Lesions of the petrous apex: classification and findings at CT and MR imaging

The petrous apex is a complex region of the central skull base that is surrounded by a number of important vascular and neural structures and can be home to a wide range of disease processes. Lesions arising in or spreading to the petrous apex cause varied and occasionally severe clinical sequelae, which typically result from mass effect or direct invasion of the cranial nerves, brainstem, or internal carotid artery. Because the petrous apex is not amenable to direct examination, cross-sectional imaging with computed tomography and magnetic resonance (MR) imaging plays an important role in diagnosis and characterization of lesions occurring there. Petrous apex lesions can be classified on the basis of their origin into the following categories: developmental lesions, inflammatory lesions, benign tumors, malignant tumors, vascular lesions, and osseous dysplasias. The most common lesions arising in the petrous apex are cholesterol granulomas, which can be reliably diagnosed with MR imaging due to their high signal intensity on both T1-weighted images and T2-weighted images. In addition, one should also be familiar with anatomic variants or pseudolesions in the petrous apex that can be mistaken for pathologic conditions.