|
| |
 |
|
| CASE REPORT |
|
| Year : 2020 | Volume
: 3
| Issue : 2 | Page : 104-107 |
|
Imaging spectrum of atypical meningiomas
Rasiq Aslam1, Musaib Ahmad Dar1, Suhail Rafiq1, Aijaz Mohideen2
1 Department of Radiodiagnosis, Government Medical College, Srinagar, Jammu and Kashmir, India
2 Department of Radiodiagnosis, SKIMS, Srinagar, Jammu and Kashmir, India
| Date of Submission | 05-Feb-2020 |
| Date of Acceptance | 29-Nov-2020 |
| Date of Web Publication | 26-Dec-2020 |
Correspondence Address:
Dr. Suhail Rafiq
Department of Radiodiagnosis, Government Medical College, Srinagar, Jammu and Kashmir
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/IJNO.IJNO_2_20
How to cite this article:
Aslam R, Dar MA, Rafiq S, Mohideen A. Imaging spectrum of atypical meningiomas. Int J Neurooncol 2020;3:104-7 |
| Introduction | |  |
Meningiomas are neoplasms that arise from meningothelial cells, which typically attach to the inner surface of the dura mater.[1] Most meningiomas are benign and classified as Grade I according to the World Health Organization (WHO) standards. The most common locations include the cerebral convexity, parasagittal, and sphenoid wing regions. Atypical meningiomas account for between 4.7% and 7.2% of all meningiomas and are considered WHO Grade 2 tumors.[2] Malignant and atypical meningiomas are more prone to recurrence and rapid growth; therefore, the distinction between benign and atypical or malignant meningioma remains a very important aspect to be described.[3] Meningiomas usually form sessile or lentiform, well-circumscribed, extra-axial mass lesions with broad-based dural attachment are characteristically hyperdense on noncontrast computed tomography, iso- to hypointense on T1-weighted, and iso- to hyperintense on T2-weighted images with uniform and strong enhancement is typically seen after contrast administration.[4] Additional features such as dural tail sign, linear internal flow voids, hyperostosis in the underlying bones, and calcification are also often observed in meningiomas.[5] Here, we present three cases of a rare variety of meningiomas diagnosed in our routine 3-tesla magnetic resource imaging (MRI) unit.
| Case Reports | | |
Case 1
A 55-year-old male patient with chief complaints of headache with increasing severity was advised a routine MRI. A left parafalcine lesion was noted causing buckling of underlying left high parietal cortex and erosion of inner table of left parietal bone invading it. The lesion showed T2 iso and T1 hypo signal characteristics with homogeneous enhancement on postcontrast images with a dural tail sign [Figure 1] and [Figure 2]. | Figure 1: T2 coronal image; left parafalcine lesion isointense to gray matter with adjacent bony invasion and buckling of cortex
Click here to view |
 | Figure 2: Postcontrast T1 sag shows high parietal homogeneously enhancing lesion with dural tail and bony invasion
Click here to view |
Case 2
A 7-year-old boy presented with a large swelling in the right parietal region of the head. MRI was advised and the following observations were made: a large T2/fluid attenuated inversion recovery (FLAIR) heterogeneously hyperintense mass lesion Iso intense on T1WI with homogenous enhancement on postcontrast images located in right parietal convexity reaching into subcutaneous planes with a subcutaneous component.” With “ A large T2/fluid attenuated inversion recovery (FLAIR) heterogeneously hyperintense mass lesion which is iso intense on T1WI and shows homogenous enhancement on postcontrast images located in right parietal convexity and reaching into subcutaneous planes with a subcutaneous component. The lesion is causing bone destruction and possible invasion of the underlying right parietal cortex. Associated perilesional T2/FLAIR hyperintensity was also noted, representing edema [Figure 3], [Figure 4], [Figure 5]. | Figure 3: Fluid-attenuated inversion recovery sag image shows large extraxial lesion with cerebrospinal fluid cleft with associated bony invasion and subcutaneous component
Click here to view |
 | Figure 4: Axial fluid-attenuated inversion recovery sequence shows heterogeneously hyperintense extraxial lesion with ill-defined planes with underlying cortex, with perlesional edema
Click here to view |
 | Figure 5: Axial T1-weighted images shows isointense extraxial lesion causing bony destruction
Click here to view |
Case 3
