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Overlooked Metastatic Lesions of the Occipital Condyle: A Missed Case Treasure Trove1

Laurie David A. Loevner, M Yousem, MD MD Radiologic images obtained in nine patients with known primary cancer and occipital or head and neck pain were retrospectively reviewed after having been initially interpreted as normal. Imaging studies included head computed tomography (CT) in five cases, brain magnetic resonance (MR) imaging in six cases, cervical spine CT and MR imaging in five cases, radiography in two cases, and scintigraphy in two cases. This reevaluation demonstrated lesions of the occipital condyles in all patients. Seven patients had unilateral occipital condyle masses, and two patients had bilateral condyle lesions. Lesions were found to either involve only the occipital condyle (n = 4), extend to the adjacent occipital bone (n = 3), or extend to the ipsilateral clivus (n = 2). Misinterpretation of radiologic examinations resulted in an average delay in diagnosis of 10 weeks from the onset of symptoms to definitive therapy (irradiation). It is important to evaluate the occipital condyles in all patients with occipital pain, especially those with cancer. Neoplastic disease involving the occipital condyles is not common; however, it is frequently missed at imaging. Careful review of unenhanced sagittal and axial Ti-weighted MR images and of the inferior sections from axial head CT studies will make it possible to avoid this potential pitfall.

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mon

INTRODUCTION of the and often occipital not bones, specifically The the occipital junction condyles, and the is relatively occipital uncorncondyles suspected. craniovertebral

Disease

are usually

because condyles, radiologic

included

it is unusual and images because (the

in all brain

for a physician these inferior

and

cervical

structures of an

spine

are axial

radiologic

request frequently brain MR

studies

evaluation seen or CT only

(Fig

1). However,

occipital edge of and

to specifically

of the at the series

small

sections

of images

the lateral For similar

missed

sections reasons,

of a sagittal abnormalities

examination,

cervical spine MR study), involving the occipital

even by experienced

they are condyles

radiologists.

often overlooked. are frequently

at radiologic

Index

term:

Skull,

secondary'

neoplasms.

127.33

RadioGraphics `From the Presented January RSNA.

1997; Department as a scientific and

17:1111-1121 of Radiolom', University of Pennsylvania Medical Center, exhibit at the 1996 RSNA scientific assembly. Received receivedjanuarv 13; acceptedJanuary 14. Address reprint 3400 Spruce St. Philadelphia, November 13. 1996; revision requests to L.A.L. PA 19104. requested

7, 1997 1997

1111

Figure

1. Normal anatomy of the occipital condyles at the crarnovertebral junction. (a) Sagittal reformatted computed tomographic (CT) scan of the cervical spine shows the occipital condyles (arrows) as inferior extensions of the occipital bones that articulate with the lateral masses of C-i . (b, c) Sagittal Ti-weighted (repetition time msec/echo time msec = 600/11) 0') and axial Ti-weighted (600/17) (c) magnetic resonance (MR) images demonstrate the normal appearance of the occipital condyles, with hyperintense fat throughout the marrow (*) and hypointense cortical margins. a.

b.

c.

Fractures serious

of the

occipital

condyle

caused

by

ported

seous body are

in another

metastases widely

patient

to almost discussed

(1 1). Although

every in the bone literature,

osin the the

trauma are the most common intrinsic lesions of this structure reported in the literature (1-5). Little has been published on neoplastic disease involving the occipital condyles;

only rarely have case studies of primary benign

occurrence ease

dressed.

and

significance condyles

of metastatic are not ad-

dis-

to the

occipital

or malignant tumors involving the occipital bones been documented (4,6-9). Furthermore, metastatic disease to the occipital condyles

rarely been reported (10, 1 1). One such case

has

in-

In this article, we demonstrate that evaluation of the craniovertebral junction, including the occipital condyles, should be a routine part of all brain and cervical spine radiologic examinations, especially in patients with cancer or

volved drome

ralysis

progressive associated

secondary

unilateral occipital pain synwith ipsilateral tongue pato metastatic disease involv-

occipital

pain.

ing the

similar

occipital

to that

condyle

of several

(10),

patients

a situation

in our study.

