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Gotohda K, Uchino A, Suzuki T, Mishima K, Homma T, Miyama Y, Baba Y. Acute subdural hematoma caused by hemorrhagic falx meningioma: A case report and review of the literature. Radiol Case Rep 2024; 19:2804-2811. [PMID: 38689814 PMCID: PMC11059303 DOI: 10.1016/j.radcr.2024.03.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 03/16/2024] [Accepted: 03/22/2024] [Indexed: 05/02/2024] Open
Abstract
We herein report a case of acute subdural hematoma caused by hemorrhagic falx meningioma. The patient was a 64-year-old woman with no significant medical history or prior history of trauma. She experienced a sudden onset of headache and weakness in her extremities. Computed tomography (CT) scan and magnetic resonance imaging (MRI) showed a mass lesion with intratumoral hemorrhage or faint calcification along the left side of the fronto-parietal cerebral falx. There was also a linear lesion at the left side of the falx, suggesting acute subdural hematoma. MRI was performed again on the eleventh day. On precontrast T1-weighted images, intratumoral hemorrhage and widespread left subdural hematoma were shown as high intensity. On postcontrast T1-weighted images, the tumor showed heterogeneous enhancement with a dural tail sign on the falx, indicative of a falx meningioma. She underwent surgical resection, and the histological subtype was transitional meningioma. Nine cases of hemorrhagic falx meningioma associated with acute subdural hematoma have been reported. If not limited to the site of occurrence, there have been 59 reported cases overall. In our investigation, the incidence of hemorrhage is higher in the convexity and lower in the skull base. It is higher for fibrous, angiomatous, and metaplastic subtypes and lower for meningothelial subtype. The location and histological subtype might be risk factors for meningioma associated with subdural hematoma. Further accumulation of cases will be necessary to establish the cause of bleeding.
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Affiliation(s)
- Kohei Gotohda
- Department of Diagnostic Radiology, Saitama Medical University International Medical Center, 1397-1 Yamane Hidaka, Saitama 350-1298, Japan
| | - Akira Uchino
- Department of Radiology, Saitama Sekishinkai Hospital, 2-37-20 Irumagawa Sayama, Saitama 350-1305, Japan
| | - Tomonari Suzuki
- Department of Neuro-Oncology/Neurosurgery, Saitama Medical University International Medical Center, 1397-1 Yamane Hidaka, Saitama 350-1298, Japan
| | - Kazuhiko Mishima
- Department of Neuro-Oncology/Neurosurgery, Saitama Medical University International Medical Center, 1397-1 Yamane Hidaka, Saitama 350-1298, Japan
| | - Taku Homma
- Department of Diagnostic Pathology, Saitama Medical University International Medical Center, 1397-1 Yamane Hidaka, Saitama 350-1298, Japan
| | - Yu Miyama
- Department of Diagnostic Pathology, Saitama Medical University International Medical Center, 1397-1 Yamane Hidaka, Saitama 350-1298, Japan
| | - Yasutaka Baba
- Department of Diagnostic Radiology, Saitama Medical University International Medical Center, 1397-1 Yamane Hidaka, Saitama 350-1298, Japan
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Leclerc A, Gohel H, Malczuk J, Anzalone L, Emery E, Gaberel T. Systematic Review of Meningiomas Revealed by Spontaneous Intracranial Hemorrhage: Clinicopathological Features, Outcomes, and Rebleeding Rate. World Neurosurg 2023; 172:e625-e639. [PMID: 36738963 DOI: 10.1016/j.wneu.2023.01.100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 01/26/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND Meningiomas are rarely revealed by an intracranial hemorrhage (ICH). Rebleeding occurrence rate and time of onset are unknown. Here, we performed a systematic review of the literature of meningiomas revealed by ICH. METHODS We retrospectively collected all meningiomas revealed by spontaneous ICH published between January 1980 and December 2021. We reported clinicopathological features of meningiomas revealed by ICH. We also estimated rebleeding rate and time to onset. RESULTS Ninety-two studies met all inclusion criteria, led to a total of 120 cases. The mean age was 56.3 years, with 66 (55%) female. Seventy-nine (66%) cases were conscious before surgery, 20 (17%) were in coma, and 17 (14%) were unconscious after deterioration. The most frequent bleeding type was subdural hemorrhage (N = 49, 41%) followed by intraparenchymal hemorrhage (IPH) (N = 44, 37%), subarachnoid hemorrhage (SAH) (N = 22, 18%), and intraventricular hemorrhage (IVH) (N = 5, 4%). IPH and hindbrain/ventricular locations are associated with poor outcomes (P = 0.031 and < 0.001, respectively). Among the 19 patients who did not undergo surgical resection of the meningioma, 14 (74%) experienced rebleeding with a median occurrence of 120 days (interquartile, [90; -]). Rebleeding occurs earlier if the type of bleeding is SAH or IVH and for hindbrain location (both P < 0.01). CONCLUSIONS ICH is a rare presentation of meningiomas. Hindbrain and ventricular tumor location and IPH are associated with poor outcomes. Rebleeding rate is high and premature. It occurs earlier if the first bleeding was SAH or IVH and for hindbrain location.
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Affiliation(s)
- Arthur Leclerc
- Department of Neurosurgery, CHU de Caen-Normandie, Caen, France; Normandie Université, UNICAEN, Caen, France.
| | | | - Joséphine Malczuk
- Department of Neurosurgery, CHU de Caen-Normandie, Caen, France; Normandie Université, UNICAEN, Caen, France
| | - Louis Anzalone
- Department of Neurosurgery, CHU de Caen-Normandie, Caen, France; Normandie Université, UNICAEN, Caen, France
| | - Evelyne Emery
- Department of Neurosurgery, CHU de Caen-Normandie, Caen, France; Normandie Université, UNICAEN, Caen, France; Normandie Université, UNICAEN, INSERM, U1237, PhIND "Physiopathology and Imaging of Neurological Disorders", Institut Blood and Brain @ Caen-Normandie, Cyceron, Caen, France
| | - Thomas Gaberel
- Department of Neurosurgery, CHU de Caen-Normandie, Caen, France; Normandie Université, UNICAEN, Caen, France; Normandie Université, UNICAEN, INSERM, U1237, PhIND "Physiopathology and Imaging of Neurological Disorders", Institut Blood and Brain @ Caen-Normandie, Cyceron, Caen, France
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Cerase A, Tampieri D, Miracco C, Grazzini I. Diagnostic neuroradiology of intracranial meningiomas presenting with hemorrhagic onset: a double center 14-year experience. Emerg Radiol 2023; 30:175-185. [PMID: 36707465 DOI: 10.1007/s10140-023-02115-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 01/23/2023] [Indexed: 01/29/2023]
Abstract
PURPOSE This study aims to increase awareness of the hemorrhagic presentation of intracranial meningiomas in the emergency department and present clues for neuroradiological diagnosis, which is crucial for pertinent management. We described the prevalence of hemorrhage in a large population of meningioma patients, with emphasis on clinical presentation, computed tomography (CT), magnetic resonance (MR), and digital subtraction angiography (DSA) findings. METHODS This retrospective analysis has been performed at two reference institutions between January 2002 and December 2015, and includes 1304 patients with histologically proven newly diagnosed intracranial meningioma. Clinical features and neuroradiological findings of intracranial meningiomas presenting with hemorrhage have been reviewed. RESULTS Twenty-four patients (1.8%, 16 females, 8 males, age range: 29-88 years) were found to have spontaneous hemorrhagic onset of the newly diagnosed meningioma. A sudden onset occurred in 23/24 patients. Sixteen patients showed isolated intralesional hemorrhage, four had subdural hematomas, and the remaining four presented combined intralesional and subarachnoid (n = 2) or intraventricular (n = 2) hemorrhages. In 13 patients, CT showed both the hemorrhage and the meningioma. In the other 11 patients, diagnosis was achieved by emergency or early surgery (n = 5), MRI (n = 5), and DSA (n = 1). CONCLUSIONS The presence of an underlying meningioma has to be considered in the differential diagnosis of spontaneous intracranial hemorrhage, although this is a rare event. CT, MRI, and occasionally DSA were useful to obtain the diagnosis; however, in up to a fifth of patients, this was achieved at surgery.
