R., and Dowling, E. : Meningoblastomas. Pren. méd. argent., 15: 801, 1928. 10. Lewis, and Dew: Practice of Surgery. Hagerstown, Md., Prior, 1951. 11. Revilla, A. G. : Differential diagnosis of tu mors of the cerebellopontine recess. Bull. Johns Hopkins Hosp., 38:187, 1948.
CORTICOSTEROID-INDUCED OCULAR HYPERTENSION* A N D RANGE OF ACCOMMODATION CHARLES SIGMUND,
M.D.
CHING-HUNG LIU,
M.D.
AND ROBERT A.
MOSES,
to see if this finding applied to steroid-in duced ocular hypertension we measured the range of accommodation in a series of sub jects who received corticosteroid drops topi cally in one eye. METHODS
T h e subjects were 18 adults without known glaucoma. Each subject received top ical corticosteroids in one eye for a period of weeks. T h e weekly testing consisted of measurement of range of accommodation, applanation tonometry and tonography. Range of accommodation was measured with a Badel optometer equipped with a 3-mm artificial pupil, a light source attached to the target carrier and a fine fixation tar get. Near-blur and far-blur points were de termined alternately for three determinations and the results averaged. Lenses were used as necessary to keep the readings on the op tometer scale. Range of accommodation in diopters was calculated in the usual manner. RESULTS
T h e difference in applanation pressure between the two eyes was 5-9 mm H g in three subjects, 10-19 mm H g in six sub jects, and 20 m m H g or more in two sub jects. I n no case was there a correlation be tween pressure difference and accommoda tion difference. In 10 cases there was a facility difference of 0.20 or more μ ΐ / m i n / m m H g between the two eyes. There was no correla tion between difference in facility of outflow and difference in range of accommodation.
M.D.
St. Louis, Missouri
DISCUSSION
Fuchs stated that premature presbyopia may be an early sign of glaucoma. I n order
While our study was in progress Miller, Peczon and Whitworth 2 published their findings on steroid-induced ocular hyperten sion. A m o n g other studies they found no particular relationship between range of ac commodation and ocular pressure or facility of outflow. O u r results corroborate those of Miller, Peczon and Whitworth.
1
* From the Department of Ophthalmology and the Oscar Johnson Institute, Washington Univer sity School of Medicine. This investigation was supported in part by research grant NB-03639 from the National Institute of Neurological Dis eases and Blindness of the National Institutes of Health, U. S. Public Health Service.
798
contrast media reached the subdural space. Both patients suffered intense pain, nausea and vomiting, but these acute initial symp toms slowly diminished and disappeared after a few hours, without after-effects. Manchester 3 reported a different compli cation following orbitography with 3 5 % Diodrast: a patient lost all light perception in the eye on the side of the injection, the im mediate fundus picture being that of an oc clusion of the central retinal artery. H o w ever, 26 hours later, vision had returned to 2 0 / 2 0 and the fundus was normal except for slight retinal edema. Orbitography with water-soluble contrast material is relatively frequent in E u r o p e and South America, judging from the de scriptions of its advantages and harmlessness. 4 " 9 T h e complications listed are con sidered rare and, to our knowledge, no per manent damage has been reported. Since the approach and technique for or bitography are identical to that used in retrobulbar anesthesia, occasional poor akinesia might be explained by rapid diffusion of the injected material into the subdural space. SUMMARY
A case is reported in which, as a result of diagnostic orbitography, radiopaque materi al entered the subdural space at the base of the midbrain and descended to the subdural space at the level of the lumbar spine. N o transient or permanent clinical damage re sulted from this complication. Room 261 /irmed Forces Institute of Pathology (20025). REFERENCES
1. Gifford, H., Jr. : Motor block of extraocular muscles by deep orbital injection. Arch. Ophth., 41 :S, 1949. 2. Lombardi, G. : Orbitography with water-sol uble contrast media. Acta radiol. (Stockh.), 47:417,1957. 3. Manchester, P. T., Jr., and Bonmati, J. : Iodopyracet (diodrast) injection for orbital tumors. Arch. Ophth., 54:591, 1955.