. MATERIALS

Our

whose

AND

consisted

studies

METHODS

of nine

of the to have patients or brain spine

study initially

group

Metastatic

hepatocellular

carcinoma

was

re-

radiologic were

were

ultimately

interpreted

believed

as normal

but

metastases

who

all

to

the

occipital

condyles.

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Table

Summary

1 of Clinical Data for Nine Patients with Missed Occipital Condyle Lesions Radiologic inations preted Brain ExamMisinteras Normal MR imaging

Patient/ Sex/Age 1/F/58 (y)

Primary Cancer Head and neck

Symptoms Leading Imaging

to

Location of Lesion Bilateral

Occurrence Metastasis

of

2/M/50

Colon

2 mo failure to thrive, headache, low oral intake 3 mo headache, right occipital pain

First manifestation of metastatic disease Prior bone liver, lung,

Right

Head

CT

metastases Brain MR imaging, cervical MR imaging, scintigraphy, plain radiography Brain MR imaging, cervical MR imaging Brain MR imaging, cervical MR imaging, head CT, cervical CT Brain MR imaging, plain radiography, scintigraphy Head CT

3/M/47

Renal

6 wk right neck pain and headache, slurred speech Right occipital and neck pain Headache, occipital neck pain right and

Right

Prior lung metastases resected, isolated bone metastases Prior bone and brain metastases Prior inguinal nodal metastases

4/F/48

Breast

Right

5/M/82

Colon

Right

6/M/52

Gastroesophageal Colon

7/M/54

Left neck and face pain, headache Headache, left occipital pain Right occipital pain

Left

Left

8/M/73

Prostate

Right

First manifestation of metastatic disease First manifestation of metastatic disease First manifestation of metastatic disease, isolated bone metastases First manifestation of metastatic disease

Brain MR imaging, head CT

9/M/68

Prostate

Neck

pain

Bilateral

Cervical MR imaging, head CT

In all cases, radiologic images were retrospectively reviewed by a neuroradiologist. In four cases, these fmdings were reviewed after

subsequent sion. diologist oncologists) Five imaging cases when came clinicians brought the showed to the a skull base or for rereview le-

mary lonic

cancer. in three,

Four

patients

had

primary

adeno-

carcinomas

of the

gastrointestinal carcinoma, and neck

carcinoma. metastatic

tract

in one),

(cotwo

gastroesophageal

attention

of the

ra-

patients had prostate tient each had head

carcinoma, had previously and breast known

and one carcinoma,

Four disease;

parenal

in

(neurologists images

patients

because of progressive the occipital region

The nine patients

symptoms referable without a clear cause.

(seven men, to 82 had two years women)

to

three cases, five patients,

this disease symptoms represented metastatic

involved related

the bones. to occipital

In

ranging in age from 47 years 59. 1 years) were seen at our

8-month period. All patients

(mean,

condyle lesions tion of presumed an

the first manifestadisease (Table 1).

institution

a known

over

pri-

September-October

1997

Loevner

and

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1113

All patients

in our pain,

study

presented

with neck

simi-

sets

of images

were

obtained

at each

CT

exami-

lar but

gressive

nonspecific

occipital

complaints,

headaches,

including

propain,

nation, other

chyma.

one

The

optimizing

cervical

bone

spine CT

detail of the

study,

and brain

the parenwhich

optimizing

evaluation

or tongue symptoms (weakness or fasciculations), that led to radiologic evaluation. Five patients complained specifically of occipital head pain associated with headache or neck pain on the side of involvement. The remaining four patients complained of more diffuse head and neck pain. One patient complained of slurred speech and tongue fasciculations related to hypoglossal nerve palsy (Table 1).

was performed at an outside cluded contiguous 3-mm-thick through the craniovertebral photographed for soft-tissue

All tions brain obtained MR imaging after studies intravenous

institution, inaxial images junction that were and bone detail.

included administration see-

All patients

imaging studies

were

evaluated head

with CT

multiple studies in

including

five

patients

and

MR imaging

examinations

of

the brain and cervical spine in six and four patients, respectively. One cervical spine CT study, two plain radiographic studies (one each of the cervical spine and skull base), and two scintigraphic studies were also performed.

