A flower in the brain: Planum sphenoidale meningioma
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A 28-year-old female presented with the chief complaint of gradual painless diminution of vision in the left eye for 1 month. On ocular evaluation, her visual acuity in the right eye was 20/20, N6 whereas in the left eye was counting fingers (CF) at a 1-m distance. Pupils reacted briskly in the right eye but there was grade 1 relative afferent pupillary defect in the left eye. Posterior segment evaluation showed mild temporal pallor of both optic discs.

The right eye was essentially normal. She was requested immediate magnetic resonance imaging (MRI) of the brain which suggested planum sphenoidale meningioma. Axial T1-weighted and T2-weighted images showed a well-defined extra-axial mass originating on the planum sphenoidal, compressing the basi-frontal and capsule-ganglionic regions. and d show the coronal and sagittal sections showing the same lesion. It showed characteristic radially oriented “spoke-wheel-like” enhancement on the post-contrast study. Such heterogeneous enhancement is atypical of meningioma and resembles the characteristic appearance of a floral pattern. Such a differential enhancement in this MRI image has an uncanny resemblance with the evening primrose flower.

Histopathological correlation was suggestive of transitional meningioma with foci of calcification. In the subsequent follow-up, 2 weeks later, visual acuity in the right eye was 20/25 but there was an improvement in visual acuity of the left eye to 20/150. Pupil reactions showed an ill sustained reaction in both eyes postoperatively. Fundus showed temporal pallor in the right eye and diffuse disc pallor of the left eye.

Planum sphenoidale meningiomas are extra-axial slow-growing tumors arising from the roof of the sphenoid sinus and the area between the optic nerves and the anterior clinoid processes. Owing to the slow-growing nature and subtle symptoms developing over a prolonged time they have a larger tendency to remain undiagnosed till late. In this patient, though the meningioma was significantly large in size, the patient complained of visual symptoms only in the left eye, and for the past 4 weeks only. However, the patient did mention that there was a progressive diminution of right eye vision also till the neurosurgical intervention was performed. This is explained by the large size of the lesion which compressed both the optic nerves. More often these are located anteriorly and in the proximity of the olfactory groove. Symptoms of dementia personality changes and anosmia are common with olfactory groove and planum sphenoidal meningioma, which reverse after removal of the tumor. None of such symptoms were noted in the patient.

Source: https://www.ijo.in/article.asp?issn=0301-4738;year=2020;volume=68;issue=11;spage=2514;epage=2516;aulast=Rath