Figure 1
Brain CT
Clival ostemyelitis
SectionNeuroradiology
Case TypeClinical Cases
AuthorsHuapaya Torres Janice, Donato Angel, Figueroa Ramon E.
Connected authors
50 years, male
Clinical History
50-year-old male patient with perceived mental health (PMH) of cocaine use, presenting with headaches and neck pain/stiffness for one month.
Imaging Findings
Brain CT shows a permeative moth-eaten appearance of the clivus, with soft tissue replacement of the dorsum sella and high density expansion of both cavernous sinuses.
Brain MRI shows an infiltrating soft tissue mass involving the central skull base centred on the clivus, extending into the cavernous sinuses bilaterally, resulting in an expanded appearance of the cavernous sinuses and abnormal signal behaviour of the bone marrow spaces of the central clivus.
Diffusion-weighted images identify punctiform areas of diffusion signal abnormality within the clivus and cavernous sinuses, interspersed within the bone marrow spaces of the central clivus and sphenoid body.
Gadolinium-enhanced images demonstrate irregular enhancement of the bone marrow spaces of the body of the sphenoid and clivus, bilateral cavernous sinus homogeneous expansion and reactive thickening and enhancement of the petroclinoid ligament and tentorium bilaterally.
Brain MRI shows an infiltrating soft tissue mass involving the central skull base centred on the clivus, extending into the cavernous sinuses bilaterally, resulting in an expanded appearance of the cavernous sinuses and abnormal signal behaviour of the bone marrow spaces of the central clivus.
Diffusion-weighted images identify punctiform areas of diffusion signal abnormality within the clivus and cavernous sinuses, interspersed within the bone marrow spaces of the central clivus and sphenoid body.
Gadolinium-enhanced images demonstrate irregular enhancement of the bone marrow spaces of the body of the sphenoid and clivus, bilateral cavernous sinus homogeneous expansion and reactive thickening and enhancement of the petroclinoid ligament and tentorium bilaterally.
Discussion
Osteomyelitis of the central skull base is an uncommon condition that is potentially life threatening if not promptly recognized and properly treated [1, 2]. It has been described in both adults and children, and can be classified as typical, like complication of otitis externa or mastoiditis, or atypical [3]. They occur in immunocompromised patients, including those with diabetes, corticosteroid use, HIV infection, or chronic inflammatory sphenoid sinus disease and they commonly involve Pseudomonas flora. The infections are usually limited to the temporal bone [3].
Atypical osteomyelitis usually arises secondary to a paranasal infection, and it localizes to the clivus [2]. A wider array of pathogens has been reported in patients with atypical infections, including gram-positive cocci, Salmonella, enterococci, Actinomyces, and Aspergillus, as well as Pseudomonas organisms.
Clinical presentation is often subtle and nonspecific, with persistent headaches, auditory or visual deficits and eventual development of cranial neuropathy. The presence of multiple cranial nerve palsies is highly suggestive of clival pathology [3].
Imaging of the skull base in the setting of cranial neuropathy and probable infection is best accomplished with MRI, which is particularly useful for assessing soft tissue planes around the skull base and abnormalities of the medullary space of the skull base.
Highly sensitive but nonspecific MR findings for osteomyelitis include bone marrow T1 hypointensity and T2 hyperintensity [2]. Clival enhancement can be seen with both infectious and neoplastic processes. Sagittal T1-weighted images of the clivus were the most useful for detecting abnormalities of the clival marrow, whereas axial T1-weighted images offered the best evaluation of the pre- and paraclival soft tissues. The coronal plane prior and after administration of gadolinium offered the best assessment of Meckel’s cave and the cavernous sinus, as well as skull base dura and inferior temporal lobes [2].
Processes to be considered in the clinical and imaging differential diagnosis of central skull base osteomyelitis include neoplastic and non-neoplastic entities. Since skull base infection should not be excluded in a patient with no fever and normal WBC count, elevation of the erythrocyte sedimentation rate (ESR) can be a helpful clinical feature in focusing the differential diagnosis [1].
Since imaging alone is not definitive for a diagnosis of malignancy; tissue biopsy and culture must be strongly encouraged [3].