All brain performed two and on cervical a 1.5-T spine system. MR Three imaging brain was and

of 0. 1 mmol/kg of gadopentetate dimeglumine, and all head CT examinations included scans obtained after intravenous administration of 100 mL of iodinated contrast material. CT and MR imaging examinations of the spine were not contrast-enhanced. In the two patients whose work-up included

plain radiography, anteroposterior, lateral, and

oblique views of the cervical spine as well as multiple views of the skull were obtained. In the two patients who underwent scintigraphy, after

1010

delayed intravenous

images injection MR and head of the

were

obtained of 20 CT mCi

2 hours (0.074 were condyles x

cervical spine formed at outside

tions included

examinations were perhospitals. All brain exarninasagittal Ti-weighted

Bq)

for

of technetium-99m

lesions masses, canal and

diphosphonate.

images

5-mm-thick

All brain sessed

asor hypo-

(500-600/10-25) images and 5-mm-thick trast material-enhanced axial Ti-weighted ages with similar acquisition parameters

conimoh-

occipital soft tissue

other

soft-tissue glossal

calvarial

bones,

and jugular

associated

foramen.

extraosseous

in the We also (fatty re-

tamed through the entire calvaria including the occipital condyles. Cervical spine MR studies consisted of 3-mm-thick sagittal Ti-weighted (500/1 1-17) and T2-weighted (2,700-4,000/

17-25, axial 1 1-13, 80-90) three-dimensional images that included the occipi-

looked

for other

fmdings

of cranial

including

neuropathies

secondary

manifestations

tal condyles.

In all cervical

spine

Fourier

MR studies,

transform volume

5#{176} angle) flip gradient-echo ages included the area from the cervicothoracic junction, thereby

C-2 level excluding

(50/ imto the

placement nerve and ynx for the sagittal MR from axial

spine were each

of the tongue for the tweLfth cranial deviation of the soft palate or pharninth and tenth cranial nerves). The (n = 4) and CT (n = 1 reformatted sections) images of the cervical

,

evaluated

for rereviewed

condylar

lesions.

Ra-

diographs

cases

and

were

scmntigrams

obtained

for the

in two

presence

the condyles.

All head institution CT with studies a helical were performed GE at our 9800 or quick

scanner (GE and consisted

the

Medical Systems, of 3-mm-thick

Milwaukee, axial images

Wis) from

tenor ages

atlantodental articulation through the posfossa, followed by 10-mm-thick axial imthrough the remainder of the brain. Two

of occipital condyle lesions. The medical records of eight of the nine patients were reviewed; one patient's chart was not available for review. Each chart was evaluated in terms of patient age and sex; site of primary carcinoma; symptoms and fmdings at

physical examination (eg, occipital pain, neck

pain,

XII);

neuropathies

history

involving

cranial

disease; and

nerves

treat-

LX-

of metastatic

ment

and

outcome.

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5,

\\i'

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2. 3.

Figures 2, 3. (2) Patient 5. Axial CT scan shows a focal lytic lesion with cortical irregularity of the right occipital condyle (arrowheads). The left condyle (N) is normal. (3) PatIent 2. Axial head CT scan shows a mottled lytic lesion with cortical destruction of the right occipital condyle extending into the occipital bone (arrows).

