====== Clivus tumor ======

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[[Endoscopic transnasal approach]] is an alternative approach to the treatment of [[clivus]] [[lesion]]s, and, in expert hands, this technique can obtain good results. Lateral extension and previous treatment were factors that could make the surgery more difficult. The intradural extension did not limit the radicality of the removal
((de Arnaldo Silva Vellutini E, Balsalobre L, Hermann DR, Stamm AC. The
Endoscopic Endonasal Approach for Extradural and Intradural Clivus Lesions. World
Neurosurg. 2014 Dec;82(6S):S106-S115. doi: 10.1016/j.wneu.2014.07.031. Review.
PubMed PMID: 25496620.
)).

Solitary non-chordomatous lesions of the clivus are rare pathologies, which represent a diagnostic challenge. 

Twenty-two non-chordomatous lesions of the clivus were collected. A retrospective analysis of clinical and radiological patterns as well as survival data was conducted.

Clinical presentation was a result of local mass effect. Imaging features, although mainly specific, were not always diagnostic. Extent of surgery was gross total in 45.5 % of cases. Depending on the histology, biological behaviour and presence of seeding, adjuvant treatment was performed, tailoring the treatment strategy to the single patient.

Solitary non-chordomatous lesions of the clival bone are more prevalent than expected. They should be approached with a correct differential diagnosis, considering specific epidemiological, radiological, and histopathological characteristics, to minimise diagnostic bias and allow the planning of the best treatment strategy
((Gagliardi F, Spina A, Boari N, Narayanan A, Mortini P. Solitary lesions of the
clivus: what else besides chordomas? An extensive clinical outlook on rare
pathologies. Acta Neurochir (Wien). 2015 Jan 16. [Epub ahead of print] PubMed
PMID: 25591803.
)).

====Lower clivus====
[[Approach]]ing [[lesion]]s located in the lower clivus and at the anterior edge of [[foramen magnum]] have always presented as a challenge to the [[neurosurgeon]]. The majority of these lesions have been approached posteriorly by [[suboccipital]] or [[retrosigmoid]] [[craniotomy]] and anteriorly by [[transoral]] and through the [[paranasal sinus approach]]es. Nevertheless all of then have [[disadvantage]]s including a great depth of [[surgical field]] and an extremely limited lateral exposure
((Rhoton AL. The posterior cranial fossa: microsurgical anatomy and surgical approaches. Neurosurgery 2001;48:1196.)).

===== Epidemiology =====
Tumors of the clivus are extremely rare, representing only 0.1-0.4% of all [[intracranial tumor]]s, with [[chordoma]]s and [[chondrosarcoma]]s being the most frequent tumors of this region 
((Pallini R, Sabatino G, Doglietto F, Lauretti L, Fernandez E, Maira G. Clivus metastases: report of seven patients and literature review. Acta Neurochir (Wien). 2009 Apr;151(4):291-6; discussion 296. doi: 10.1007/s00701-009-0229-1. Epub 2009 Mar 4. PMID: 19259614.))


===== Diagnosis =====

==== Biopsy ====
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===== Differential diagnosis =====

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===== Clivus chordoma =====

see [[Clivus chordoma]]

===== Clivus myeloma =====

see [[Clivus myeloma]].

===== Clivus lymphoma =====
[[Clivus lymphoma]].

===== Clivus metastases =====
[[Clivus metastases]]
===== Case reports =====

An 83-year-old woman presented with 4 weeks of headaches and blurry vision. Examination revealed partial right abducens and left oculomotor palsies. Magnetic resonance imaging (MRI) identified a large, weakly enhancing sellar and clival mass with sphenoid sinus extension. An aggressive subtotal endoscopic endonasal resection was performed with removal of all sphenoid, clival, and sellar disease without cavernous sinus wall resection. Pathology confirmed colorectal adenocarcinoma; computed tomography (CT) imaging identified an ascending colon mass with metastases to the liver and mesenteric nodes. Palliative oncologic therapies were recommended, but she elected hospice, and died 3 months after initial presentation. Gastrointestinal clival metastases are exceedingly rare among sellar and clival pathologies, with eight prior cases reported, most of which presented with diplopia from abducens nerve involvement. Conclusion Clival masses are uncommon skull base lesions that are associated with more aggressive diseases. We present a consolidated framework for decision-making in these challenging patients, alongside an unusual case example that illustrates the importance of increased suspicion for malignant clinical entities in this setting
((Baier MP, Cheong DA, Shi HH, Peterson JEG, Fung KM, Dunn IF, McKinney KA, Graffeo CS. Decision-Making in Clival Mass Lesions: Risk Factors for Malignant Disease and an Illustrative Case Example. J Neurol Surg Rep. 2023 Dec 20;84(4):e156-e162. doi: 10.1055/a-2215-0974. PMID: 38124781; PMCID: PMC10733071.))
===== Case report from the HGUA =====

7 years Child transferred from another hospital due to a mass in the [[nasal fossa]] and right [[cavum]].


Constant [[headache]], not relieved with paracetamol. [[Diplopia]] 

Magnetic Resonance Imaging (MRI):

{{:pasted:20240119-122315.png?400}}

Lytic, expansive, and aggressive tumor centered on the [[clivus]].
Invasion of multiple holes at the base of the skull, including the [[optic canal]] and right [[superior orbital fissure]].
Tumoral involvement with stenosis of the cavernous portion of the [[internal carotid artery]].
Destruction of the walls of the right optic canal and right superior orbital fissure.
Extension towards [[pterygoid process]]es, [[cavernous sinus]]es, with probable tumor infiltration of the [[pituitary]].

Physical Examination:

Visual acuity: 1/1 in both eyes.
Intraocular pressure (IOP): 16/15 mmHg.
No deviation from the normal position of the eyes (proptosis).
Mild torticollis to the right.
Endotropia of approximately 15º in the right eye (OD).
Complete limitation in abduction, supradextroversion, and infradextroversion in OD.
Fundus Examination (FO):

Clear vitreous, retina flat.
Optic disc with well-defined borders; slight congestion of the vascularization of the papilla in the right eye.
Ophthalmological Clinical Findings:

Paralysis of the sixth cranial nerve (VI) in the right eye in the context of a mass in the cavum.

Treatment Plan:

Alternating occlusion to alleviate binocular diplopia.

Follow-up for post-surgical assessment of FO and limitation of ocular movements in OD.
Additional Notes:

A biopsy is suggested to confirm the diagnosis and determine the most appropriate treatment plan. Continuous evaluation is required to monitor post-surgical evolution and adjust management as needed. Ophthalmological collaboration is essential to address visual symptoms and ensure comprehensive care.