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This patient presenting with unilateral sensorineural hearing loss (Rinne test revealed air > bone conduction and Weber test localization to normal ear), tinnitus, vertigo (spinning room sensation), and trigeminal abnormalities (numbness in V2 face distribution) mostly likely has an acoustic neuroma, which would be found in the cerebellopontine angle. Acoustic neuromas, also known as vestibular schwannomas, are benign tumors that develop from the Schwann cell sheath of the vestibulocochlear nerve. They are primarily found in the cerebellopontine angle, which is a subarachnoid cistern located between the cerebellum and pons. However, during their initial development, acoustic neuromas may be solely located within the internal auditory canal. Classical symptoms include slowly progressive sensorineural loss, tinnitus, and vestibular symptoms. Patients with suspected acoustic neuromas should receive audiometric testing and intracranial imaging. Depending on the size of the tumor, treatment involves observation, resection, or radiosurgery. Figure A is a sagittal view of a normal brain MRI. A is pointing to the sella turcica. B is pointing to the foramen magnum. C is pointing to the dorsal midbrain. D is pointing to the cerebellum. E is pointing to the cerebellopontine angle. Patel et al. review some of the diagnostic considerations for acoustic neuromas. While most patients present with unilateral hearing loss, tinnitus, and imbalance, atypical symptoms arise if there is sufficient mass effect on other structures. These include increased intracranial pressure (e.g., headache, nausea, and vomiting), trigeminal symptoms (e.g., facial numbness or pain), facial weakness, and dysarthria. Acoustic neuromas are contrast-enhancing and may demonstrate auditory canal widening while protruding into the cerebellopontine angle. Incorrect Answers: Answer 1: A points to the sella turcica, which is a depression in the sphenoid bone that contains the pituitary gland. Common tumors that arise in this location include pituitary adenomas and craniopharyngioma. Both can present with bitemporal hemianopsia due to compression of the optic chiasm. They are not associated with abnormalities of the vestibulocochlear nerve and the patient does not have any visual symptoms. Answer 2: B points to the foramen magnum, which is an opening in the occipital bone where the spinal cord exits. Arising from the arachnoid cells of the craniocervical junction dura, meningiomas can develop in this location. Patients initially present with unilateral posterior cervical and occipital pain, but can eventually develop additional motor and sensory deficits depending on the tumor mass effect. The patient does not have any pain, motor, or sensory problems. Answer 3: C points to the dorsal surface of the midbrain, which includes the pineal gland and tectum. Pathologies that arise here include tectal gliomas and pinealomas. Parinaud syndrome, also known as dorsal midbrain syndrome, classically results from compression of the superior tectal plate. Due to interruption of the vertical gaze center, the triad of upward gaze palsy, convergence-retraction nystagmus, and pupillary light-near dissociation is observed. These symptoms were not seen in the patient. Answer 4: D points to the cerebellum. Abnormalities that arise in the cerebellum include astrocytomas and hemangioblastomas. These can generate cerebellar symptoms such as ataxia, vertigo, and imbalance. However, hearing loss and tinnitus would not be expected. Bullet Summary: Acoustic neuromas are primarily located in the cerebellopontine angle and can lead to sensorineural loss, tinnitus, and vestibular symptoms.
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