A 17-year-old female presented with a headache and MRI was advised. A large well-defined intraventricular mass lesion was noted in the right lateral ventricle centered at the atrium causing effacement of the frontal and occipital horn of the right lateral ventricle with contralateral midline shift and mass effect on adjacent brain tissue. The lesion was T2/FLAIR hyperintense with central hypointensity showing intense homogeneous enhancement on postcontrast images. Few linear flow voids were also noted within the lesion. No sign of any adjacent brain tissue invasion was noted. Post biopsy, the lesion proved to be a meningioma [Figure 6], [Figure 7], [Figure 8], [Figure 9]. | Figure 6: Axial T2-weighted images image shows large hyperintense intraventricular lesion with central hypointensity and few flow voids
Click here to view |
 | Figure 7: Axial fluid-attenuated inversion recovery image shows large hyperintense intraventricular lesion with central hypointensity and few flow voids
Click here to view |
 | Figure 8: Axial postcontrast T1-weighted images demonstrated homogeneous intense enhancement
Click here to view |
 | Figure 9: Saggital postcontrast T1-weighted images demonstrated homogeneous intense enhancement
Click here to view |
| Discussion | | |
MRI plays an important role in the diagnosis of meningioma. On MRI, the tumor is iso- or hypointense on noncontrast T1-W, and iso- or hyperintense on T2-W with homogeneous enhancement is observed after contrast administration. About 15% of all meningiomas show unusual radiological features because of cystic, necrotic, or fatty changes, thus demonstrate an abnormal enhancement which may present as heterogeneous pattern of enhancement.[6],[7] Most of the meningiomas do not demonstrate diffusion restriction or facilitation on diffusion-weighted images as compared with the brain parenchyma.[8] Meningiomas rarely present with hemorrhage and are an unusual presentation of meningiomas with very few reported cases in the literature.[9] The distinction between benign and atypical or malignant meningiomas is not reliably accomplished when assessing the imaging features on routine MRI.[10]
We came across three cases with unusual features other than benign meningiomas. Case one with typical signal characteristics of benign meningiomas, however, shows evidence of bone invasion. Case two shows evidence of ill-defined planes with underlying cortex and bony invasion. Case third shows a large intraventricular meningioma with heterogeneous signal intensity on T1WI and T2/FLAIR, however, shows homogeneous contrast enhancement.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Bosman FT, Jaffe ES, Lakhani SR, Ohgaki H, editors. WHO Classification of Tumours of the Central Nervous System. 4 th ed. Lyon: International Agency for Research on Cancer; 2007.  |
| 2. | Louis DN, Scheithauer BW, Budka H, Kepes JJ. Meningiomas. In: Kleihues P, Cavenee WK, editors. World Health Organization Classification of Tumours. Pathology and Genetics. Tumours of the Nervous System. Lyon, France: IARC Press; 2000. p. 176-84. |
| 3. | Ja ¨a ¨Skela ¨Inen J, Haltia M, Servo A. A typical and anaplastic meningiomas: Radiology, surgery, radiotherapy, and outcome. Surg Neurol 1986;25:233-42. |
| 4. | Buetow MP, Buetow PC, Smirniotopoulos JG. Typical, atypical, and misleading features in meningioma. Radiographics 1991;11:1087-106. |
| 5. | Tokumaru A, O'Uchi T, Eguchi T, Kawamoto S, Kokubo T, Suzuki M, et al. Prominent meningeal enhancement adjacent to meningioma on Gd-DTPA-enhanced MR images: Histopathologic correlation. Radiology 1990;175:431-3. |
| 6. | Ginsberg LE. Radiology of meningiomas. J Neurooncol 1996;29:229-38. |
| 7. | O'Leary S, Adams WM, Parrish RW, Mukonoweshuro W. Atypical imaging appearances of intracranial meningiomas. Clin Radiol 2007;62:10-7. |
| 8. | Santelli L, Ramondo G, Della Puppa A, Ermani M, Scienza R, d'Avella D, Manara R. Diffusion-weighted imaging does not predict histological grading in meningiomas. Acta Neurochir (Wien). 2010;152:1315-9; discussion 1319. |
| 9. | Bosnjak R, Derham C, Popović M, Ravnik J. Spontaneous intracranial meningioma bleeding: clinicopathological features and outcome. J Neurosurg. 2005 Sep;103:473-84. |
| 10. | Filippi CG, Edgar MA, Ulug AM, Prowda JC, Heier LA, Zimmerman RD. Appearance of meningiomas on diffusion-weighted images: Correlating diffusion constants with histopathologic findings.AJNR Am J Neuroradiol 2001;22:65-72. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
|
Search Pubmed for