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Affiliation(s)
- Alfonso Cerase
- Unit of Neuroimaging, Diagnostic and Functional Neuroradiology, Clinical Department of Neurological and Motor Sciences, Azienda Ospedaliero-Universitaria Senese, Santa Maria Alle Scotte National Health System and University Hospital, Tuscany, Siena, Italy
| | - Donatella Tampieri
- Department of Radiology, Diagnostic and Interventional Neuroradiology, Kingston Health Science Centre, Queen's University, Kingston, ON, Canada
| | - Clelia Miracco
- Unit of Pathology, Clinical Department of Oncology, Azienda Ospedaliero-Universitaria Senese and Department of Medicine, Surgery, and Neurosciences, University of Siena, Santa Maria Alle Scotte National Health System and University Hospital, Tuscany, Siena, Italy
| | - Irene Grazzini
- Department of Diagnostic Imaging, Section of Neuroradiology, San Donato National Health System Hospital, Pietro Nenni Street, 52100, Arezzo, Tuscany, Italy.
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Halalmeh DR, Alrashdan M, Kharouf M, Sbeih I, Molnar PT, Moisi MD. Brain Meningiomas Manifesting as Intracranial Hemorrhage: Comprehensive Systematic Review and Report of the First Case of Hemorrhagic Meningiomatosis. World Neurosurg 2023; 169:73-86.e6. [PMID: 36332779 DOI: 10.1016/j.wneu.2022.10.113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 10/26/2022] [Accepted: 10/27/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To characterize the salient features of hemorrhagic manifestation of meningiomas and to report on the first case of hemorrhagic meningiomatosis. METHODS A comprehensive systematic review of the English-language literature was performed using MEDLINE, PubMed, and Google Scholar databases to identify case reports and series of brain meningiomas manifesting as intracranial hemorrhage. RESULTS A total of 65 patients were evaluated. Most patients were female (64.6%). The average age at presentation was 58.1 ± 14.3 years. The most common presenting symptom was focal neurologic deficits (n = 47; 71.2%). Identification of tumor was missed/not possible in 24.6% of patients. The most common reported comorbidity was hypertension. Most tumors were located in convexity (n = 36; 55.3%). Subdural hematoma (± other hemorrhages) was the most common type of intracranial hemorrhage (n = 46; 70.7%). Computed tomography hyperintensity (25.7%) and magnetic resonance imaging T2 hypointensity (22%) were the most prevalent radiologic findings. The predominant histopathology subtype was meningothelial (syncytial) (n = 24; 36.4%). The estimated mortality was 13.8%. Among those who survived, 39.9% had residual deficits at a median follow-up of 8.1 ± 5.8 months. CONCLUSIONS Intracranial hemorrhage induced by meningiomas is associated with significant mortality and morbidity. Identifying unexpected meningioma in the setting of intracranial bleed can help optimize preoperative planning (e.g., surgical approach) and facilitate total resection of the underlying tumor. Therefore, clinicians should have a high index of suspicion with a low threshold for investigation of meningiomas in the setting of intracranial hemorrhage.
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Affiliation(s)
- Dia R Halalmeh
- Department of Neurosurgery, Hurley Medical Center, Flint, Michigan, USA.
| | | | | | | | - Petrica T Molnar
- Department of Neurosurgery, Hurley Medical Center, Flint, Michigan, USA
| | - Marc D Moisi
- Department of Neurosurgery, Hurley Medical Center, Flint, Michigan, USA
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Xie ZR, Wang HC, Tong YL, Li SW, Chen MS, Wang BD. Radiological classification of meningiomas with hemorrhagic onset and its clinical significance. Oncol Lett 2022; 24:341. [PMID: 36072002 PMCID: PMC9434713 DOI: 10.3892/ol.2022.13461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 07/07/2022] [Indexed: 11/30/2022] Open
Abstract
Meningiomas are the most common benign intracranial tumors and frequently present with a gradual onset of neurological deficits; conversely, their acute presentation with hemorrhagic onset appears to be a rare event. Nonetheless, as early surgical evacuation is the foundation of treatment, a timely diagnosis of this rare type of intracranial hemorrhage is necessary. The purpose of the present single-center study was to investigate the radiological characteristics and propose a new bleeding classification for guiding the diagnosis and treatment. A total of 19 patients consecutively diagnosed with hemorrhagic meningioma were enrolled in this retrospective study. Intracranial extra-axial mass, tumor-associated hemorrhage and peritumoral brain edema were the three main radiological features of the hemorrhagic meningiomas. The site of tumor-associated hemorrhage included the peritumoral space, subarachnoid space, subdural space, brain parenchyma and/or intratumor region. Based on the anatomical relationship between meningioma and hematoma, the spontaneous hemorrhage stemming from meningiomas was further summarized into three bleeding patterns involving purely intratumoral hemorrhage (type I), purely extratumoral hemorrhage (type II) and combined intra/extratumoral hemorrhage (type III); furthermore, the type III hemorrhage usually came from type I bleeding that extended into the surrounding regions. The symptoms in type I patients were generally mild and early surgery was performed following adequate preoperative evaluations. The symptoms in type II patients were mild in certain cases and moderate to severe in others, so early or emergency surgery was chosen according to the clinical status of the patient. Almost all type III patients had moderate to severe symptoms and these patients usually required emergency surgery. In addition, patients with different bleeding types may have different pathological mechanisms underlying the tumor bleeding. Apart from being convenient for diagnosis, this concise and practical bleeding classification may aid in the selection of the treatment strategy and facilitate the understanding of the associated mechanisms.
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Affiliation(s)
- Zuo-Run Xie
- Department of Neurosurgery, The Affiliated Lihuili Hospital of Ningbo University, Ningbo, Zhejiang 315040, P.R. China
| | - Hong-Cai Wang
- Department of Neurosurgery, The Affiliated Lihuili Hospital of Ningbo University, Ningbo, Zhejiang 315040, P.R. China
| | - Yi-Lei Tong
- Department of Neurosurgery, Hwa Mei Hospital of University of Chinese Academy of Sciences, Ningbo, Zhejiang 315040, P.R. China
| | - Shi-Wei Li
- Department of Neurosurgery, The Affiliated Lihuili Hospital of Ningbo University, Ningbo, Zhejiang 315040, P.R. China
| | - Mao-Song Chen
- Department of Neurosurgery, The Affiliated Lihuili Hospital of Ningbo University, Ningbo, Zhejiang 315040, P.R. China
| | - Bo-Ding Wang
- Department of Neurosurgery, Hwa Mei Hospital of University of Chinese Academy of Sciences, Ningbo, Zhejiang 315040, P.R. China
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Jenson M, Nguyen QH, Fiester P, Patel J, Rao D. Meningiomas Can Present as Intracranial Hemorrhage in Rare Cases: A Case Report of a Patient With a History of Minor Trauma and Massive Intracranial Hemorrhage. Cureus 2022; 14:e25823. [PMID: 35822144 PMCID: PMC9271313 DOI: 10.7759/cureus.25823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2022] [Indexed: 11/23/2022] Open
Abstract
Meningiomas are relatively common intracranial tumors. While typically discovered incidentally or related to symptoms from regional mass effect, on rare occasions, they can present as acute intracranial hemorrhage. We report a case of a 62-year-old male who presented with significant acute intracranial hemorrhage with a history of minor trauma. Imaging workup demonstrated a hemorrhagic mass to be the likely cause of the hemorrhage. Upon resection of the mass, pathology demonstrated meningioma. It is important to thoroughly investigate intracranial hemorrhage, particularly when it appears out of proportion to any known causative event, in order to accurately diagnose, manage, and treat these patients.
