Intratumoral Hemorrhage within Petrous Meningioma

Systematic Review of Meningiomas Revealed by Spontaneous Intracranial Hemorrhage: Clinicopathological Features, Outcomes, and Rebleeding Rate

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.

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.

Intracranial Hemorrhage in Patients with Anticoagulant Therapy Undergoing Stereotactic Radiosurgery for Brain Metastases: A Bi-Institutional Analysis

Background: Stereotactic radiosurgery (SRS) is a well-established treatment modality for brain metastases (BM). Given the manifold implications of metastatic cancer on the body, affected patients have an increased risk of comorbidities, such as atrial fibrillation (AF) and venous thromboembolism (VTE), which includes pulmonary embolism (PE) and deep-vein thrombosis (DVT). These may require therapeutic anticoagulant therapy (ACT). Limited data are available on the risk of intracranial hemorrhage (ICH) after SRS for patients with BM who are receiving ACT. This bi-institutional analysis aimed to describe the bleeding risk for this patient subgroup. Methods: Patients with ACT at the time of single-fraction SRS for BM from two institutions were eligible for analysis. The cumulative incidence of ICH with death as a competing event was assessed during follow-up with magnetic resonance imaging or computed tomography. Results: Forty-one patients with 97 BM were included in the analyses. The median follow-up was 8.2 months (range: 1.7–77.5 months). The median and mean BM volumes were 0.47 and 1.19 cubic centimeters, respectively. The most common reasons for ACT were PE (41%), AF (34%), and DVT (7%). The ACT was mostly performed utilizing phenprocoumon (37%), novel oral anticoagulants (32%), or low-molecular-weight heparin (20%). Nine BM from a group of five patients with ICH after SRS were identified: none of them caused neurological or any other deficits. The 6-, 12-, and 18-month cumulative bleeding incidences per metastasis were 2.1%, 12.4%, and 12.4%, respectively. The metastases with previous bleeding events and those originating from malignant melanomas were found to more frequently demonstrate ICH after SRS (p = 0.02, p = 0.01). No surgical or medical intervention was necessary for ICH management, and no observed death was associated with an ICH. Conclusion: Patients receiving an ACT and single-fraction SRS for small- to medium-sized BM did not seem to have a clinically relevant risk of ICH. Previous bleeding and metastases originating from a malignant melanoma may favor bleeding events after SRS. Further studies are needed to validate our reported findings.

Spontaneous or Traumatic Intratumoral Hemorrhage? A Rare Presentation of Parafalcine Meningioma

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.

Continuous progression of hemorrhage of sphenoid ridge meningioma causing cerebral hernia: A case report and literature review

The aim of the present study was to explore the clinical characteristics of repeated hemorrhages of meningioma and analyze the causes of hemorrhage. Meningiomas are mostly benign tumors that rarely manifest hemorrhagic strokes. In the present study, a case of sphenoid ridge meningioma with repeated hemorrhages is reported. Internal hemorrhage was first observed, which, on further aggravation, formed a hematoma in the brain parenchyma and finally led to the development of a hernia. No neurological deficit was present after surgery and rehabilitation. A postoperative pathological examination showed increased levels of Ki-67, abnormal blood vessels in the tumors and the presence of progesterone, which indicate possible causes of the hemorrhage. A review of associated previous studies revealed that hemorrhages originate mainly from inside the meningioma. Two cases of meningiomas with repeated hemorrhages have been reported; one in the foramen magnum region and the other in the pineal gland area. The foramen magnum tumor had an interval of 1.33 months between two hemorrhagic episodes. Collecting relevant data from the latter case was not possible. In the present case report, the interval between two bleeding episodes was 3 days. The literature review also revealed that the average age of onset of meningioma is relatively young at only 28.00±6.24 years. In conclusion, repeated hemorrhages in meningiomas are extremely rare and the causes have not yet been identified. Increased Ki-67 and abnormally proliferating blood vessels may be potential causes of hemorrhage. Early diagnosis and rapid surgical intervention are essential to prevent further episodes of bleeding, which may otherwise have fatal consequences for the patients.