Temporomandibular Joint Lesions with Intracranial Extension: Illustrative Cases from a Systematic Review of the Literature and Our Institution

Clinical Snapshot

Key Findings

• P Value: Not applicable for descriptive analysis

• Effect Size: 33% of cases with imaging differential did not consider TMJ pathology (18/55 cases)

• Primary Outcome: Diagnostic accuracy and characterization of intracranially extending TMJ lesions

• Nnt Or Sensitivity: 90% diagnostic accuracy when both CT and MRI performed; 83% CT and 75% MRI showed nonenhancing lesions

• Confidence Interval: Not reported

Clinical Application

Highly feasible - requires standard CT and MRI imaging available in most Australian radiology departments Directly applicable to Australian neuroradiology practice. Medicare rebates available for CT and MRI imaging. Relevant to radiologists, neurosurgeons, and oral maxillofacial surgeons across public and private sectors Patients presenting with skull base or extra-axial lesions on imaging, particularly those with jaw symptoms or TMJ dysfunction

Abstract

BACKGROUND: Intracranially extending temporomandibular joint (TMJ) lesions may be radiologically misinterpreted as primary intracranial or skull base pathologies, leading to diagnostic delays or inappropriate management. PURPOSE: This systematic review aimed to characterize the clinical and imaging features of such TMJ lesions and evaluate the impact of radiologic misclassification. We also aimed to develop a diagnostic framework for when to consider an intracranially extending TMJ lesion, based on clinical and radiologic features. DATA SOURCES: A comprehensive search of MEDLINE, Scopus, and EMBASE, conducted in accordance with PRISMA guidelines, yielded 2255 records. STUDY SELECTION: After screening with predetermined inclusion and exclusion criteria, 128 studies involving 152 patients were included in the final analysis. DATA ANALYSIS: Statistical analyses were performed using STATA software. We also identified 3 patient cases through our institutional neuroradiology practice who were clinically and radiologically assessed for intracranially extending TMJ lesions. DATA SYNTHESIS: Patients had symptoms for an average of 34 months before diagnosis (47% women, mean age 50 years). The most common pathologies were pigmented villonodular synovitis/tenosynovial giant-cell tumor (43%) and synovial chondromatosis (24%). Neurologic symptoms were reported in 48% of cases, most frequently hearing loss (70%). Nearly one-third (33%) of cases with an imaging differential did not list a TMJ pathology (18/55). In cases with accurate imaging diagnosis, 90% had both CT and MRI performed. Most lesions were nonenhancing (CT 83%, MRI 75%) and demonstrated no adjacent brain edema (96%). In 2 cases, a TMJ ganglion cyst and pseudogout were misdiagnosed as intracranial tumors, resulting in unnecessary intervention, including repeat craniotomy and radiotherapy. LIMITATIONS: There were inherent biases of case report literature, including variability in the reporting of the imaging and clinical features, management, and follow-up. CONCLUSIONS: TMJ lesions with intracranial extension often present with nonspecific symptoms and can mimic extra-axial tumors, leading to misdiagnosis on imaging. Recognition of hallmark imaging features, including lack of parenchymal invasion and distinct imaging patterns, may help improve radiologic accuracy and prevent overtreatment. We propose a diagnostic framework outlining when to suspect intracranially extending TMJ lesions based on clinical and imaging features, and how to avoid common diagnostic pitfalls.

References

1. 1.McKee, H., Rohringer, T., Yang, A. Z., Patel, Y., Alshafai, L., Blanchette, E., Glastonbury, C. M., Mosimann, P. J., Germann, J., Hiremath, S., & Boutet, A. (2026). Temporomandibular joint lesions with intracranial extension: Illustrative cases from a systematic review of the literature and our institution. AJNR American Journal of Neuroradiology. https://doi.org/10.1016/j.ijscr.2016.01.026