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Acute, nontraumatic subdural hemorrhage as a presentation of meningioma: A report of two cases and literature review. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Huang R, Su S, Yang Z, Wang H, Hong L, Chen L, Wu X, Zheng Y, Zhuang R, Liu Y. Neuroradiologic Findings and Clinical Features of Meningiomas With Spontaneous Hemorrhagic Onset: A Single-center 10-year Experience. World Neurosurg 2022; 162:e605-e615. [PMID: 35338017 DOI: 10.1016/j.wneu.2022.03.080] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 03/17/2022] [Accepted: 03/17/2022] [Indexed: 02/05/2023]
Abstract
OBJECTIVE This study aimed to elucidate the clinicoradiologic features of spontaneous hemorrhagic meningiomas (HMs) and examine risk factors associated with meningioma hemorrhage. METHODS We retrospectively reviewed 651 consecutive meningioma patients who underwent surgical resection in our hospital between January 2011 and January 2021. After exclusions, 169 patients were included for analysis. Patients were grouped according to presence of hemorrhage in the meningioma: the HM group (n = 19) and non-HM group (n = 150). Clinicoradiologic patient data were examined and compared using univariate and multivariate analysis. RESULTS HMs accounted for 2.9% of the entire series of meningiomas. HMs were mainly located at the convexity (63.2%). Mean diameter of HMs was 4.8 cm. On computed tomography, most HMs appeared as mixed isodensity and hyperdensity (84.2%). On magnetic resonance imaging, most appeared as mixed isointensity and hyperintensity on T1-weighted imaging and mixed hypointesity and hyperintensity on T2-weighted imaging (52.6%). Seventeen tumors exhibited heterogeneous enhancement, a dural tail, and peritumoral brain edema. Thirteen showed intratumoral cystic change. The misdiagnosis rate was significantly higher in HMs than non-HMs (31.6% vs. 7.3%; P = 0.005). Intratumoral cystic change was the only independent predictor of meningioma hemorrhage in multivariate analysis (odds ratio 4.116; 95% confidence interval 1.138-14.894; P = 0.031). CONCLUSIONS Mixed isodensity/intensity and hyperdensity/intensity on computed tomography/magnetic resonance imaging in conjunction with heterogenous enhancement, a dural tail, and varying degrees of peritumoral brain edema suggest a high possibility of HM. Presence of intratumoral cystic change was an independent risk factor associated with meningioma hemorrhage.
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Affiliation(s)
- Ruibin Huang
- Department of Radiology, First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, P.R.China
| | - Shuyan Su
- Department of Radiology, First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, P.R.China
| | - Zhiqi Yang
- Department of Radiology, Meizhou People's Hospital, Meizhou, Guangdong, P.R.China
| | - Huanpeng Wang
- Department of Radiology, First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, P.R.China
| | - Liangli Hong
- Department of Pathology, First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, P.R.China
| | - Liujiang Chen
- Department of Radiology, First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, P.R.China
| | - Xiaojia Wu
- Department of Radiology, First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, P.R.China
| | - Yungui Zheng
- Department of Neurosurgery, First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, P.R.China
| | - Ruyao Zhuang
- Department of Radiology, First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, P.R.China
| | - Yuan Liu
- Department of Radiology, First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, P.R.China
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Abolfotoh M, Brzezicki G, Fiester P, Tavanaiepour D. A Rare Case of Life-Threatening Multicompartmental Spontaneous Intracranial Hemorrhage From a Grade 1 Convexity Meningioma. Cureus 2021; 13:e19178. [PMID: 34877188 PMCID: PMC8642124 DOI: 10.7759/cureus.19178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 10/29/2021] [Indexed: 11/25/2022] Open
Abstract
Meningiomas are slowly growing benign tumors. The incidence of hemorrhage associated with intracranial meningiomas is in the 0.5%-2.4% range. However, intracranial meningiomas with hemorrhagic presentation are associated with higher rates of overall major morbidity (36%) and mortality (21.1%). We report a case of a convexity meningioma presenting with intraparenchymal hematoma and bilateral acute subdural hematomas (SDH) in a comatose patient (Glasgow Coma Scale (GCS) score: 7) who had a history of recurrent episodes of headaches over the past few months. Hemorrhagic presentation of a meningioma is a rare but potentially devastating event. Early recognition of the potential underlying meningioma as a cause of bleeding followed by rapid appropriate additional imaging is crucial to direct treatment plans to achieve the best outcome.
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Affiliation(s)
| | | | - Peter Fiester
- Neuroradiology, University of Florida Health, Jacksonville, USA
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10
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Meningiomas associated with subdural hematomas: A systematic review of clinical features and outcomes. World Neurosurg 2021; 158:e465-e475. [PMID: 34763104 DOI: 10.1016/j.wneu.2021.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 10/30/2021] [Accepted: 11/01/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Meningiomas associated with subdural hematomas (SDH) are exceedingly rare. As such, the clinical features, optimal medical and surgical management, and outcomes of treatment for these lesions remain unknown. METHODS We performed a systematic review of the Pubmed and SCOPUS databases for case reports and case series on patients with presumptive clinical or definitive diagnoses of meningiomas presenting with a subdural hematoma on CT scan or MRI. Data on demographics, clinical manifestations, surgical management, adjuvant treatment, and outcome on last follow-up were collected. RESULTS A total of 59 cases met the inclusion criteria, including one described in the current study. The mean age of patients was 62 years (range 5 - 85 years), with a slight female predilection (1.3:1). The most common clinical symptom and sign were headache and focal weakness, respectively. All except two cases underwent surgery - either done singly or staged - for evacuation of hematoma and/or excision of tumor. Treatment for meningiomas associated with SDH was associated with a mortality rate of 12% (6/51) at a median follow up of 3 months. Complete neurologic recovery was reported in 71% of patients. CONCLUSION Subdural hematomas are rare presenting manifestations of intracranial meningiomas. Current management is largely surgical for immediate relief of mass effect and oncologic control. Most patients survived with complete neurologic recovery.
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Huang RB, Chen LJ, Su SY, Wu XJ, Zheng YG, Wang HP, Zhuang RY, Liu Y. Misdiagnosis and Delay of Diagnosis in Hemorrhagic Meningioma: A Case Series and Review of the Literature. World Neurosurg 2021; 155:e836-e846. [PMID: 34520866 DOI: 10.1016/j.wneu.2021.09.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/04/2021] [Accepted: 09/06/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To evaluate the clinicoradiologic characteristics of hemorrhagic meningiomas (HMs) that are missed or misdiagnosed on radiologic imaging studies. METHODS Clinical and radiologic data from 6 patients with HM who were initially misdiagnosed were collected and recorded respectively. In addition, we performed a literature review for misdiagnosed HM and summarized the results. RESULTS Five of the 6 patients with misdiagnosed HM were female, and 1 was male. Both computed tomography (CT) and magnetic resonance imaging were performed in 4 patients, and CT alone was performed in 2. On CT, the HM was heterogeneously hyperdense in 5 patients and isodense in 1 patient. In all 4 patients who underwent magnetic resonance imaging, the HM was mixed iso- and hypointense on T1-weighted imaging and heterogeneously hyperintense on T2-weighted imaging. Marked heterogeneous contrast enhancement was observed in 2 patients, strong rim enhancement in 1, and peripheral enhancement in 1. The dural tail sign was seen in only 1 patient. The initial radiologic misdiagnoses were subdural hematoma (n = 1), malignant glioma (n = 1), ruptured arterial aneurysm (n = 1), metastasis (n = 2), and uncertain (n = 1). In the literature review, 22 cases of HM diagnostic error were collected. The main misdiagnoses were subdural hematoma (27.3%), traumatic hematoma (13.6%), vascular anomaly (13.6%), malignant glioma (4.5%), and metastasis (4.5%). CONCLUSIONS Our study showed that in patients with HM with inadequate imaging evaluation, a small tumor associated with massive hematoma and atypical imaging features was more likely to be misdiagnosed.
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Affiliation(s)
- Rui-Bin Huang
- Department of Radiology, First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, P. R. China
| | - Liu-Jiang Chen
- Department of Radiology, First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, P. R. China
| | - Shu-Yan Su
- Department of Radiology, First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, P. R. China
| | - Xiao-Jia Wu
- Department of Radiology, First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, P. R. China
| | - Yun-Gui Zheng
- Department of Neurosurgery, First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, P. R. China
| | - Huan-Peng Wang
- Department of Radiology, First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, P. R. China
| | - Ru-Yao Zhuang
- Department of Radiology, First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, P. R. China.
| | - Yuan Liu
- Department of Radiology, First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, P. R. China
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Nam JW, Park ES, Park JB, Seo JH, Kim M, Jung NY. Benign meningioma manifesting with acute subdural hematoma and cerebral edema: a case report and review of the literature. J Med Case Rep 2021; 15:335. [PMID: 34187580 PMCID: PMC8244191 DOI: 10.1186/s13256-021-02935-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 05/31/2021] [Indexed: 01/09/2023] Open
Abstract
Background Spontaneous subdural hematoma rarely presents with a hypervascular or malignant tumor but even less frequently in a benign tumor like meningioma. We encountered a patient with acute subdural hematoma associated with benign meningioma. Here, we report this case along with a review of previous reports, especially focusing on their clinical features and possible bleeding mechanisms. Case presentation A 53-year-old Asian woman presented with severe headache and progressive neurologic deterioration due to cerebral edema. The patient was submitted to open surgery for evacuation of the subdural hematoma and concurrent tumor removal on the ipsilateral parietal convexity. A hypervascular, encapsulated mass was identified during surgery and completely removed including the adjacent dura mater (Simpson grade 0). The tumor was histologically confirmed as an angiomatous meningioma (World Health Organization grade I). Her clinical course was uneventful after surgery. Conclusions Although meningiomas are commonly benign according to their histological traits, they can lead to spontaneous bleeding and cause neurologically unstable condition. Therefore, meningiomas need to be considered as a cause of spontaneous subdural hematoma if radiologically suspicious, which should be reflected by proper management for a positive outcome. Supplementary Information The online version contains supplementary material available at 10.1186/s13256-021-02935-x.
