Atypical Meningioma with Perineural Spread Along Hypoglossal Nerve

A 50-year-old female presented with acute onset bilateral limb weakness, episodes of severe occipital headache with multiple episodes of loss ofconsciousnesswith a background history of left side neck pain, and occipital headache in the past 4 years. There was no signi fi cant past medical/surgical, social, or familyhistory.On examination,therewasleft-sided deviation of the tongue with left-sided face weakness. Bilateral upper limb has power was 2/5 and lowerlimb power was 3/5 without any bowel and bladder incontinence. On imaging, magnetic resonance imaging (MRI) revealed a large well-de fi ned lobulated extra-axial left petroclival dura-based mass. The mass was seen extending along the prepon-tine, left cerebellopontine, and cerebellomedullary cisterns and inferiorly into the spinal canal through the foramen magnum ( ► Fig. 1A – D ). The mass was isointense on T1-weighted(T1)imagingandonT2-weighted(T2)imaging.There was no signi fi cant diffusion restriction in diffusion-weighted imaging or blooming in gradient images. The tumor displayed intense, homogeneous post-contrast enhancement. The mass showed broad base along the tentorium cerebelli and clivus. Laterally the lesion was seen widening and eroding the hypo-glossal canal and extending intotheleft parapharyngeal