Subsequent imaging follow-up after established antibiotic therapy necessitate inflammatory markers, since oedema and contrast enhancement remain non-specific [3]. Nuclear medicine Gallium scan abnormalities have shown to be useful to monitor response to treatment and evaluate osteomyelitis recurrence [1].
Atypical osteomyelitis usually arises secondary to a paranasal infection, and it localizes to the clivus [2]. A wider array of pathogens has been reported in patients with atypical infections, including gram-positive cocci, Salmonella, enterococci, Actinomyces, and Aspergillus, as well as Pseudomonas organisms.
Clinical presentation is often subtle and nonspecific, with persistent headaches, auditory or visual deficits and eventual development of cranial neuropathy. The presence of multiple cranial nerve palsies is highly suggestive of clival pathology [3].
Imaging of the skull base in the setting of cranial neuropathy and probable infection is best accomplished with MRI, which is particularly useful for assessing soft tissue planes around the skull base and abnormalities of the medullary space of the skull base.
Highly sensitive but nonspecific MR findings for osteomyelitis include bone marrow T1 hypointensity and T2 hyperintensity [2]. Clival enhancement can be seen with both infectious and neoplastic processes. Sagittal T1-weighted images of the clivus were the most useful for detecting abnormalities of the clival marrow, whereas axial T1-weighted images offered the best evaluation of the pre- and paraclival soft tissues. The coronal plane prior and after administration of gadolinium offered the best assessment of Meckel’s cave and the cavernous sinus, as well as skull base dura and inferior temporal lobes [2].
Processes to be considered in the clinical and imaging differential diagnosis of central skull base osteomyelitis include neoplastic and non-neoplastic entities. Since skull base infection should not be excluded in a patient with no fever and normal WBC count, elevation of the erythrocyte sedimentation rate (ESR) can be a helpful clinical feature in focusing the differential diagnosis [1].
Since imaging alone is not definitive for a diagnosis of malignancy; tissue biopsy and culture must be strongly encouraged [3].
Subsequent imaging follow-up after established antibiotic therapy necessitate inflammatory markers, since oedema and contrast enhancement remain non-specific [3]. Nuclear medicine Gallium scan abnormalities have shown to be useful to monitor response to treatment and evaluate osteomyelitis recurrence [1].
Differential Diagnosis List
Clival ostemyelitis
Squamous cell carcinoma
Lymphoma
Haematogenous metastasis
Wegener granulomatosis
Tuberculosis
Sarcoid
Final Diagnosis
Clival ostemyelitis
References
[1] Chang PC, Fischbein NJ, Holliday RA. (2003) Central skull base osteomyelitis in patients without otitis externa: imaging findings. AJNR Am J Neuroradiol 2003 Aug;24(7):1310-6. (PMID: 12917118)
[2] Nabavizadeh SA, Vossough A, Pollock AN. Clival osteomyelitis. (2013) Clival osteomyelitis. Pediatr Emerg Care 2013 Sep;29(9):1030-2 (PMID: 24201988)
[3] Butterfield MC, Gomez JS, Ly N, Palacios E. (2016) Clival lesion: Atypical osteomyelitis vs. a neoplastic process. Ear Nose Throat J Jan;95(1):17-8. (PMID: 26829679)
Case information
| URL: | https://eurorad.org/case/14763 |
| DOI: | 10.1594/EURORAD/CASE.14763 |
| ISSN: | 1563-4086 |
License
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Figure 2
Brain CT Bone windows
Brain CT shows a permeative moth-eaten appearance of the clivus, with soft tissue replacement of the dorsum sella and high density expansion of both cavernous sinuses.
Brain CT shows a permeative moth-eaten appearance of the clivus, with soft tissue replacement of the dorsum sella and high density expansion of both cavernous sinuses.
Brain CT shows a permeative moth-eaten appearance of the clivus, with soft tissue replacement of the dorsum sella and high density expansion of both cavernous sinuses.
Figure 3
Brain MRI with gadolinium coronal
Brain MRI shows an infiltrating soft tissue mass involving the central skull base centred on the clivus, extending into the cavernous sinuses bilaterally, resulting in an expanded appearance of the cavernous sinuses.