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Affiliation(s)
- Ji Won Nam
- Department of Neurosurgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Eun Suk Park
- Department of Neurosurgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Jun Bum Park
- Department of Neurosurgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Jae Hee Seo
- Department of Pathology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Minsoo Kim
- Department of Neurosurgery, Gangneung Asan Hospital, Gangneung, Republic of Korea
| | - Na Young Jung
- Department of Neurosurgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea.
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13
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Dang DD, Mugge L, Awan O, Dang J, Shenai M. Spontaneous or Traumatic Intratumoral Hemorrhage? A Rare Presentation of Parafalcine Meningioma. Cureus 2020; 12:e11486. [PMID: 33329982 PMCID: PMC7735529 DOI: 10.7759/cureus.11486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
While hemorrhage is commonly encountered in various intracranial tumors, it is relatively rare in benign meningiomas. We present an interesting case report of a 75-year-old male who fell during intoxication, sustaining right frontal cranial trauma, coincidentally directly overlying a previously undiagnosed right frontal meningioma. He experienced an acute neurological decline and was found to have an intracranial hematoma, causing significant mass effect and herniation. Based on the radiographic appearance, an underlying neoplasm with significant edema was suspected. Intraoperatively, the hematoma and mass were successfully evacuated, and post-operative pathology confirmed the presence of a World Health Organization Grade I meningioma with a microcystic and angiomatous pattern. We speculate on the mechanism of injury and hemorrhage in this patient through review of the literature and discussion of medical and pathological risk factors.
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Affiliation(s)
- Danielle D Dang
- Neurological Surgery, Inova Hospital System, Falls Church, USA
| | - Luke Mugge
- Neurological Surgery, Inova Hospital System, Falls Church, USA
| | - Omar Awan
- Neurological Surgery, Inova Hospital System, Falls Church, USA
| | - John Dang
- Internal Medicine, Walter Reed National Military Medical Center, Bethesda, USA
| | - Mahesh Shenai
- Neurological Surgery, Inova Health System, Falls Church, USA
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14
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Alghabban FA, Alhamss YJ, Farag AA, Alfahmi JA, Al-Saiari SA, Alghamdi F, Abdoh MG. Incidental intraoperative finding of meningioma in spontaneous acute subdural hematoma: A case report from Saudi Arabia and review of literature. Int J Surg Case Rep 2020; 77:314-317. [PMID: 33197775 PMCID: PMC7677660 DOI: 10.1016/j.ijscr.2020.10.136] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 10/29/2020] [Accepted: 10/29/2020] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION An association of meningioma with spontaneous acute subdural hematoma has been rarely reported in the literature. Up to date, 38 cases have been reported. PRESENTATION OF CASE A 74-year-old Saudi female known case of hypertension presented suddenly with dizziness, headache, and left lower limb weakness for 6 h. No history of trauma or anticoagulant medication. Computed tomography scan showed acute subdural hematoma. Pre-operative images were negative for any vascular pathology or lesional tissue. The patient underwent surgery for evacuation of the subdural collection. The presence of abnormal soft tissues within the hematoma was discovered during the surgery and sent for analysis. Histopathological results showed meningothelial subtype grade I meningioma. The patient recovered well, with no obvious neurological deficit or immediate complication. DISCUSSION Spontaneous acute subdural hematoma without a predisposing factor is a rare occurrence; consequently, a thorough investigation is mandatory in such case to reach the hidden aetiology. CONCLUSION In this report a rare association of meningioma with an acute subdural hematoma described. Our case was the first one reported where meningioma incidentally discovered during procedure without preoperative suspicion. A small size intracranial lesion may not be detected by preoperative radiological assessment in the presence of a hematoma. Systematic inspection of the operative field is an important surgical step despite negative preoperative radiological images. Our case supports the mechanism of rupture of abnormal vascular structure. More cases needed to understand the mechanism of such a rare association.
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Affiliation(s)
- Fatimah Abdulrahim Alghabban
- Neurosurgery Department, Neuroscience Center, King Abdullah Medical City, Holy Capital, Saudi Arabia; Neurosurgery Department, King Abdulaziz Speciality Hospital, Taif, Saudi Arabia
| | - Yoseri Jameel Alhamss
- Neurosurgery Department, Neuroscience Center, King Abdullah Medical City, Holy Capital, Saudi Arabia
| | - Ahmed A Farag
- Neurosurgery Department, Neuroscience Center, King Abdullah Medical City, Holy Capital, Saudi Arabia
| | - Julnar Ayman Alfahmi
- Neurosurgery Department, Al-Noor Specialist Hospital, Holy Capital, Saudi Arabia
| | - Sultan Ali Al-Saiari
- Neurosurgery Department, Neuroscience Center, King Abdullah Medical City, Holy Capital, Saudi Arabia
| | - Faisal Alghamdi
- Interventional Neuroradiology Department, King Abdullah Medical City, Holy Capital, Saudi Arabia
| | - Mohammad Ghazi Abdoh
- Neurosurgery Department, Neuroscience Center, King Abdullah Medical City, Holy Capital, Saudi Arabia.
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15
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Pereira BJA, de Almeida AN, Paiva WS, de Aguiar PHP, Teixeira MJ, Marie SKN. Assessment of hemorrhagic onset on meningiomas: Systematic review. Clin Neurol Neurosurg 2020; 199:106175. [PMID: 33027728 DOI: 10.1016/j.clineuro.2020.106175] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/01/2020] [Accepted: 08/20/2020] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To review the data published on the subject to create a more comprehensive natural history of the haemorrhagic onset of meningiomas (IVMs). PATIENTS AND METHODS A Medline search up to June 2020, using the search term "bleeding meningioma," returned 136 papers. As a first selection step, we adopted the following inclusion criteria: series and case reports about bleeding meningioma. Papers written in other languages but with abstracts written in English were also evaluated. RESULTS A total of 190 tumours were evaluated, specifically 109 tumours from female patients and 81 tumours from male patients with a ratio of 1.34 female to 1.0 male (mean age of 54.86 ± 16.1years old). The majority were located in the convexity (129-67.9 %). Among the 190 tumours evaluated, 171 patients (90 %) presented with GI tumours, with a predominance of the meningothelial subtype (32.6 %). Nine patients (4.7 %) presented with grade GII tumours, and 10 (5.3 %) presented with GIII tumours. The most prevalent type was intracerebral haemorrhage (ICH) at 50 %, followed by subdural at 27.36 %; the mortality rate was 13.1 % (25 deaths), the distribution of both location (prevalence of convexity: 18-72 %) and histopathology (grade 1: 22-88 %). CONCLUSION These tumours follow the histopathological distribution of meningiomas, in general. The age distribution shows prevalence among the adult population but with a greater proportion in the elderly. The fact that the overwhelming majority of cases involve meningiomas with a benign histological subtype is noteworthy. Another relevant factor observed is that most reports are from Asian origin.