Table

Clinical Patient I 2 3 4 5 6

2

sequelae Time of Delay Delay in Diagnosis (wk) Seque!ae of Delay in Diagnosis Treatment None XRT XRT None XRT XRT in Diagnosis 13 13 7

4/2

13 13

7 8

6 13

9

Note.-CN

=

9

cranial nerve, XRT

=

9th, 10th, 12th CN palsies 1 2th CN palsy 9th, 10th, 12th CN palsies None Severe progressive pain 9th, 10th, 12th CN palsies, dura! sinus thrombosis due to cxtension into jugular foramen Severe progressive pain 1 2th CN palsy None radiation therapy.

XRT XRT XRT

RESULTS Follow-up physical examination revealed that five patients had developed neuropathies of the twelfth cranial nerve. One patient preU

were found to either involve only the occipital condyle (n = 4) (Fig 2), extend to the adjacent occipital bone (n = 3) (Fig 3), or extend to the

ipsilateral tients, bone clivus lesions

(n

=

2) (Fig

4).

In four with

paan

sented

with

and

three

patients

subsequently

were

associated

developed neuropathies of the ninth and tenth cranial nerves that manifested as dysphagia related to the extension of abnormal soft tissue into the jugular foramen (Table 2). Seven patients had unilateral occipital

condyle patients masses had (five bilateral right, condyle two left), lesions. and two Lesions

extraosseous soft-tissue mass extending into the perivertebral space or epidural compartment of the foramen magnum and posterior

fossa (Fig 5c-5e). Evaluation of the remaining

September-October

1997

Loevner

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a.

b.

c. Figure 4. PatIent 3. (a, b) Sagittal unenhanced in the right

d. Ti-weighted (600/1 1) MR images show

replacement of the normal marrow occipital condyle by hypointense tissue (arrowhead in a), compared with the normal left condyle (* in b). Arrows indicate vertebral arteries. (c, d) Axial Ti-weighted (600/17) MR images (c obtained at a lower level than d) show the right condyle lesion (*) with abnormal soft tissue extending into the right hypoglossal canal (white arrows). The left hypoglossal canal (black arrows) is normal.

Figure 5. Patient 8. (a) Axial head CT scan shows a mottled, lyric lesion with cortical destruction of the right occipital condyle and occipital bone (arrows) (cf the normal left side). (b) Sagittal unenhanced Ti-weighted (600/1 1) MR image shows soft tissue replacing the right condyle (*) and occipital bone. (c, d) Axial Ti-weighted (600/17) (c) and T2-weighted (2,500/85) (d) MR images show the right condyle and occipital bone mass. Abnormal extraosseous soft tissue extends into the jugular foramen (JF), the epidural compartment of the foramen magnum (arrows), and the prevertebral space where there is anterior displacement of the longus muscle complex (L) from the vertebral column. (e) Axial Ti-weighted (600/17) MR image demonstrates replacement of the normal marrow in the civus and occipital bone, which constitute the medial and lateral borders of the hypoglossal canal, respectively. Soft tissue fills the right hypoglossal canal (arrows). Extraosseous soft tissue extends into the prevertebral space (M) with secondary mass effect on the retropharyngeal fat (arrowheads). (fl Axial Tiweighted (600/17) MR image obtained at the level of the oropharynx shows secondary' findings of palsies of the ninth, tenth, and twelfth cranial nerves, including deviation of the soft palate (SF) and fatty replacement of the

right

side

of the

tongue

(F).

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a.

b.

c.

d.

C.

f.

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Figure

6. PatIent 6. (a) Plain radiograph obtained to evaluate left occipital pain demonstrates a lytic, mildly expansile lesion of the left occipital bone (arrows). .b) Posteroanterior delayed scintigram obtained 1 week later shows focal radiotracer uptake in the left occipital bone (arrows). L = left, R = right. (c) Sagittal Tl-weighted (600/1 1) MR image demonstrates abnormal soft tissue replacing the left occipital condyle (*) and occipital bone

(arrows). weighted

(*) with rows).

