Neuroradiologic Findings and Clinical Features of Meningiomas With Spontaneous Hemorrhagic Onset: A Single-center 10-year Experience

Intra-and peritumoral hemorrhage in the meningioma of a nonagenarian due to administration of direct oral anticoagulants after mechanical thrombectomy

Background

Spontaneous intratumoral hemorrhage of meningiomas is rare, and their incidence due to anticoagulants is unclear. The incidence of both meningioma and cardioembolic stroke increases with age. We report the very elderly case of intra- and peritumoral hemorrhage in frontal meningioma induced by direct oral anticoagulant (DOAC) following mechanical thrombectomy, in whom, surgical resection was required 10 years after the tumor was first indicated.

Case Description

A 94-year-old woman with independence in daily living who suffered sudden consciousness disturbance, total aphasia, and right hemiparesis was admitted to our hospital. Magnetic resonance imaging showed an acute cerebral infarction and left middle cerebral artery occlusion. There was also a left frontal meningioma with peritumoral edema, which was discovered 10 years prior, and the size and edema had remarkably increased. The patient underwent urgent mechanical thrombectomy, and recanalization was achieved. Administration of DOAC was initiated for the atrial fibrillation. Computed tomography (CT) revealed an asymptomatic intratumoral hemorrhage at postoperative day 26. The patient's symptoms gradually improved; however, she suffered sudden disturbance of consciousness and right hemiparesis on postoperative day 48. CT revealed intra- and peritumoral hemorrhages with compression of the surrounding brain. Therefore, we decided to perform tumor resection instead of conservative treatment. The patient underwent surgical resection, and the postoperative course was uneventful. It was diagnosed with transitional meningioma with no malignant features. The patient was transferred to another hospital for rehabilitation.

Conclusion

Peritumoral edema representing a pial blood supply might be a significant factor associated with intracranial hemorrhage due to DOAC administration in patients with meningioma. The evaluation of hemorrhagic risk due to DOACs is important not only for meningioma but also for other brain tumor cases.

Diagnostic neuroradiology of intracranial meningiomas presenting with hemorrhagic onset: a double center 14-year experience

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.

Brain Meningiomas Manifesting as Intracranial Hemorrhage: Comprehensive Systematic Review and Report of the First Case of Hemorrhagic Meningiomatosis

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.

Vascular complications in patients with brain tumors

PURPOSE OF REVIEW

Venous thromboembolism (VTE) and other vascular events are common in patients with brain tumors, but their optimal management is not firmly established, in large part due to the competing risk of intracranial hemorrhage (ICH) in this population.

RECENT FINDINGS

There is conflicting evidence on whether therapeutic anticoagulation increases the risk of ICH in patients with brain tumors, with several metanalysis and retrospective cohort studies showing an increased risk and others showing no differences. Current guidelines recommend anticoagulating brain tumors patients with VTE with either low-molecular weight heparin (LMWH) or direct oral anticoagulants (DOACs), and several retrospective studies have shown the risk of ICH with DOACs is similar or smaller than with LMWH.

SUMMARY

An increased risk of VTE exists in a variety of brain tumor types. Most patients with brain tumors and VTE should receive therapeutic anticoagulation, and recent retrospective evidence supports the use of both LMWH and DOACs as effective and relatively safe in this setting. Patients with brain tumors are also at increased risk of other vascular tumor- or treatment-related complications whose optimal management is unclear.

Acute subdural hematoma associated with disruption of tumor vessels due to rapid growth of falx meningioma: A case report and literature review

Background:

Meningiomas associated with acute subdural hematoma (ASDH) are rare. The rapid growth of meningiomas has been shown to be one of the mechanisms underlying bleeding. We report the first case of ASDH during an imaging follow-up for the rapid growth of a falx meningioma.

Case Description:

A 77-year-old woman was diagnosed with an incidental tumor along the right falx cerebri 3 years before bleeding. The follow-up magnetic resonance imaging (MRI) after 3 years showed that the tumor volume had rapidly increased from 4.31 cm3 to 22.27 cm3. The blood vessels around the tumor were stretched. The patient was scheduled to undergo tumor removal surgery. However, the patient experienced a sudden onset of disturbance of consciousness and was transferred to our hospital. On arrival, her Glasgow Coma Scale (GCS) score was 6 (E1V1M4) and right hemiplegia was observed. The patient had no history of traumatic events. Computed tomography (CT) showed left hemispheric and interhemispheric ASDH. Digital subtraction angiography revealed neither tumor staining nor abnormal vessels. Gross total tumor removal and hematoma evacuation were performed. There were no obvious active intraoperative bleeding points. The pathologic diagnosis was meningioma, the World Health Organization Grade I. Postoperative course revealed a GCS score of 10 (E4V1M5) and she was transferred to a rehabilitation hospital.

Conclusion:

The disruption of tumor vessels due to the rapid growth of meningiomas may be a cause of bleeding. Incidental falx meningiomas with stretched tumor vessels due to rapid growth could indicate the need for early surgery.