4. Montresor, D. : Orbitografia con mezzi di contrasta. A. Hi. Soc. oft. Lomb, 2:258, 1952 5. Pettinati, S. : La localizzazione radiologica dei corpi estrangi orbtiari con I'auslio dei mezzi di contrasta radio-opachi idrosolubih. Riv. otoneuro-oftal., Rass. ital. Ottal., 22:587, 1953. 6. Montresor, D. : Ulteriore contribute all'indagine orbitografica con mezzi di contrasta iodici idrosolubili. Riv. oto-neuro-oftal., 29:258, 1954. 7. Chinaglia, V., and Santelli, F . : Impiego di mezzi di contrasta nella diagnostica delle affezioni dellOrbita. Riv. oto-neuro-oftal., 29:24, 1954. 8. Cowie, J. W., and Groves, J. S. : Preliminary report on the use of contrast media in orbital ra diography. Brit. J. Ophth., 39:283,1955. 9. Ananos, V. A.: Orbitography with sodium diatrizoate (hypaque). Sem. med. (B. Aires), 22:165, 1963. 10. Lombardi, G. : Personal communication.
MIDDLE CRANIAL FOSSA MENINGIOMA* CAUSING
UNILATERAL
LOSS
OF
VISUAL
ACUITY GILBERT S M O L I N ,
M.D.
Columbus, Ohio Middle cranial fossa meningiomas and the chondromatous type of meningioma are both relatively rare entities. T h e patient here presented had both of these conditions. In addition, the large size of the tumor mass resulted in diverse ophthalmologic and neu rologic symptomatology. C A S E REPORT
M. M. S., a 46-year-old white woman, was ad mitted on November 13, 1964, for the first time to Ohio State University Hospitals. About eight years prior to admission, the patient noted the onset of left esotropia, dysphagia, lagophthalmos of the left eye, staggering gait to the right and left occipital headaches. Diplopia was present in certain fields of gaze and clonic twitching was noted around both eyes. She was seen at the Cleveland Clinic Hospital from August 4 to 12, 1957, and demonstrated pa resis of the left VI, VII, X and XI cranial nerves. A spinal fluid examination was within * From the Department of Ophthalmology, The Ohio State University.
NOTES, CASES, INSTRUMENTS normal limits. A pneumoencephalogram per formed on August 5, 1957, was similarly inter preted as being normal. The tentative diagnosis of posterior fossa tumor was made and explora tion recommended. The patient refused surgery. The symptoms progressed slightly until 1960 when excessive fatigability arose, concomitant with a 10-lb weight loss, brown discoloration of her skin, decreased blood pressure and syncopal attacks. A diagnosis of Addison's disease was made and the patient was placed on cortisone and digitoxin. She had suffered 12 syncopal attacks since 1960 and required two hospitalizations. Within the last five or six weeks she had noted increasing severity of her left-sided occipital headache, increased fatigability and pronounced myokymia. The dysphagia and syncope had wor sened. A boring intermittent pain arose behind her left eye and her visual acuity became worse. The patient had been wearing a frosted lens over her left eye for the past seven years because of intolerable diplopia. However, light perception and movements were noted with the left eye in the past; most recently only light could be per ceived. Physical examination revealed a thin white woman with tan skin. Her vital signs were with in normal limits. The woman was 4 ft, 11.5 in. tall and weighted 80 lb. Examination of the cranial nerves revealed the following: (I) no ab normalities were noted; (II) the visual acuity was 20/25 O.D., and no light perception, O S . ; ( I l l ) no abnormalities were noted; (IV) weakness of the left superior oblique muscle existed; (V) the corneal reflex was absent in the left eye; (VI) the left lateral rectus muscle was paretic and end-point nystagmus was present on lateral gaze to either side, more marked on the right; (VII) there was weakness of the left orbicularis muscle, lack of facial expression, and no salt taste on the left side of the tongue (anterior two thirds) ; (VIII) hearing loss was present on the left side; (IX) a decreased gag reflex