Bilateral Cerebellopontine Angle Masses in a 72-Year-Old Woman With Prior Malignant Melanoma and a Cochlear Implant: A Diagnostic and Management Challenge

TL;DR

A 72-year-old woman with a history of melanoma and a cochlear implant faced diagnostic and treatment challenges due to bilateral brain lesions, highlighting the difficulties in managing such cases when MRI is not possible.

Contribution

This case study emphasizes the challenges in diagnosing and managing bilateral cerebellopontine angle lesions in melanoma patients with contraindications to MRI.

Findings

Bilateral cerebellopontine angle lesions were identified in a melanoma patient with a cochlear implant, complicating MRI-based diagnosis.

The patient's condition worsened despite antibiotic treatment, with no viable surgical or targeted therapy options due to frailty and implant constraints.

Palliative care was initiated, underscoring the importance of early involvement to manage symptoms and support families in complex cases.

Abstract

Cerebellopontine angle masses are most frequently vestibular schwannomas, but may also represent metastatic disease, particularly in patients with a history of malignant melanoma. We describe the case of a 72-year-old woman with a prior history of melanoma and a right cochlear implant who presented with rapidly progressive bilateral hearing loss, visual impairment, imbalance, and right-sided facial weakness. An initial non-contrast CT scan was reported as normal, although a later multidisciplinary review identified bilateral cerebellopontine angle lesions. MRI, the gold standard for characterising lesions of this region, could not be performed because of the cochlear implant. The differential diagnosis included bilateral vestibular schwannomas and metastatic melanoma.

During hospitalisation, the patient developed an infection that resolved with antibiotic therapy but continued to deteriorate neurologically, with worsening visual loss and recurrent falls. A repeat contrast-enhanced CT scan demonstrated enlargement of the cerebellopontine angle lesions with associated cerebral oedema and ventricular dilatation. Her past genetic testing had confirmed BRAF positivity, though her frailty and poor functional status excluded neurosurgical or targeted systemic treatment. Following multidisciplinary and family discussions, palliative care was initiated. The patient experienced progressive decline and died 45 days after admission. This case illustrates the diagnostic and therapeutic challenges associated with bilateral cerebellopontine angle lesions in patients with a history of melanoma when MRI is contraindicated. It highlights the aggressive behaviour of melanoma metastases, the limitations in imaging and treatment options in frail patients with implants, and the importance of involving palliative care early to optimise symptom management and family support.

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