Angiomatous meningioma: a diagnostic dilemma

Primary endodermal hemangiopericytoma/solitary fibrous tumor of the cervical spine: a case report and literature review

Background

Hemangiopericytoma (HPC), also known as solitary fibrous tumor (SFT), is a type of soft tissue sarcoma with a special aggressive behavior. The HPC/SFT is locally aggressive with possibility of late recurrence locally or distant extraneural metastasis. The most common location of this HPC/SFT is the lower extremities. The HPC/SFT in the central nervous system (CNS) is very rare, and compared with the brain, it is rarer in the spinal region. However, clinicians also lack an overall understanding of the diagnosis of HPC/SFT in the spinal cord.

Case presentation

In this study, we report a rare case of primary cervical spine HPC/SFT in a 53-year-old woman. Two to three weeks before admission, she experienced pain and numbness in her left upper extremity. After computerized tomography (CT) and magnetic resonance imaging (MRI), a gross total resection was performed. Obvious neurological improvement was observed postoperatively. The pain and numbness in the patient's left upper limb were relieved subsequently. We then reviewed the literature on HPC/SFT, such as its clinical presentation, imaging characteristics, treatment, and follow-up.

Conclusions

Diagnosis of HPC/SFT relies on magnetic resonance spectroscopy, enhanced CT, and MRI. Postoperative radiotherapy is strongly recommended to reduce the HPC/SFT recurrence. Immunohistochemical analysis can also help in the differential diagnosis. However; early and long-term follow-up is necessary for patients.

Whole-tumor histogram analysis of apparent diffusion coefficient in differentiating intracranial solitary fibrous tumor/hemangiopericytoma from angiomatous meningioma

PURPOSE

To assess the role of histogram analysis of apparent diffusion coefficient (ADC) maps based on whole-tumor in differentiating intracranial solitary fibrous tumor/hemangiopericytoma (SFT/HPC) from angiomatous meningioma (AM).

MATERIALS AND METHODS

Pathologically confirmed intracranial SFT/HPC (n = 15) and AM (n = 20) were retrospectively collected and their clinical and conventional MRI features were analyzed. Diffusion-weighted (DW) images (b = 0 and 1000 s/mm²) were processed with the mono-exponential model. Regions of interest covering the whole tumor were drawn on all slices of the ADC maps to obtain histogram parameters, including mean ADC (ADCmean), median ADC (ADCmedian), maximum ADC (ADCmax), minimum ADC (ADCmin), skewness and kurtosis, as well as the 5th, 10th, 25th, 75th, 90th and 95th percentile ADC (ADC5, ADC10, ADC25, ADC75, ADC90 and ADC95). Differences of histogram parameters between SFT/HPC and AM were compared using Mann-Whitney U test. Receiver operating characteristic (ROC) curve was used to determine the diagnostic performance.

RESULTS

The ADCmin (P = 0.001) and ADC5 (P = 0.045) were significantly lower in SFT/HPCs than in AMs, while no significant difference was found in sex, age, conventional MRI features or any other histogram parameters between the two entities (P = 0.051-1.000). ADCmin showed the best diagnostic performance (area under curve [AUC], 0.86; sensitivity, 81.3%; specificity, 83.3%) in differentiating SFT/HPC from AM with optimal cutoff value being 569.00 × 10^-6  mm²/s, followed by ADC5 (AUC, 0.72; sensitivity, 68.8%; specificity, 75%) with optimal cutoff value being 781.97 × 10^-6  mm²/s.

CONCLUSION

SFT/HPC and AM share similar conventional MR appearances. Whole-tumor histogram analysis of ADC maps may be a useful tool for differential diagnosis, with ADCmin and ADC5 being potential parameters.

Angiomatous Meningiomas Have a Very Benign Outcome Despite Frequent Peritumoral Edema at Onset

OBJECTIVE

Angiomatous meningioma (AM) is a rare subtype of meningioma characterized by highly vascular tumor tissue comprising predominantly variable sized hyalinized blood vessels. The aim of this study is to evaluate the clinical radiologic features of AM and the long-term prognosis in a single neurosurgical center.

METHODS

A total of 93 patients who underwent surgical resection of AMs between 2003 and 2008 were enrolled for analysis. Clinical information, treatment, and radiologic images were collected and analyzed; follow-up was carried out as well. Expression of estrogen receptor, progesterone receptor, and vascular endothelial growth factor was analyzed by immunohistochemistry.

RESULTS

Forty-eight females and 45 males were identified. Forty-four patients (47.31%) manifested as hypersignal in T1-weighted imaging sequences and 68 (73.12%) as hypersignal in T2-weighted imaging, and a characteristic ringlike signal was observed in 28 patients (30.11%). Eighty-one cases (87.10%) showed different degrees of peritumor brain edema and it was significantly correlated with the vascular endothelial growth factor expression (P < 0.001). Simpson I resection was achieved in 63 patients (67.74%), grade II in 27 patients (29.03%), and grade III in 3 patients (3.23%). The extent of resection was not associated with the postoperative neurologic function (P = 0.546). Only 4 patients experienced recurrences during the follow-up and these 4 patients were stable until the last follow-up.

CONCLUSIONS

AMs were a special subtype of meningioma with distinctive radiologic features. AMs manifest benign behavior with a satisfying outcome, which makes Simpson grade II resection an option.