was present. The pal ate was elevated on the left side; (X) dysphagia was present; (XI) no abnormalities were noted; (XII) atrophy and fasiculations of the muscles on the left side of the tongue were noted. Position sense was normal. The Babinski sign was negative and no ankle clonus was present. The finger to nose and the heel to shin tests were poorly executed. Sensation was diminished to the following: the left side of the face, the left ear, the left side of the palate and the left side of the tongue. The left forehead had normal sensation, indicating central facial nerve involvement. The patient staggered to the right upon walk ing and fell to the left during the Romberg test. Deep tendon reflexes were symmetrical (either l-f or 2 + ) . The abdominal reflex was gone. On November 19, 1964, roentgenologic exami nation revealed a radiolucent defect in the poste rior midportion of the petrous bone. The sella
799
turcica was enlarged and only one anterior clinoid process was seen (right side). The diagnosis was that of a lesion in the region of the middle crani al fossa on the left On November 20, an eye consultation was ob tained. In addition to the neurologic findings al ready listed, several other findings were noted. The exophthalmometer reading was 24, O.D., and 28, O.S. External examination revealed a left esotropia of 70 prism diopters in the primary po sition, and the lower third (exposed portion) of the cornea showed punctate staining with fluorescein. The pupil responded very sluggishly to direct light, O.S. Fundus and slitlamp examination re vealed no further abnormalities (the optic discs showed no evidence of pathology). Tangent screen examination was a 3-mm white test ob ject demonstrated an enlarged blindspot 24/22 cm but otherwise normal field, O.D. No field was present, O.S. The impression was that the patient had a large cerebellopontine angle tumor. An electroencephalogram performed on the following day showed localization to the lower central area of the left cerebrum. A pneumoen cephalogram was cancelled when the patient had a Jacksonian convulsive seizure. On November 24, 1964, angiography demonstrated a mass with a 5 cm diameter in the area of the left cerebello pontine angle elevating the left middle cerebral and posterior communicating arteries. On Novem ber 29, 1964, the maintenance dose of steroids was increased and the patient received 1,500 cc of whole blood over a 24-hour period. On November 30, 1964, a left fronto-parieto-temporal craniotomy was performed. The temporal dura was in cised and a firm pink encapsulated mass was noted beneath the temporal lobe lying intradurally and extending into the anterior, temporal and posterior fossae (with left cerebellar hemisphere involvement). It also extended into the sella and posteriorly into the petrous portion of the tempo ral bone. The III, V, VII, VIII, IX and X cranial nerves were thinned and markedly dis placed. The pituitary gland could not be iden tified. The impression was that this was a large middle cranial fossa meningioma. The pathologic examination of the tumor re vealed that the lesion was an interweaving pat tern of immature chondroid cells (figs. 1 and 2) and blood vessels in a pattern which is fairly typ ical of a meningioma. The unusual feature of this case was that the total differentiation of the mesenchymal cells present was toward immature cartilage rather than the usual fibroblastic tissue. The tumor was a chondromatous meningioma. The patient had a stormy postoperative course for several days. On December 16, 1964, a lateral tarsorrhaphy was performed (Elschnig tech nique), O.S., under local anesthesia. The patient was discharged the next day on the following medications: Dilantin, cortisone acetate, probanthine and trionine. Her neurologic examination on discharge remained unchanged.
NOTES, CASES, INSTRUMENTS
800
Fig. 1 (Smolin). Chondromatous meningioma under low-power magnification.