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Affiliation(s)
| | | | - Wellingson Silva Paiva
- Departamento de Neurologia da Faculdade de Medicina da Universidade de São Paulo, SP, Brazil
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16
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Matos D, Pereira R. Meningioma-related subacute subdural hematoma: A case report. Surg Neurol Int 2020; 11:264. [PMID: 33024602 PMCID: PMC7533084 DOI: 10.25259/sni_337_2020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 08/08/2020] [Indexed: 11/04/2022] Open
Abstract
Background Meningiomas are the most frequent benign head tumors, although spontaneous hemorrhage is a rare form of presentation of such lesions. Of all possible bleeding locations associated with them, the subdural space is one of the most uncommon, with very few cases reported worldwide. Case Description A middle-aged woman presented with progressively worsening left-sided headache, initiated 2 weeks before, with no other complaints, denying any previous head trauma. Head computed tomography revealed a subacute left hemisphere subdural hematoma and left frontal, suggestive of meningioma on magnetic resonance imaging. Surgical treatment was performed with hematoma evacuation and lesion removal. Neuropathology showed a transitional meningioma with signs of hemorrhage. After surgery, no neurological deficits were registered, and headache abated. Conclusion As we could not identify any other cause for the subacute subdural hematoma, hemorrhage from the meningioma was the most probable cause, and thus, we decided to remove it along with clot evacuation. Based on neuropathological findings, we propose an alternative mechanism for this spontaneous hemorrhage from the meningioma, involving the place where the periphery of the lesion insertion, the dura mater as the origin of the hemorrhage. Knowledge of this association could help define the best treatment in such cases.
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Affiliation(s)
- Daniela Matos
- Department of Neurosurgery, Coimbra University Hospital Centre, Portugal
| | - Ricardo Pereira
- Department of Neurosurgery, Coimbra University Hospital Centre, Portugal.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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17
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Sadegh Masoudi M, Zafarshamspour S, Ghasemi-Rad M, Soleimani N, Rakhsha A, Lincoln C. Acute Subdural Hemorrhage of a Convexity Meningioma in the Postpartum Period; Case Report and Literature Review. Bull Emerg Trauma 2019; 7:324-329. [PMID: 31392235 DOI: 10.29252/beat-0703018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
New onset seizures in pregnancy or the postpartum period can be of great importance and denote various underlying pathologies. Eclampsia and cerebrovascular accidents are common, and brain tumors are uncommon causes of postpartum seizures among others. Acute presentation of brain tumors in pregnancy or the postpartum period is extremely rare. Meningiomas are the most common benign intracranial tumors. Although 1.3 to 2.4% of these benign tumors may bleed, acute presentation of them with hemorrhage is quite rare. Herein, we report a rare case of a 36-year-old lady who presented with severe headache, seizure, and loss of consciousness in the postpartum period, five days after delivery of a full-term baby. Primary emergency evaluation revealed an extra-axial lesion with subdural hemorrhage. A Decompressive craniectomy was performed, hematoma was evacuated, and the tumor was totally resected. Histopathologic evaluation was consistent with a fibroblastic meningioma (WHO grade I). She was discharged in good general condition. Our case highlights the significance of complete evaluation of patients with new-onset seizures in pregnancy or the postpartum period. Although uncommon, brain tumors in pregnancy can have potentially devastating outcomes which may necessitate prompt surgical intervention.
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Affiliation(s)
- Mohammad Sadegh Masoudi
- Departmet of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran.,Neurotrauma Research Center, AJA University of Medical Sciences, Tehran, Iran
| | | | | | - Neda Soleimani
- Departmemt of Pathology, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Abbas Rakhsha
- Departmet of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Christie Lincoln
- Department of Radiology, Baylor college of medicine, Houston, Texas, USA
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18
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Aloraidi A, Abbas M, Fallatah B, Alkhaibary A, Ahmed ME, Alassiri AH. Meningioma Presenting with Spontaneous Subdural Hematoma: A Report of Two Cases and Literature Review. World Neurosurg 2019; 127:150-154. [PMID: 30947005 DOI: 10.1016/j.wneu.2019.03.248] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 03/22/2019] [Accepted: 03/23/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND Although meningiomas are considered benign, encapsulated brain tumors, their distinct intracranial location can lead to devastating complications. Although a highly vascularized tumor, a rarely reported complication of meningioma is hemorrhage. To the best of our knowledge, only 19 cases of meningioma presenting with a subdural hematoma have been reported. CASE DESCRIPTION We have outlined the clinical presentation, radiological findings, and outcomes of 2 female patients with a diagnosis of a spontaneous subdural hematoma associated with meningioma. The coagulation profile was within normal limits for both patients. The postoperative histopathologic examination results showed an angiomatous/microcystic subtype of meningioma (patient 1) and meningothelial meningioma (patient 2). Both patients underwent right frontal craniotomy, resection of the dural-based tumor, and evacuation of the subdural hematoma. CONCLUSIONS We comprehensively reviewed the pertinent data for meningiomas presenting as subdural hematomas. The mechanism of hemorrhage in meningiomas remains unclear. Therefore, further studies are required to investigate the possible mechanisms of bleeding in such tumors.
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Affiliation(s)
- Ahmed Aloraidi
- Department of Neurosurgery, King Abdulaziz Medical City, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Munzir Abbas
- Department of Neurosurgery, King Abdulaziz Medical City, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Bassam Fallatah
- National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Ali Alkhaibary
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
| | - Muhammad Ejaz Ahmed
- Medical Imaging Department, King Abdulaziz Medical City, Ministry of National Guard, Riyadh, Saudi Arabia
| | - Ali H Alassiri
- Department of Pathology and Laboratory Medicine, King Abdulaziz Medical City, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
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19
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Matsuoka G, Eguchi S, Ryu B, Tominaga T, Ishikawa T, Yamaguchi K, Kawamata T. Treatment Strategy for Recurrent Hemorrhage from Meningioma: Case Report and Literature Review. World Neurosurg 2019; 124:75-80. [PMID: 30620893 DOI: 10.1016/j.wneu.2018.12.124] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 12/12/2018] [Accepted: 12/13/2018] [Indexed: 11/28/2022]
Abstract
We came across a rare case of recurrent hemorrhage from a meningioma. Here, we describe this case and discuss the treatment strategies for recurrent hemorrhage from a meningioma using a literature review. A 61-year-old woman with a history of two episodes of hemorrhage from a meningioma originating from the left falx cerebri, presented to our outpatient clinic. She was asymptomatic, and MRI revealed a small tumor along the falx cerebri; however, we decided to remove the hemorrhagic meningioma. No abnormal vascular structures were recognized on preoperative angiography and on intraoperative evaluation. The tumor was easily removed along the falx cerebri (Simpson grade I). The pathological diagnosis was transitional meningioma, World Health Organization grade I. The patient experienced no recurrence of tumor or hemorrhage for up to 15 months after surgery. The incidence of repeated bleeding from meningiomas is very rare and is seldom reported, because the mortality associated with hemorrhage in meningiomas is high (28-50%). Immediate diagnosis and surgical treatment with both hematoma evacuation and tumor removal are crucial to avoid inadequate and delayed treatment that may cause mortality.
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Affiliation(s)
- Go Matsuoka
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan.
| | - Seiichiro Eguchi
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Bikei Ryu
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Tadasuke Tominaga
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Tatsuya Ishikawa
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Koji Yamaguchi
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Takakazu Kawamata
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
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20
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Teramoto S, Tsunoda A, Kawamura K, Sugiyama N, Saito R, Maruki C. Malignant Subdural Hematoma Associated with High-Grade Meningioma. Surg J (N Y) 2018; 4:e91-e95. [PMID: 29896565 PMCID: PMC5995683 DOI: 10.1055/s-0038-1660511] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 05/01/2018] [Indexed: 11/16/2022] Open
Abstract
A 70-year-old man, who had previously undergone surgical resection of left parasagittal meningioma involving the middle third of the superior sagittal sinus (SSS) two times, presented with recurrence of the tumor. We performed removal of the tumor combined with SSS resection as Simpson grade II. After tumor removal, since a left dominant bilateral chronic subdural hematoma (CSDH) appeared, it was treated by burr hole surgery. However, because the CSDH rapidly and repeatedly recurred and eventually changed to acute subdural hematoma, elimination of the hematoma with craniotomy was accomplished. The patient unfortunately died of worsening of general condition despite aggressive treatment. Histopathology of brain autopsy showed invasion of anaplastic meningioma cells spreading to the whole outer membrane of the subdural hematoma. Subdural hematoma is less commonly associated with meningioma. Our case indicates the possibility that subdural hematoma associated with meningioma is formed by a different mechanism from those reported previously.
