Case 15: progressive blindness

posted: February 23, 1997

Resident: Ian Angel, MD
Attending: Deepak Awasthi, MD

CLINICAL PRESENTATION: This 54 white woman presented to the neurosurgery clinic with a 2 year history of progressive blindness (right side) and right sided proptosis. Patient denied any history of headaches, nausea/ vomiting, weakness, sensory changes, double vision, seizures disorder, gait difficulty, diabetes mellitus, hypertension, heart disease or thyroid disease. Physical examination revealed right optic nerve atrophy, 20/100 vision on the right side, no other focal neurological deficits were appreciated; no papilledema. Mild proptosis of the right eye was noted. The rest of the general examination was normal.

What is you differential diagnosis?

Please comment: dawast@lsuhsc.edu

Initial diagnostic study was an MRI scan of the brain with/ without contrast. An axial T1-weighted contrast enhanced view is shown below:

Note the small homogenously-enhancing mass in the region of the right sphenoid wing- anterior temporal lobe. Also note the mild proptosis of the right eye.

At this point we elected to perform a cranial CT scan with and without contrast as well as with bone windows. An axial bone window view is shown below:

Note the extensive hyperostosis of the right sphenoid bone with encroachment of the optic canal and proptosis.

Most likely diagnosis was an en plaque sphenoid meningioma with hyperostosis- it was felt that the hyperostosis was causing the optic nerve compression on the right.

What steps would you take at this time? What surgical procedure, if any, would you plan?

Please comment: dawast@lsuhsc.edu

STEPS TAKEN AT LSU: The patient was taken to the operating roon with the primary goal of optic nerve decompression. Through an extradural approach, the optic canal was decompressed and the hyperostotic bone drilled- this bone was partially involved with tumor. The dura was opened, the tumor (meningioma) was noted to be an en plaque lesion requiring dural resection and subsequent dural repair with patch as well as repair of the orbital roof.

Postoperatively, the patient's vision did show a mild improvement. There were no other focal deficits or CSF leak.

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