Fig. 2 (Smolin). Chondromatous meningioma under high-power magnification. DISCUSSION
Meningiomas constitute 15% of all intracranial tumors. 1 The frequency in females to males is 6 to 4 and the average age of the patient is 46.6 years of age. Meningiomas are rare in childhood and in the aged. There is an increased incidence in Negroes. The
relationship of meningioma to trauma is doubtful.2 Uihlein stated that meningiomas arise from clusters of arachnoid cells and tend to occur in specific sites.3 Cushing and Eisenhardt list three theories as to the origin. They are as follows: (1) neuroectoderm (in a sense gliomatous), (2) fibroblastic and (3) a middle ground (from primitive leptomeningeal cells from that part of the ecto derm giving origin to the cell masses of the neural groove and neural crest). 2 Meningiomas, over the course of years rarely, if ever, tend to alter in type. Cushing classifies meningiomas as nine types. The most frequent type is nonreticulin or colla gen forming tumors and the least frequent type chondroblastic and lipoblastic menin giomas. Only one case of chondroblastic me ningioma was listed by Cushing in his series of 306 meningiomas. This case occurred in the temporal fossa and it acted like a menin gioma of the more common variety. The etiology is believed to be a transition from meningeal fibroblasts to cartilage.2 The site of the meningioma in decreasing frequency is as follows: parasagittal, free convexity, sphenoidal ridge, olfactory groove, suprasellar, posterior fossa, spine, temporal fossa, falx, without durai attach ment, Gasserian, multiple, and finally in traorbital. They are more common internal to the dura.2 It must be emphasized that meningiomas may occur anywhere within the human skull and that the direction these so-called "harm less or benign" growths may take in their expansion is not predictable. (Meningiomas are considered benign because of their histol ogy.) They may attain quite a large size and may extend from one cranial fossa to another as illustrated in this case. This peculiarity of extension is common with sagittally located tumors. They may grow from one cerebral hemisphere to another be neath the falx, or from one temporal fossa to infratentorial levels, or out of the poste rior fossa into the parasellar region.4
NOTES, CASES, INSTRUMENTS Meningiomas account for the unilateral loss of vision in 4.6% of the 310 cases Uihlein studied.3 Lesions of the structures of the eyeball and glaucoma were equally fre quent and together accounted for 50% of the cases. Trauma accounted for 13%. Lesions of the optic nerve or visual pathways ac counted for 34.8%. The meningiomas were included in this last group. Sphenoidal ridge,5 inner ridge 8 and ante rior clinoid process meningiomas3 have been reported as causing unilateral loss of visual acuity. Generally speaking the visual acuity loss is much slower with tumors than with optic neuritis. Inner ridge meningiomas have associated homolateral optic atrophy and visual field defects. In the sphenoidal ridge tumors the most common ocular finding was visual loss. Proptosis was also a common finding. Anterior clinoid process meningiomas are discussed by Uihlein and Weyand in their article on unilateral visual acuity loss.8 Eisberg described meningiomas in the middle cranial fossa in 14.7% of his 767 cases,1 but Cushing found such tumors to be uncommon. Mingazzini,7 Weber 8 and Obarrio 9 have reported similar cases of middle cranial fossa meningiomas. The tumor is firm, encapsulated, and grows for ward and back as in this case. The blood supply of this tumor is the meningeal artery; 2 however, Eisberg lists branches of the posterior cerebral and middle cerebral arteries as possible sources.1 The tumor primarily involves what is es sentially a silent region. Subjective symp toms may be slight and objective findings meager when the neoplasm is of consider able size. The reason is the slow growth and probably that the surrounding brain can ac commodate to its changing relationship. Our case revealed the slow growth of this tumor over at least an eight-year period. Convulsive seizures may precede other symptoms but usually the epileptogenic zones are not involved. Visual field changes are by no means as frequent as one would
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expect from the location of the lesion. Homonymous field defects arose in 27% of Elsberg's cases. Enlarged blindspots and con tracted fields also occurred. Papilledema of varying degrees or secondary optic atrophy may arise in the majority of cases. Our pa tient showed neither defect. Diplopia and blurry vision may also occur.1 Sixty percent of the patients have lateral gaze nystagmus. Speech is unaffected unless the lesion is large. Other signs that are usually present are: decreased sense of smell, unsteady gait, trigeminal neuralgia, some hemiparesis, pos itive Romberg's sign, increased contralateral deep tendon reflexes, unilateral occipitalfrontal headaches, central facial nerve loss, sella turcica changes and personality changes.1·2 If the lesion expands into the posterior fossa (as it did in our case) then more ex tensive symptomatology can be expected. Cerebellopontine involvement can cause briefly the following symptoms: unilateral deafness, absent corneal reflex, trigeminal neuralgia, lagophthalmos, numbness of the face, facial palsy, loss of taste of the whole tongue, ocular muscle palsies, nystagmus, staggering gait, positive Romberg facial twitching, dysphagia, palate weakness and hemiatrophy of the tongue j 1 · 10 · 11 our patient had all of these signs. Almost no brainstem signs were present. Although headaches were present, there were no signs of in creased intracranial pressure. These neu rologic findings are compatible with the tumor location in this case. SUMMARY
A case is reported of a woman who had a huge middle cranial fossa chondromatous meningioma which extended into the poste rior fossa and up to the sella, causing uni lateral visual acuity loss (without fundus changes) associated with diverse neurologic findings. The possibility of a surgical lesion being responsible for unilateral loss of visu al acuity must be considered. 410 West Tenth Avenue (43210).