(d-g) (600/1

expansion, Soft tissue (600/i enhancing

Follow-up MR images obtained 5 weeks later to evaluate increasing occipital pain. Sagittal i) (d) and axial Ti-weighted (600/17) (e) MR images show progression of the left condyle

cortical now extends i) MR image soft tissue disruption, into the demonstrates (7) extending and extension through foramen (if). the inner (1) Axial cortical table of the occipital bone left jugular contrast-enhanced, fat-suppressed

Timass

(arTi-

weighted

normal

(600/1

1) MR image

demonstrates

arrows), transverse

enhancement thrombosis

(straight of the left

enhancing tissue in the occipital condyle and bone (*) as well as abinto the left posterior fossa. (g3 Coronal fat-suppressed Ti-weighted tumor (1) in the left occipital bone, extension through the cortical tables, dural and transdural spread (curved arrows). There has been interval development of sinus (arrowhead).

calvaria

revealed

no

additional

focal

lesions

in

eight

skull

of nine

lesions

patients.

consistent

In one

with

patient,

metastases

multiple

were

Retrospective obtained in two

lytic tients lesions

review patients

occipital subtle

of plain radiographs demonstrated focal

bone but (Fig definite 6a), and

of the

noted. In two patients, unilateral occipital condyle lesions were the sole foci of metastatic disease (Table 1). Condyle lesions were best detected with CT

scans processed with bone windows, which

retrospective

demonstrated

analysis radiotracer

of scintigrarns uptake in the

pathologic aspirations

in two

in-

paoc-

creased

cipital agnosis In no

involved

proof or disease

condyle case (ie, presumed no

(Fig was

6b). there of diopen to

clearly demonstrated rarefaction of bone and cortical destruction (Figs 2, 3). At MR imaging, replacement of normal hyperintense fat with abnormal hypointense soft tissue on unenhanced sagittal and axial Ti-weighted images was the most useful fmding in the detection of condyle lesions (Fig 4a, 4b).

In the nerve five patients and with tweLfth four cranial patients neuropathies in the

fine-needle

surgical

were

biopsies

were

to have

performed).

metastatic

All patients

with ninth and and CT imaging

extending and jugular In two was into

tenth cranial nerve revealed abnormal

the ipsilateral respectively cranial

palsies, MR soft tissue

canal 4d, Se). (Figs nerve

the occipital condyles on the basis of clinical and radiologic findings. Furthermore, all patients had a known primary cancer, four patients had previously known biopsy-proved metastatic disease (with skeletal involvement in two cases), and three patients developed multiple new bone lesions consistent with metastatic disease that were seen at follow-up

scintigraphy (1 month after detection of the

hypoglossal

foramen,

patients with twelfth symptoms, fatty replacement

seen on the involved side,

occipital months ranging average

agnosis were

condyle lesion after detection

there

4'/2

in two cases in one case).

a delay

and

3

of the

and

tongue

in two pa-

In all cases,

was

in diagnosis

tients with ninth and tenth cranial nerve neuropathies, associated deviation of the soft palate was seen at cross-sectional imaging (Fig Sf).

In one S weeks patient, after a follow-up the initial MR study image (the obtained results of

from delay

was initially

weeks to 13 weeks with of iO weeks before a correct

(Table for 2). benign Three patients occipital

an dineu-

made treated

ralgia blocks.

initially After

with

multiple

and

medications

morphine

such

as well

as

as nerve

carbarnazepmne

which

misinterpreted as normal) showed development of soft tissue in the jugular foramen complicated by thrombosis of the ipsilateral jugular bulb, sigmoid sinus, and

transverse extension sinus, into the as well inferior as dural left invasion cerebellar and hemi-

had been

In two thought

lesions

other patients, to be secondary

of the occipital

symptoms were to arthritis.

condyles were

identified,

sphere

(Fig

6e-6h).

seven patients were diation therapy, which resulted provement of symptoms. Five patients are known to be alive

months after completion

treated with rain marked imof these seven (presently 4-12

Three of

of therapy).

the

five

patients

have

developed

new

osseous

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September-October

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Loevner

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metastases (ribs, marked progression

spine), one has developed of a right occipital mass

scalp

and

provide

meningeal

rarni

to the

poste-

af-

ter 6 months of symptomatic relief, and one is stable without disease progression. patient died of complications from extensive metastatic disease to multiple organ systems 2 days after diagnosis of skull base metastases. The seventh patient was lost to follow-up.

