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Clinical Note |

Hemorrhagic Petrous Apex Cholesterol Granuloma Clinical Correlation With Imaging

Ananth Narayan, MD; Rajan Jain, MD; Wilson B. Chwang, MD, PhD; Michael Seidman, MD; Jack Rock, MD
Arch Otolaryngol Head Neck Surg. 2012;138(12):1180-1183. doi:10.1001/jamaoto.2013.1024.
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Cholesterol granulomas are commonly found in the petrous apex. Patients with cholesterol granulomas may present with headache or symptoms related to mass effect on adjacent structures and cranial nerves, and cholesterol granulomas often may be an incidental finding on neuroimaging for other reasons.1 Although these lesions may remain dormant for many years, they can also suddenly enlarge, with expansion and subsequent remodeling of the petrous apex. The most common explanation for expansion or enlargement of cholesterol granuloma is thought to be internal hemorrhage.1 The ability to identify cholesterol granuloma is crucial, since in the acute setting it can simulate an enlarging aggressive lesion.

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Figure 1. Imaging studies in case 1. Precontrast T1-weighted (A) and T2-weighted (B) axial baseline magnetic resonance (MR) images show a small, hyperintense lesion in the left petrous apex (arrow). Precontrast T1-weighted (C) and T2-weighted (D) axial MR images performed 15 months after the initial baseline study show an interval enlargement of the previously known hyperintense lesion in the left petrous apex (arrow), suggesting interval hemorrhage, which corresponds to the patient's clinical complaints. High-resolution noncontrast computed tomographic scans centered on the left temporal bone show bony expansion and remodeling of the left petrous apex (arrow) (E and F). Precontrast T1-weighted (G) and T2-weighted (H) axial MR images performed 2 months after resolution of acute clinical symptoms show almost complete resolution of the expansile lesion in the left petrous apex (arrow), suggesting resolution of the hemorrhage.

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Figure 2. Imaging studies in case 2. Precontrast (A) and postcontrast (B) T1-weighted and T2–fluid-attenuated inversion recovery (T2-FLAIR) (C) magnetic resonance (MR) images obtained at the time of patient's acute clinical symptoms show a heterogeneous, expansile, hemorrhagic lesion in the left petrous apex with heterogeneous enhancement. Precontrast (D) and postcontrast (E) T1-weighted and T2-FLAIR) (F) MR images obtained 14 months after resolution of clinical symptoms show significant improvement in the enhancement as well as a slightly smaller size of the lesion, suggesting resolution of the hemorrhage and inflammation previously seen at the patient's clinical presentation of acute symptoms.

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