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Affiliation(s)
| | - Akira Tsunoda
- Department of Neurosurgery, Koshigaya Municipal Hospital, Saitama, Japan
| | - Kaito Kawamura
- Department of Neurosurgery, Koshigaya Municipal Hospital, Saitama, Japan
| | - Natsuki Sugiyama
- Department of Neurosurgery, Koshigaya Municipal Hospital, Saitama, Japan
| | - Rikizo Saito
- Department of Neurosurgery, Koshigaya Municipal Hospital, Saitama, Japan
| | - Chikashi Maruki
- Department of Neurosurgery, Koshigaya Municipal Hospital, Saitama, Japan
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21
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Suzuki Y, Fujimoto M, Kawakita F, Asakura F, Murata H, Morooka Y, Suzuki H. Tiny Falx Meningioma Causing Massive Interhemispheric Subdural Hematoma: A Case Report. NMC Case Rep J 2018; 5:51-55. [PMID: 29725568 PMCID: PMC5930240 DOI: 10.2176/nmccrj.cr.2017-0091] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 08/10/2017] [Indexed: 11/25/2022] Open
Abstract
Bleeding from meningiomas is well known, but massive subdural hemorrhage from a very small meningioma is rare. A 61-year-old woman presented with a sudden-onset headache and slight right hemiparesis without a history of trauma. Computed tomographic scan showed bilateral acute/subacute interhemispheric subdural hematoma, but contrast-enhanced computed tomography (CT) scan, non-enhanced magnetic resonance imaging (MRI) and digital subtraction angiography failed to detect the cause. The hematoma was conservatively treated. Three weeks later, CT scans showed a vestige of the hematoma along the falx. However, repeated angiogram revealed a tumor stain on the falx supplied by the middle meningeal arteries, leading to the tentative diagnosis of meningioma. The tumor was removed and histologically diagnosed as angiomatous meningioma. It is rare that falx meningioma causes massive interhemispheric subdural hematoma, and the diagnosis of the causative lesion is challenging if tumor is small. We review the literature and discuss the characteristics.
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Affiliation(s)
- Yume Suzuki
- Department of Neurosurgery, Saiseikai Matsusaka General Hospital, Matsusaka, Mie, Japan.,Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Masashi Fujimoto
- Department of Neurosurgery, Saiseikai Matsusaka General Hospital, Matsusaka, Mie, Japan
| | - Fumihiro Kawakita
- Department of Neurosurgery, Saiseikai Matsusaka General Hospital, Matsusaka, Mie, Japan
| | - Fumio Asakura
- Department of Neurosurgery, Saiseikai Matsusaka General Hospital, Matsusaka, Mie, Japan
| | - Hiroto Murata
- Department of Neurosurgery, Saiseikai Matsusaka General Hospital, Matsusaka, Mie, Japan
| | - Yoshito Morooka
- Department of Neurosurgery, Saiseikai Matsusaka General Hospital, Matsusaka, Mie, Japan
| | - Hidenori Suzuki
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
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22
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Shekarchizadeh A, Masih S, Reza P, Seif B. Acute Subdural Hematoma and Subarachnoid Hemorrhage Caused by Ruptured Cortical Artery Aneurysm: Case Report and Review of Literature. Adv Biomed Res 2017; 6:46. [PMID: 28503501 PMCID: PMC5414414 DOI: 10.4103/2277-9175.204589] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
The present report describes an acute subdural hematoma (ASDH) associated with subarachnoid hemorrhage (SAH), due to ruptured cortical aneurysm. To our knowledge, extremely rare cases of this sort have been reported so far. A 23-year-old male patient without previous trauma presented with severe headache and rapidly decreasing level of consciousness to decerebrate status. Computed tomography (CT) scan has demonstrated an ASDH together with SAH. Hematoma has immediately been evacuated without any evaluation by angiography. After evacuation of the thick subdural clot, a 10-mm aneurysm was revealed on a precentral artery of frontal cortex, which was ligated. However, after 35 days the patient discharged with left side hemiparesis and dysphasia, and just after several months of admission he got symptom free. Ruptured cortical aneurysm should be considered as one of the causes of spontaneous ASDH. Vascular anomaly investigations are suggested for these cases, thus CT angiography or digital subtraction angiography has to be considered if clinical condition allows.
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Affiliation(s)
- Ahmad Shekarchizadeh
- Department of Neurosurgery, Kashani Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Saburi Masih
- Department of Neurosurgery, Al Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Pourkhalili Reza
- Department of Neurosurgery, Al Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Bahram Seif
- Department of Neurosurgery, Kashani Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
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23
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Quiñones-Hinojosa A, Raza SM, Lazaridis C, Olivi A. Olfactory Groove Meningiomas: Acute Presentation and Potential : Pitfalls in Management and Functional Restoration. ACTA NEUROCHIRURGICA. SUPPLEMENT 2017; 124:155-158. [PMID: 28120068 DOI: 10.1007/978-3-319-39546-3_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Meningiomas are typically benign, slow-growing lesions that present after an insidious onset of symptoms related to mass effect. The acute presentation of a patient who has suffered a transtentorial herniation event due to a meningioma is rare. There are only few publications describing such a presentation in the absence of hemorrhage [1]. In this case report, a patient with an olfactory groove meningioma presenting with signs and symptoms of transtentorial herniation in the absence of tumor-associated hemorrhage is discussed. This is a unique presentation of such a lesion. The patient developed Anton's syndrome-binocular visual loss with blindness denial. Management considerations for patients with meningiomas that present with acute deterioration are discussed.
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Affiliation(s)
- Alfredo Quiñones-Hinojosa
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Department of Oncology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Shaan M Raza
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Department of Oncology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Christos Lazaridis
- Department of Neurosciences Critical Care, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Alessandro Olivi
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, USA.
- Department of Oncology, Johns Hopkins School of Medicine, Baltimore, MD, USA.
- Department of Neurosurgery and Oncology, Phipps 1-100 - The Johns Hopkins Hospital, 600 N. Wolfe Street, Baltimore, MD, 21287, USA.
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24
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Role of Tumor Vessels' Features in Determining Risk of Bleeding in Meningiomas: Which Came First, the Chicken or the Egg? World Neurosurg 2016; 95:590-593. [PMID: 27586174 DOI: 10.1016/j.wneu.2016.08.092] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 08/20/2016] [Indexed: 11/20/2022]
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25
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Wang HC, Wang BD, Chen MS, Li SW, Chen H, Xu W, Zhang JM. An Underlying Pathological Mechanism of Meningiomas with Intratumoral Hemorrhage: Undifferentiated Microvessels. World Neurosurg 2016; 94:319-327. [PMID: 27443229 DOI: 10.1016/j.wneu.2016.07.042] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 07/11/2016] [Accepted: 07/11/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Meningiomas usually present with a gradual onset of symptoms, and their acute presentation with a hemorrhagic event appears to be a rare condition. Although many clinical features of such a condition have been characterized, pathophysiological mechanisms underlying the bleeding remain unclear, and some contradictory results have been reported. The value of tumor vascularity as an index for the bleeding propensity of meningiomas is inconsistent. We sought to identify whether meningiomas have different types of blood vessels, and to explore the association of the different tumor vessels with intratumoral hemorrhage. METHODS Six patients with meningioma with acute onset due to intratumoral hemorrhage were identified, and 12 nonhemorrhagic meningiomas were matched according to specific clinical data. The characteristics of tumor vessels were examined through immunohistochemical staining of CD31, CD34, and smooth muscle actin (SMA). The number of stained vessels was counted and compared between the 2 groups. RESULTS Two distinct types of blood vessels were determined in all meningiomas: undifferentiated (CD31+/CD34-) and differentiated (CD31+/CD34+) vessels, and most differentiated vessels were covered by pericytes marked by SMA. However, only the mean number of undifferentiated vessels in hemorrhagic meningiomas was significantly higher than that in controls (15.3 ± 4.9 vs. 6.4 ± 3.6; P < 0.01). Neither the number of differentiated vessels nor the total number of tumor vessels were significantly different between the 2 groups (P > 0.05). CONCLUSIONS Our results suggest that tumor vasculature in meningiomas is heterogeneous, and that the undifferentiated vessels may play a pivotal role in the spontaneous intratumoral hemorrhage from meningiomas.