U

rior fossa. Anastomoses between muscular branches of the occipital and vertebral arteries are common. Venous drainage of the occiput through the condylar veins, the inferior petrosal sinus, and the cival venous the plexus.

is

Other

cussion dyles

anatomic

of disease the

regions

involving hypoglossal

important

occipital canal

to the

conthe and

dis-

include

DISCUSSION Normal Anatomy

jugular foramen. The hypoglossal canal is 1cated at the anterior margin of the occipital

condyles and transmits the twelfth cranial

.

The occipital

condyles

nor extensions of the a portion of the lateral

magnum.

are small, bilateral infeoccipital bones and form aspect of the foramen

nerve.

nerves and

The

IX-XI, superior

jugular

which to the

foramen

are occipital

transmits

located condyles.

cranial

Abnor-

anterolateral

The condyles articulate with the lateral masses of the C-i vertebral body (Fig 1). They are intimately related to the other osseous skull structures base by at the a number foramen magnum and attachof ligamentous

malities involving these forarnina lower cranial nerve neuropathies. . Pathologic

of disease

may

result

in

Processes

processes may affect the

A variety

ments.

extension

The

tectorial

of the

membrane,

posterior

the

superior

liga-

longitudinal

craniovertebral junction. In the pediatric population, abnormalities may be either congenital

(Arnold-Chiari monly, acquired maLformations) (posttraumatic, or, less cominflammatory,

ment, consists of longitudinally oriented fibers that arise from the dorsal surface of the C-2 vertebral body, extending cephalad to attach to

the right anterior aspect of the occipital bone. The

and left alar ligaments arise from the odontoid process of the C-2 vertebral body and attach to their respective occipital condyles. These as well as other ligaments are of particular importance in injuries condyles to the craniovertebral caused by traujunction or occipital

neoplastic) (5,8- iO, i 2). Patients may present with occipital pain or with symptoms related to compression of the cervicomedullary junetion. In adults, acquired lesions involving the craniovertebral junction and forarnen magnum

may ries be the result of trauma (eg, occipital

condyle sion tion

arthritis

fractures

related

with

to axial

ipsilateral

loading

flexion,

injuavul-

in association

ma. The cervical vertebrae may be supplied with blood from the ascending cervical, deep cervical, and vertebral arteries. Additional sources of blood at the craniovertebral junction are the ascending pharyngeal and occipital arteries, which also supply most of C-i and C-2. The occipital artery arises from the external carotid artery and courses between the occipital bone and C-i . Its terminal branches supply musculocutaneous structures of the upper neck and

fractures from and contralateral

disorders and metabolic

a combination head flexion)

such disorders

of head rota(i-3, i 3). Insuch as Paget

flammatory

as rheumatoid

disease common

(12).

and hyperparathyroidism and may result in basilar

are not uninvagination

Although osseous metastases to the remainder of the skeleton are widely discussed in the literature, the occurrence and significance of metastatic disease to the occipital condyles are not addressed. In our experience, metastases to the occipital condyles are not rare. Spread is most likely hematogenous by way of arterial embolization or venous spread. Although we do not have pathologic proof, we believe each