Brain MRI shows an infiltrating soft tissue mass involving the central skull base centred on the clivus, extending into the cavernous sinuses bilaterally, resulting in an expanded appearance of the cavernous sinuses.
Brain MRI shows an infiltrating soft tissue mass involving the central skull base centred on the clivus, extending into the cavernous sinuses bilaterally, resulting in an expanded appearance of the cavernous sinuses.
Figure 4
Brain MRI diffusion
Diffusion-weighted images identify punctate areas of diffusion signal abnormality in the clivus and cavernous sinuses within the clivus and sphenoid body bone marrow spaces.
ADC maps show diffusion restriction matching the punctate areas of diffusion signal abnormality within the clivus and sphenoid body bone marrow spaces.
Figure 5
Brain MRI with gadolinium
Brain MRI shows an infiltrating soft tissue mass involving the central skull base centred on the clivus, extending into the cavernous sinuses bilaterally, resulting in an expanded appearance of the cavernous sinuses.
Brain MRI shows an infiltrating soft tissue mass involving the central skull base centred on the clivus, extending into the cavernous sinuses bilaterally, resulting in an expanded appearance of the cavernous sinuses.
Brain MRI shows an infiltrating soft tissue mass involving the central skull base centred on the clivus, extending into the cavernous sinuses bilaterally, resulting in an expanded appearance of the cavernous sinuses.
Brain CT
Brain CT Bone windows
Brain CT shows a permeative moth-eaten appearance of the clivus, with soft tissue replacement of the dorsum sella and high density expansion of both cavernous sinuses.
Augusta university, Georgia, USA.
Augusta university, Georgia, USA.
Brain CT shows a permeative moth-eaten appearance of the clivus, with soft tissue replacement of the dorsum sella and high density expansion of both cavernous sinuses.
Augusta university, Georgia, USA.
Augusta university, Georgia, USA.
Brain CT shows a permeative moth-eaten appearance of the clivus, with soft tissue replacement of the dorsum sella and high density expansion of both cavernous sinuses.
Augusta university, Georgia, USA.
Augusta university, Georgia, USA.
Brain MRI with gadolinium coronal
Brain MRI shows an infiltrating soft tissue mass involving the central skull base centred on the clivus, extending into the cavernous sinuses bilaterally, resulting in an expanded appearance of the cavernous sinuses.
Augusta university
Augusta university
Brain MRI shows an infiltrating soft tissue mass involving the central skull base centred on the clivus, extending into the cavernous sinuses bilaterally, resulting in an expanded appearance of the cavernous sinuses.
augusta university
augusta university
Brain MRI shows an infiltrating soft tissue mass involving the central skull base centred on the clivus, extending into the cavernous sinuses bilaterally, resulting in an expanded appearance of the cavernous sinuses.
augusta university
augusta university
Brain MRI diffusion
Diffusion-weighted images identify punctate areas of diffusion signal abnormality in the clivus and cavernous sinuses within the clivus and sphenoid body bone marrow spaces.
Augusta university center, Georgia, USA
Augusta university center, Georgia, USA
ADC maps show diffusion restriction matching the punctate areas of diffusion signal abnormality within the clivus and sphenoid body bone marrow spaces.
augusta university
augusta university
Brain MRI with gadolinium
Brain MRI shows an infiltrating soft tissue mass involving the central skull base centred on the clivus, extending into the cavernous sinuses bilaterally, resulting in an expanded appearance of the cavernous sinuses.
augusta university
augusta university
Brain MRI shows an infiltrating soft tissue mass involving the central skull base centred on the clivus, extending into the cavernous sinuses bilaterally, resulting in an expanded appearance of the cavernous sinuses.
Medical College of Georgia at Augusta University
Medical College of Georgia at Augusta University
Brain MRI shows an infiltrating soft tissue mass involving the central skull base centred on the clivus, extending into the cavernous sinuses bilaterally, resulting in an expanded appearance of the cavernous sinuses.
Medical College of Georgia at Augusta University
Medical College of Georgia at Augusta University