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Affiliation(s)
- Hong-Cai Wang
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China; Department of Neurosurgery, Li Hui Li Hospital of Medical Center of Ningbo, Ningbo, China
| | - Bo-Ding Wang
- Department of Neurosurgery, Li Hui Li Hospital of Medical Center of Ningbo, Ningbo, China
| | - Mao-Song Chen
- Department of Neurosurgery, Li Hui Li Hospital of Medical Center of Ningbo, Ningbo, China
| | - Shi-Wei Li
- Department of Neurosurgery, Li Hui Li Hospital of Medical Center of Ningbo, Ningbo, China
| | - Hai Chen
- Department of Neurosurgery, Li Hui Li Hospital of Medical Center of Ningbo, Ningbo, China
| | - Wei Xu
- Department of Neurosurgery, Li Hui Li Hospital of Medical Center of Ningbo, Ningbo, China
| | - Jian-Min Zhang
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China.
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26
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Hambra DV, Danilo DP, Alessandro R, Sara M, Juan GR. Meningioma associated with acute subdural hematoma: A review of the literature. Surg Neurol Int 2014; 5:S469-71. [PMID: 25422791 PMCID: PMC4235119 DOI: 10.4103/2152-7806.143724] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2014] [Accepted: 09/24/2014] [Indexed: 11/19/2022] Open
Abstract
Background: Classically meningiomas present with a gradual onset of symptoms and their acute presentation with hemorrhagic events seems to be a rare event. A review of the literature shows only 18 cases of meningioma associated with acute subdural hematoma. The possible mechanisms of hemorrhage are not yet fully understood. Case Description: We report a case of sphenoid wing meningioma associated with acute subdural hematoma, without history of trauma. The presence of meningioma was discovered during the surgery. The tumor and hematoma were removed without postoperative complications. Conclusions: The authors have discussed the etiology of an acute subdural hemorrhage and reviewed the pertinent literature.
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Affiliation(s)
- Di Vitantonio Hambra
- Department of Life, Health and Environmental Sciences (MESVA), University of L'Aquila, L'Aquila, Italy
| | - De Paulis Danilo
- Department of Neurosurgery, San Salvatore City Hospital, L'Aquila, Italy
| | - Ricci Alessandro
- Department of Neurosurgery, San Salvatore City Hospital, L'Aquila, Italy
| | - Marzi Sara
- Department of Neurosurgery, San Salvatore City Hospital, L'Aquila, Italy
| | - Galzio Renato Juan
- Department of Life, Health and Environmental Sciences (MESVA), University of L'Aquila, L'Aquila, Italy
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27
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Munivenkatappa A, Shukla DP. Atypical meningioma and acute subdural hemorrhage. J Neurosci Rural Pract 2014; 5:203-4. [PMID: 24966575 PMCID: PMC4064202 DOI: 10.4103/0976-3147.131693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Ashok Munivenkatappa
- Department of Clinical Neurosciences, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Dhaval P Shukla
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
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28
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Rocha AJD, Saade N, Silva AZD. Meningioma associated with non-traumatic subdural hematoma: an outstanding appearance of this common intracranial tumor. ARQUIVOS DE NEURO-PSIQUIATRIA 2014; 71:417. [PMID: 23828541 DOI: 10.1590/0004-282x20130052] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 12/28/2012] [Indexed: 11/21/2022]
Affiliation(s)
- Antônio José da Rocha
- Section of Neuroradiology, Santa Casa de Misericórdia de São Paulo, São Paulo,SP, Brazil.
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29
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Abstract
The authors present the case of a 46-year-old woman who was admitted to their institution after suffering acute intratumoral hemorrhage. There was no history and evidence of neoplasms, trauma, seizures and coagulopathy in the patient. Surgery was performed for evacuation of the hematoma and tumor excision after brain CT scan. Post operative results her neurologic function recovered completely. The pathology reports revealed angioblastic meningioma. The key to make an early and accurate diagnosis is good radiological examination, and definitive surgery can bring a more favorable outcome, lowering the morbidity and mortality rate.
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Affiliation(s)
- Robert Sinurat
- Department of Surgery and Neurosurgery, Medical Faculty and Hospital of Christian University of Indonesia, Jalan Mayjen, Soetoyo - Cawang, Jakarta, Indonesia
| | - Jusuf D Banjarnahor
- Department of Surgery and Neurosurgery, Medical Faculty and Hospital of Christian University of Indonesia, Jalan Mayjen, Soetoyo - Cawang, Jakarta, Indonesia
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30
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Sakowitz OW, Harting I, Kohlhof P, Unterberg AW, Steiner HH. Acute haemorrhage into a microcystic meningioma leading to cerebral herniation. Br J Neurosurg 2009; 19:260-4. [PMID: 16455530 DOI: 10.1080/02688690500208734] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Low-grade (WHO level I) meningiomas are slow-growing, benign tumours typically presenting with unspecific symptoms (e.g. headache), seizures, cranial nerve compression and neuropsychological symptoms determined by location and size of the lesion. Haemorrhagic onset and sequelae are rare, and have been described infrequently. This is a case of a 50-year-old male presenting with signs of tentorial herniation secondary to hyperacute intratumoural haemorrhage (ITH) into a previously undiagnosed meningioma. Emergency surgical decompression and exstirpation of the lesion helped to achieve a favourable outcome. ITH has been described in all including benign intracranial neoplasms. Factors associated with a higher risk for haemorrhage in meningiomas are discussed. Though haemorrhages associated with meningiomas have been reported, ITH into low-grade meningiomas leading to herniation remains a rarity. Bearers of known lesions and their treating physicians who opt for conservative or delayed treatment should be aware of this remote complication.
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Affiliation(s)
- O W Sakowitz
- Department of Neurosurgery, University of Heidelberg, Germany.
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31
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Kashimura H, Arai H, Ogasawara K, Beppu T, Kurose A, Ogawa A. Lipomatous meningioma with concomitant acute subdural hematoma--case report--. Neurol Med Chir (Tokyo) 2009; 48:466-9. [PMID: 18948682 DOI: 10.2176/nmc.48.466] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A 55-year-old man presented with a rare lipomatous meningioma associated with acute subdural hematoma manifesting as sudden onset of severe headache, but no neurological deficit. No evidence of trauma or underlying predisposition to hemorrhage was seen. Fluid-attenuated inversion-recovery magnetic resonance imaging showed a thin hyperintense area in the right temporal convexity, and an extra-axial mass appearing as mixed hypointensity and hyperintensity. Two weeks later, right temporal craniotomy was performed and the tumor was totally resected with the attached dura. The hematoma was localized at the inferior margin of the mass and connected directly with the tumor. Histological examination of the resected specimen revealed typical meningothelial meningioma admixed with mature adipose tissue. Longstanding intratumoral congestion probably caused hyaline deposition in the tissue, leading to vessel rupture.
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Affiliation(s)
- Hiroshi Kashimura
- Department of Neurosurgery, Iwate Medical University School of Medicine, Morioka, Iwate, Japan.
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32
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Di Rocco F, Mannino S, Puca A, Lauriola L, Pompucci A. Intracranial meningiomas associated with non-traumatic chronic subdural hematoma. Acta Neurochir (Wien) 2006; 148:1097-102; discussion 1102. [PMID: 16917666 DOI: 10.1007/s00701-006-0861-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2005] [Accepted: 06/12/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND Non-traumatic subdural hematomas are very rarely associated with intracranial meningiomas. Pathophysiological mechanisms of such an association are not yet fully understood. CASE DESCRIPTION We report on two patients harboring an intracranial meningioma and ipsilateral non-traumatic chronic subdural hematoma. Their history was negative for risk factors for subdural hematoma. Both patients were submitted to surgery for evacuation of the subdural collection. The presence of the meningioma was discovered during surgery. A second operation was necessary in our first case. CONCLUSIONS We retrospectively analyzed our radiological data and the literature to provide some features that may help in the pre-operative diagnosis of a meningioma in patients presenting with a chronic subdural hematoma. Furthermore the mechanisms responsible for this association are discussed on the basis of our pathological evidence.
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Affiliation(s)
- F Di Rocco
- Institute of Neurosurgery, Catholic University Medical School, Rome, Italy.
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33
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Abstract
✓The authors present the case of a 60-year-old woman who was admitted to their institution after suffering a subarachnoid hemorrhage (SAH). Neuroimaging data demonstrated an olfactory groove meningioma surrounded by a slight edema, but there was no evidence of SAH, although results of the lumbar puncture demonstrated xanthochromic cerebrospinal fluid. Angiography confirmed the diagnosis of meningioma, but results of magnetic resonance imaging led the authors to suspect a cavernoma within the meningioma. This diagnosis was established by pathological examination of the resected lesion. The patient did well and was discharged soon after surgery. This very rare association and the propensity of each of these lesions to be revealed by hemorrhage are discussed.