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Number

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case because

in our (a)

study

represents had

metastatic a known

disease primary

U

all patients

cancer,

disease osseous condyle tomatic allows tebral identifying condyles

(b)

four

patients

and after and cranial Sagittal

had

three

prior

developed

metastatic

other of the were therapy. MR imaging cranioversymp-

elsewhere metastases masses, and excellent junction. responded

identification to radiation

(c) all patients

and and cervical of the axial

Multiplanar

visualization

unenhanced

Ti-weighted

MR images

abnormalities because the

are the

of the hyperintense

most

occipital fat

useful

within

in

the marrow agent" and

mal Axial and nal ous hanced marrow ing sive prompt of the lesions lesion hypointense

is an excellent intrinsic " contrast replacement of this fat with abnorsoft spread foramen into tissue the (Figs is readily are 4-6). also On less hypoglossal axial seen. useful in canal 12images

REFERENCES Noble ER, Smoker WRK. The forgotten condyle: the appearance, morphology, and classification of occipital condyle fractures. AJNR i996; 17:507-5i3. 2. Clayman DA, Sykes CH, Vines FS. Occipital condyle fractures: clinical presentation and radiologic detection. AJNR 1994; 15:i309-i315. 3. Anderson PA, Montesano PX. Morphology and treatment of occipital condyle fractures. Spine 1988; 13:731-736. 4. Link TM, Schuierer G, Hufendiek A, Horch C, Peters PE. Substantial head trauma: value of routine CT examination of the cervicocranium. Radiology 1995; 196:741-745. i

.

5.

Ti-weighted jugular intensity (Figs 4f, and

identifying

6.

weighted

images,

and Sd). were identification

lesions

thus they Similarly,

had

were on

intermediate

conspicunon-fat-saturated

sig7. fatty mak8.

contrast-enhanced

in the

images,

isointense surrounding more

the

masses

bone,

ento the

relative normal difficult.

In patients

occipital careful occipital are

with

head

known

and neck

carcinoma,

pain of the but should skull may of tumor foramen

progresbase Condyle be bilatand

9.

evaluation condyles unilateral

in particular.

usually

io.

the in 1i

.

eral.

ropathies

Patients

may

related canal

have

associated

cranial

neuinto

to extension or jugular

hypoglossal

as seen

five

toms

of the

related

nine

to isolated

patients

occipital metastatic

in our

condyle

study.

lesions

Sympmay

be the

addition,

first condyle

indication may

of metastatic

disease

disease.

to an oc-

In

12.

cipital

may torns.

occur.

Radiation

therapy

of symp13. inaxial seeit

result Radiologists

in dramatic should

improvement be aware that

Stroobants J, Seynaeve P, Fidlers L, Klaes R, Brabnats K, Van Hoye M. Occipital condyle fracture must be considered in the pediatric population: case report. J Trauma 1994; 36: 440-44 1. Banerjee AK, Kak VK. Benign osteoblastoma of the occipital bone. Ear Nose Throat J i99i; 70: 215-2i6. Dumas MD, Munk PL, Munoz DG, Pelz D. Chondromyxoid fibroma of the occipital bone. Can Assoc RadiolJ 1994; 45:303-306. Binatli 0, Ersahin Y, Coskun 5, Bayol U. Ossifying fibroma of the occipital bone. Clin Neurol Neurosurg 1995; 97:47-49. Zenke K, Hatakeyama T, Hashimoto H, Sakaki 5, Manabe K. Primary Ewing's sarcoma of the occipital bone: case report. Neurol Med Chir i994; 34:246-250. [Japanese] Pascual J, Gutierrez A, Polo JM, Berciano J. Occipital condyle syndrome: presentation of a case. Neurologia 1989; 4:293-295. Ogasawara H, Inagawa 1, Yamamoto M, Kamiya K, Monden S. Cranial metastasis of hepatocellular carcinoma: case report. No Shinkei Geka 1988; 16:1479-1482. [Japanese] Johnson MH, Smoker WR. Lesions of the craniovertebral junction. Neuroimaging Clin N Am 1994; 4:599-617. Deeb ZL, Rothus WE, Goldberg AL, Daffner

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