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LETTER TO EDITOR
Year : 2015  |  Volume : 63  |  Issue : 3  |  Page : 437-439

Cavernous sinus syndrome due to skull base metastasis: A rare presentation of hepatocellular carcinoma


1 Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India
2 Department of Radiology, Christian Medical College, Vellore, Tamil Nadu, India

Date of Web Publication5-Jun-2015

Correspondence Address:
Ronald A. B. Carey
Department of Medicine, Christian Medical College, Vellore, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.158247

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How to cite this article:
Carey RA, Nathaniel S D, Das S, Sudhakar S. Cavernous sinus syndrome due to skull base metastasis: A rare presentation of hepatocellular carcinoma. Neurol India 2015;63:437-9

How to cite this URL:
Carey RA, Nathaniel S D, Das S, Sudhakar S. Cavernous sinus syndrome due to skull base metastasis: A rare presentation of hepatocellular carcinoma. Neurol India [serial online] 2015 [cited 2019 Sep 19];63:437-9. Available from: http://www.neurologyindia.com/text.asp?2015/63/3/437/158247


Sir,

We report the case of a 38-year-old man who presented with right-sided headache, drooping of the eyelids, decreased right-sided facial sensation and blurred right eye vision for 2 months. He also had abdominal distension, and loss of weight and appetite. On examination, he was emaciated and icteric, and had features of right-sided cavernous sinus syndrome with right pupil dilated and sluggishly reacting to light, ptosis, impaired right eye extraocular movements, absent right-sided facial sensation and atrophic right masseter. His abdomen revealed a hard nodular liver of 8 cm and ascites.

An magnetic resonance imaging (MRI) of the brain revealed a large lobulated solid lesion involving the right cavernous sinus and encasing the cavernous part of the right internal carotid artery [Figure 1]a and b The computed tomography (CT) scan revealed a tumor in the right lobe of the liver and in the portal vein with features characteristic of hepatocellular carcinoma (HCC) [Figure 2]a-c. Ascitic fluid analysis revealed low protein (0.8 g/dL), high serum ascites albumin gradient (2.6 g/dL) and total white blood cell count of 90 cells/cubic mm with 90% lymphocytes. Hepatitis B surface antigen was positive. Alfa fetoprotein (AFP) was 185,000 IU/mL. Biopsy of the lesion was deferred. The patient was initiated on symptomatic treatment. On explanation of the nature and prognosis of the disease, the patient's family opted for palliative care.
Figure 1: Axial (a) and coronal T2-weighted image (b) showing a large T2 hypointense right cavernous sinus mass (black arrow) encasing the internal carotid artery (ICA) (small white arrow), extending to the sphenoid sinus (white arrow) and masticator space (asterix). Axial post-contrast fat-suppressed image (c) shows moderate enhancement of the lesion (white arrow) and its extension to the posterior ethmoid sinuses and right orbital apex (black arrow). Also note the dural thickening and enhancement along the middle cranial fossa (arrowhead)

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Figure 2: Axial computed tomography (CT) image in the venous phase (a, b) shows an ill-defined, hypodense right lobe lesion (white double arrows) against a background of chronic liver disease changes (black arrow) with ascites (white arrows); right portal vein thrombus (asterix) is also seen. Axial CT at the pelvic level (c) shows a permeative lesion with soft tissue in the right iliac bone (white arrow) suggestive of metastasis

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The diagnosis of HCC in a patient with underlying chronic liver disease is established by the characteristic imaging features in MRI, along with elevated AFP levels. Biopsy is necessary only when the diagnostic imaging results are inconclusive.

The most common sites of metastases are the lungs, lymph nodes and bones. Metastases to the skull is rare, found only in 0.5-1.6% of patients. [1] Among these, the base of skull was involved in 16 of 59 (27%) patients in a literature review. [2] Lee reported 16 cases of craniospinal metastases in HCC, of which six cases had skull metastases. [3] There is only one reported case of HCC presenting as cavernous sinus syndrome. [4]

Palliative radiotherapy for skull metastases provides excellent pain relief and resolution of the cranial nerve deficits. Sorafenib, an oral multikinase inhibitor that blocks tumor cell proliferation and angiogenesis by acting on serine/threonine kinases Raf-1/B-Raf, tyrosine kinases of vascular endothelial growth factor receptor-2/-3 and platelet-derived growth factor receptor -bis, is the only drug currently available for advanced HCC. The prognosis for patients with bone metastases remains poor, with a median survival of just 7 months.

 
  References Top

1.
Chan CH, Trost N, McKelvie P, Rophael JA, Murphy MA. Unusual case of skull metastasis from hepatocellular carcinoma. ANZ J Surg 2004;74:710-3.  Back to cited text no. 1
    
2.
Guo X, Yin J, Jiang Y. Solitary skull metastasis as the first symptom of hepatocellular carcinoma: Case report and literature review. Neuropsychiatr Dis Treat 2014;10:681-6.  Back to cited text no. 2
    
3.
Lee JP. Hepatoma presenting as craniospinal metastasis: Analysis of sixteen cases. J Neurol Neurosurg Psychiatry 1992;55:1037-9.  Back to cited text no. 3
    
4.
Kao HJ, Cheng ST, Chen WH, Yin HL. Cavernous sinus syndrome and hepatoma metastasis. Kaohsiung J Med Sci 1998;14:117-20.  Back to cited text no. 4
    


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