NOTES, CASES, INSTRUMENTS
802 REFERENCES
1. Eisberg, C. A. : The meningeal fibroblastomas on the undersurface of the temporal lobe and their surgical treatment. Bull, neurol. inst. N.Y., 2:95, 1932. 2. Cushing, H., and Eisenhardt, L. : Meningiomas. Springfield, 111., Thomas, 1962. 3. Uihlein, A., and Weyand, R. D. : Meningiomas of the anterior clinoid process as a cause of uni lateral loss of vision: Surgical considerations. Arch. Ophthal., 49:261, 1953. 4. Fincher, E. F. : Symposium on Neurological Surgery: Experiences with meningiomas. Surg. Clin. N. Am., 34: 1037, 1954. 5. Kearns, T. P., and Wagener, H. P. : Ophthalmological diagnosis of meningiomas of the sphenoidal ridge. Am. J. M. Sei., 226:221, 1953. 6. Walsh, F. B. : Clinical Neuro-Ophthalmology. Baltimore, Williams & Wilkins, 1957, ed. 2, pp 1934-1942. 7. Mingazzini, G. : Neue klinische und anatomopathologische Studien über Hirngeschwülste und Abszesse. Arch. Psychiat. Nervenkr., 47:1028, 1910. 8. Weber, R., and Papadaki, A. : De quelques altérations du tissu cérébral dues à la présence de tumeuras. Nouv. Icongr. Salpet., 18:140, 1905. 9. Obarrio, J. M., Orlando, R., and Dowling, E. : Meningoblastomas. Pren. méd. argent., 15: 801, 1928. 10. Lewis, and Dew: Practice of Surgery. Hagerstown, Md., Prior, 1951. 11. Revilla, A. G. : Differential diagnosis of tu mors of the cerebellopontine recess. Bull. Johns Hopkins Hosp., 38:187, 1948.
CORTICOSTEROID-INDUCED OCULAR HYPERTENSION* A N D RANGE OF ACCOMMODATION CHARLES SIGMUND,
M.D.
CHING-HUNG LIU,
M.D.
AND ROBERT A.
MOSES,
to see if this finding applied to steroid-in duced ocular hypertension we measured the range of accommodation in a series of sub jects who received corticosteroid drops topi cally in one eye. METHODS
T h e subjects were 18 adults without known glaucoma. Each subject received top ical corticosteroids in one eye for a period of weeks. T h e weekly testing consisted of measurement of range of accommodation, applanation tonometry and tonography. Range of accommodation was measured with a Badel optometer equipped with a 3-mm artificial pupil, a light source attached to the target carrier and a fine fixation tar get. Near-blur and far-blur points were de termined alternately for three determinations and the results averaged. Lenses were used as necessary to keep the readings on the op tometer scale. Range of accommodation in diopters was calculated in the usual manner. RESULTS
T h e difference in applanation pressure between the two eyes was 5-9 mm H g in three subjects, 10-19 mm H g in six sub jects, and 20 m m H g or more in two sub jects. I n no case was there a correlation be tween pressure difference and accommoda tion difference. In 10 cases there was a facility difference of 0.20 or more μ ΐ / m i n / m m H g between the two eyes. There was no correla tion between difference in facility of outflow and difference in range of accommodation.
M.D.
St. Louis, Missouri
DISCUSSION
Fuchs stated that premature presbyopia may be an early sign of glaucoma. I n order
While our study was in progress Miller, Peczon and Whitworth 2 published their findings on steroid-induced ocular hyperten sion. A m o n g other studies they found no particular relationship between range of ac commodation and ocular pressure or facility of outflow. O u r results corroborate those of Miller, Peczon and Whitworth.
1
* From the Department of Ophthalmology and the Oscar Johnson Institute, Washington Univer sity School of Medicine. This investigation was supported in part by research grant NB-03639 from the National Institute of Neurological Dis eases and Blindness of the National Institutes of Health, U. S. Public Health Service.