Meningioma Presenting with Spontaneous Subdural Hematoma: A Report of Two Cases and Literature Review

Acute subdural hematoma caused by hemorrhagic falx meningioma: A case report and review of the literature

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.

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.

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.

A case of microcystic meningioma associated with acute subdural hematoma in the posterior cranial fossa

A 53-year-old woman was brought to the emergency room with headache and progressive deterioration of consciousness. Radiological examinations revealed acute subdural hematoma extending along the cerebellar tentorium to the falx cerebri, and a mass lesion with hemorrhage in the left cerebellum, with acute hydrocephalus. Emergency tumor and hematoma removal with decompressive craniectomy of the occiput was performed. Histopathological diagnosis was microcystic meningioma. Postoperatively, the patient recovered to clear consciousness with sequelae of left cerebellar ataxia, cerebellar dysarthria, and vertigo. This case of tentorial microcystic meningioma associated with acute subdural hematoma in the posterior cranial fossa is extremely rare, with only reported 4 similar cases.

Radiological classification of meningiomas with hemorrhagic onset and its clinical significance

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.

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

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.

Meningiomas associated with subdural hematomas: A systematic review of clinical features and outcomes

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.

The usefulness of postmortem computed tomography angiography for subdural hematoma caused by rupture of the cortical artery: A report of two autopsy cases and a literature review

Acute subdural hematoma (SDH) occurs following severe head trauma with brain contusion or rupture of bridging veins. Conversely, SDH caused by rupture of a cortical artery without trauma or with minor trauma is also possible. Although over 150 cases of the latter SDH have been reported, they were predominantly diagnosed only during surgery, and therefore, no adequate histological evaluation has been performed. Therefore, essential etiology of this SDH type has remained unclear. In addition, the scarcity of autopsy cases may be attributed to arterial rupture being missed if the macroscopic findings are too minimal to detect during autopsy. Here, we describe two autopsy cases of SDH of cortical artery origin. Extravasation on postmortem computed tomography angiography and arterial leakage on macroscopic observation during autopsy facilitated detection of the ruptured artery and allowed detailed histological evaluation of the ruptured artery and adjacent dura mater. The etiology of arterial rupture is briefly described on the basis of histopathological findings in this study and the available literature.

Benign meningioma manifesting with acute subdural hematoma and cerebral edema: a case report and review of the literature

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.

A convexity meningioma presenting with an acute subdural hematoma

Background:

Meningiomas presenting with acute subdural hematomas are extremely rare. To the best of our knowledge, only 45 cases have been reported to date. We report on a case of a meningioma mimicking an acute subdural hematoma as well as a thorough literature review.

Case Description:

A 67-year-old man with no history of trauma was referred to our hospital with sudden onset of decreased level of consciousness and left hemiplegia. Computed tomography revealed an acute convexity subdural hematoma. Emergency surgery to remove the hematoma was performed. The hematoma was found to exist in the extra-axial space and the attached dura mater and pia mater remained intact. Pathological examination revealed a transitional meningioma, the World Health Organization Grade 1. Detailed medical history taken postoperatively revealed that a convexity meningioma had been diagnosed incidentally at another facility 1 year earlier.

Conclusion:

Acute subdural hematomas due to meningiomas are rare, and establishing the cause is challenging. Prompt and precise diagnosis of such entities may afford patients a better prognosis.

Meningioma-related subacute subdural hematoma: A case report

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.