Six different extremely calcified lesions of the brain: brain stones

BACKGROUND

This study aimed to extend clinical documentation of cerebral calculi by reporting six cases of cerebral calculi with distinct etiologies and localizations.

METHODS

We evaluated the age, sex distribution, presenting symptoms, neurological examination findings, pathology results, and location of the calcifications of six patients with intracranial calcifications.

RESULTS

Three of the six patients with brain stones were female (50%), and three were male (50%). The patient ages ranged from 12 to 46 years. A radiological examination of each patient's cranium was performed with pre-operative cranial computed tomography and magnetic resonance imaging. All of the lesions were completely excised. The patients' pathologies were determined to be distinct hyalinization, dystrophic calcification, hamartoma, ossification developing from widespread pituitary adenoma tissue, benign mesenchymal neoplasia, a mass consisting of sporadically ossified fibrous tissue, and angiomatous meningioma with distinct hyalinization and fibrosis.

CONCLUSIONS

Intracranial calcifications are a common phenomenon in neurosurgical practice. However, brain stones, as well as solid calcifications also termed cerebral calculi, are rarely encountered. Brain stones can be classified on the basis of their etiology and localization. Additionally, we suggest that lesions smaller than 1 cm might be classified as calcifications and those greater than 1 cm as brain stones. We further suggest that the differentiation between calcification and brain stones might be based on size. These pathologies typically manifest as seizures and are occasionally identified during routine brain tomography. Meningiomas constitute an important portion of extra-axial calcifications, whereas tumorous and vascular causes are more prevalent among intra-axial calcifications.

Epidural angiomatous meningioma of the thoracic spine: A case report

Spinal epidural angiomatous meningiomas (AMs) are extremely rare lesions. Here, we report on a case of an epidural AM of the thoracic spine with chronic but severe cord compression. The patient underwent a T6-T8 laminectomy through the posterior approach. En bloc resection was achieved, and histopathological examination demonstrated an AM. Delayed paraplegia occurred 4 h postoperatively. The patient was treated with methylprednisolone, hyperbaric oxygen and rehabilitation. Gradually, over the next six months, the bilateral leg strength was improved compared with the preoperative status, and no tumor recurrence was noted. Although epidural AM is extremely rare, it should be included in the differential diagnosis of spinal epidural lesions. A definitive diagnosis is difficult based on magnetic resonance imaging alone due to the nonspecific characteristics of the tumor. Since AM is a histologically benign and highly vascularized tumor, timely gross total resection (GTR) is the most effective treatment. A good clinical outcome may be expected following GTR (Simpson grade I and II resection).

Surgical treatment of intraspinal angiomatous meningiomas from a single center

Intraspinal angiomatous meningiomas (AMs) are rare lesions, and no case series have been reported. We retrospectively reviewed the data of 12 patients with intraspinal AMs. All patients underwent magnetic resonance imaging (MRI) of the spine. Computed tomography angiography was performed for three cases with cervical lesion. The series included six females and six males with a mean age of 49.6 years. Five tumors were located in the cervical, one in the cervicothoracic, five in the thoracic, and one in the thoracolumbar spine. The most common symptom was motor deficits and the mean duration of symptoms was 18 months. All patients were treated surgically with gross total resection (GTR) (Simpson grade I and II resection). No patients underwent embolization. After surgery immediately, the neurological function was improved in five patients, remained stable in six patients, and was deteriorated in one patient. During an average follow up of 78.6 months, 11 patients experienced an improvement in the neurological function and one patient maintained preoperative status. No tumor recurrence was observed on MRI. Compared to conventional meningiomas, AMs have no special clinical and radiological features. The accurate diagnosis depends on pathology. Timely GTR (en bloc resection) is the best treatment and embolization is not necessary for most patients. Radiotherapy is not recommended after GTR (Simpson grade I and II resection), and the risk of tumor recurrence is low.

Hemangiopericytomas in the Spine

BACKGROUND:

Intraspinal hemangiopericytoma (HPC) is a rare and malignant extra-axial tumor with a strong tendency to recur and metastasize. There is a paucity in the literature of large case series of patients with intraspinal HPCs.

OBJECTIVE:

We retrospectively analyzed the clinical radiological and histological features, classification, and treatment of 26 patients with HPCs in the spine.

METHODS:

Twenty-six patients with HPCs in the spine were treated at our institution between 1987 and 2010. Medical records were reviewed retrospectively to collect data on the clinical features, tumor morphology, surgical resection, recurrence, and follow-up.

RESULTS:

The 26 patients were predominantly male, and the mean age at diagnosis was 33.8 years. The intraspinal HPCs were divided into 3 types and 5 subtypes. Most of them involved the neighboring segments and/or caused bony erosion. All tumors were immunohistochemically positive for vimentin and negative for epithelial membrane antigen. All patients underwent at least 1 surgery, and most of them received postsurgical radiotherapy. The 5-year Kaplan-Meier rate of survival was 76%. The 5-year recurrence-free rate of survival was 29.4%. Only the tumor pathological grade was significantly associated with survival time and recurrence.

CONCLUSION:

High-grade tumors had a shorter survival time and recurred earlier than low-grade tumors. Surgical removal and postoperative radiotherapy are critical for the treatment of intraspinal HPCs. However, total resection may not necessary for these tumors. Stereotactic radiosurgery may be a good alternative to control the recurrent lesions.