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Affiliation(s)
- Olivier Klein
- Department of Neurosurgery, Hôpital Central, Nancy, France.
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34
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Bosnjak R, Derham C, Popović M, Ravnik J. Spontaneous intracranial meningioma bleeding: clinicopathological features and outcome. J Neurosurg 2005; 103:473-84. [PMID: 16235680 DOI: 10.3171/jns.2005.103.3.0473] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The aim of this study was to determine the clinicopathological features of patients with intracranial bleeding from unsuspected meningioma and to relate these data to surgery-related outcome. METHODS The authors report on two cases in which hemorrhage of an unsuspected meningioma occurred in the tentorial ridge and in the falx, and they discuss the details of 143 cases described in the literature. A bleeding propensity index of the meningioma, related to the patient's age, sex, and the lesion's intracranial location and histological type was computed as a ratio between the frequencies of bleeding meningioma and all meningiomas. This was tested by independent samples t-test for proportions. A chi-square test was used to determine the correlations between several variables: location and type of bleeding; survival and type of bleeding; and consciousness and survival. Increased bleeding tendency was found to be associated with two age groups (< 30 years and > 70 years), convexity and intraventricular locations, and fibrous meningiomas. The overall mortality rate documented in cases of bleeding meningiomas was 21.1% (13.9% in the computerized tomography [CT] scanning era), and that in surgically treated cases was 9.5% (7.5% in the CT scanning era). The overall major morbidity rate was 36% (33.8% in the CT scanning era). Overall 96.2% of conscious patients survived after their meningiomas spontaneously hemorrhaged. In patients who were unconscious before surgery, overall mortality rate was 74.1%, and that in surgically treated cases was 46.2%. CONCLUSIONS The mortality rate in preoperatively conscious patients (those in whom acute deterioration and irreversible brain damage were prevented by early diagnosis and definitive surgery) was similar (< 3% in the CT scanning era) to that documented in cases in which meningiomas did not bleed. In contrast, the associated morbidity rates were much higher. One-stage total removal of the hemorrhagic meningioma and hematoma is the treatment of choice in such patients.
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Affiliation(s)
- Róman Bosnjak
- Department of Neurosurgery, University Hospital Center, and Institute of Pathology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.
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35
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Abstract
To characterize histopathological and clinical features of angiomatous meningioma, 38 cases of angiomatous meningioma, ie, meningiomas whose vascular component exceeded 50% of the total tumor area, are reported. In addition to histologic examinations, clinical characteristics as well as follow-up data were compiled. Angiomatous meningiomas constituted 2.1% of all meningiomas. Histologic signs of atypia or anaplasia were not observed in any tumor. The mean MIB-1/Ki67 proliferation index was 2.4%. Based on vessel size, two distinct histologic subtypes were identified, which differed in localization but not with regards to sex, age, presence of peritumoral edema, MIB-1/Ki67 proliferation index, or progesterone receptor status. In patients with gross tumor resection, no recurrences occurred. To conclude, angiomatous meningiomas share histologic and clinical features of benign meningiomas. Since all angiomatous meningiomas examined here were grade 1 tumors, the diagnosis of angiomatous meningioma may have prognostic implications. Therefore, the existence of this rare subgroup of meningioma appears justified.
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Affiliation(s)
- Martin Hasselblatt
- Institute of Neuropathology, University Hospital Münster, Münster, Germany.
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36
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Abstract
Coagulation disorders are common in cancer patients. In patients with solid tumors, a low-grade activated coagulation can result in systemic and cerebral arterial or venous thrombosis. Cancer treatments may also contribute to this coagulopathy, which usually, but not exclusively, occurs in the setting of advanced malignant disease. There may be TIAs or cerebral infarctions. Because of the widespread distribution of cerebral thromboses, there may be a superimposed encephalopathy; sometimes this is the only sign. Concurrent systemic thrombosis is present in many patients and is a useful clue to the diagnosis. In cerebral venous occlusion, the initial symptom is usually a headache. Except for cerebral intravascular coagulation that is unassociated with NBTE, neuriomaging studies usually demonstrate one or more parenchymal infarctions. MRI or MRV may demonstrate venous thrombosis. The laboratory evidence of coagulopathy is difficult to distinguish from the asymptomatic coagulopathy that often accompanies advanced cancer, and the test results must be interpreted cautiously. NBTE can be diagnosed by transesophageal echocardiography. There is no established treatment for the thrombotic coagulopathy associated with cancer, but anticoagulation should be considered. In leukemia and lymphoma, the coagulopathy is typically acute DIC that can lead to systemic and brain hemorrhages. It is especially common in acute myelogenous leukemias. The clinical signs of cerebral hemorrhage are fulminant and may be fatal. The bleeding usually occurs in the brain or subdural compartment, and rarely in the subarachnoid space. The diagnosis can be suspected by the clinical setting and by systemic thrombosis or hemorrhage. It can be established by examination of the peripheral smear, the platelet count, and tests of coagulation function. Therapy of acute DIC is controversial and should be individualized for the clinical setting. Cerebrovascular disorders can complicate metastatic or primary tumor in the brain, skull, dura, or leptomeninges. The clinical signs of infarction are indistinguishable from other causes of stroke, except that tumor-related venous occlusion will usually first produce signs of increased intracranial pressure. The diagnosis of tumor-related infarction can usually be established by neuroimaging studies that show infarction and may show extracerebral sites of tumor. CSF examination is useful in diagnosing leptomeningeal metastasis. A search for lung or cardiac tumor should be performed when embolic tumor infarction is suspected. Primary or metastatic tumors in the brain or dura may hemorrhage, producing the initial clinical signs of the brain tumor or a change in chronic signs induced by the tumor. There are helpful clues to a neoplastic hemorrhage on brain CT or MRI scans. The brain hemorrhage may require evacuation and the underlying tumor will usually require additional antineoplastic treatment. Hyperleukocytosis (extreme elevation of the cell count) in acute myelogenous leukemia is a less common cause of brain hemorrhage in recent years because of improved methods to lower the cell count. Cerebral arterial or venous thrombosis is sometimes the result of cancer therapy. The attribution of thrombosis to chemotherapy in many published cases is only speculative, because carefully conducted prospective studies that include investigation for other thrombotic causes are not available. The best-known associations with thrombosis are L-asparaginase, which is typically used in the induction therapy of acute lymphocytic leukemia, and combination hormonal therapy and chemotherapy for breast cancer. Radiation to the head and neck, typically administered for head and neck epithelial cancers or lymphoma, may result in delayed carotid atherosclerosis. The distribution of stenosis or occlusion is within the radiation portal and is typically more extensive than is atherosclerosis that develops in the absence of radiation. Small clinical series suggest that surgical treatment is equally effective as in nonirradiated carotid atherosclerosis. In children, the cerebral vessels can be affected by brain radiation resulting in stenosis or occlusion. Brain hemorrhages can result from chemotherapy effects on the hemostatic system or a microangiopathic anemia. Hemorrhages from radiation-induced vascular abnormalities are rare. Opportunistic infections, especially fungal infections, can complicate cancer or its treatment. Septic cerebral emboli may result in focal cerebral signs, seizures, or encephalopathy. Sometimes there is an associated hemorrhagic vasculitis or cerebritis. Rarely, mycotic aneurysms may bleed. A high index of suspicion is needed to diagnose fungal infection because of the difficulty in culturing the organism from the blood or CSF. A clinician can usually establish the cause of stroke in the cancer patient by performing a careful review of the clinical setting--including the type and extent of cancer and the type of antineoplastic therapy--in which the stroke occurred. Systemic thrombosis, embolism, or hemorrhage can be a clue to the cause, and appropriate neuroimaging and coagulation studies to aid in the diagnosis are available. Therapy may ameliorate symptoms or prevent further episodes. The identification of one of these unusual stroke syndromes that leads to the diagnosis of an occult and treatable cancer can be particularly rewarding.
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Affiliation(s)
- Lisa R Rogers
- Departments of Neurology and Neurosurgery, Hermelin Brain Tumor Center, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, MI 48202, USA
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