Spontaneous peritumoral haemorrhage associated with sinus confluence meningioma: case report

Surgical Outcome of Torcula Herophili Meningioma: An Institutional Experience

INTRODUCTION

Resection of meningiomas (THMs) at the torcular Herophili poses challenges to surgeons due to complex regional anatomy. The current study aims to evaluate factors affecting the extent of resections, progression-free survival, and the role of radiation.

METHODS

We did a retrospective study of all the THM patients treated at our institute between May 1987 and June 2022. The demographic data, signs and symptoms, surgical notes, postoperative details, and radiotherapy were gathered retrospectively. Survival analysis was done with Kaplan-Meier tests along with predictors of the extent of resection as well as recurrence.

RESULTS

A total of 39 patients qualified to be included in the study, with 10 male patients (male:female 1:2.9) and an average age of 50.8 years. The average follow-up duration was 75.9 months. Simpson's grade 2 excision was achieved in 19 (48.7%) patients, followed by Simpson's grade 3 excision in 17 patients (43.6%). Progression-free survival in subtotal resection was 60 months, and 100 months in gross total resection. Statistically, the extent of the resection was determined by the involvement of sinuses/torcula and the number of quadrants involved around torcula. A total of 16 patients received radiosurgery for the residual or small reccurrence of the lesion. Follow-up revealed reccurrence in 5 cases.

CONCLUSIONS

Torcular meningiomas are relatively uncommon, described in few reports, and represent a therapeutic dilemma. Though some experts recommend complete removal of tumor and reconstruction of the sinus, others suggest maximum safe resection, followed by radiosurgery. The present study reflects reasonable control of the residual lesion with radiosurgery after maximum safe resection.

Surgical Management of Meningiomas Involving the Torcula, Transverse Sinus, and Jugular Bulb: A Technical Note and Review of the Literature

Meningiomas that invade the confluens sinuum are rare and require extensive preoperative planning. Here, we describe the surgical and radio-oncological management of an aggressive large occipital meningioma invading the superior sagittal sinus, torcula, right and left transverse sinus down to the level of the jugular bulb in a 21-year-old female patient. Details of the surgical approach are presented to highlight the planned staged resection of this tumor at the level of the torcula to initially debulk the lesion while preserving venous outflow through the patent's sinus. Once the tumor fully occluded the confluens, a second-stage en bloc resection ensued. Postsurgical adjuvant radiation therapy was delivered via fractionated external beam therapy which has provided local control of the tumor since. This case is being discussed in the context of the pertinent literature to demonstrate the highly complex interdisciplinary and staged management of partially intravascular meningiomas involving the major venous sinuses.

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.

Assessment of hemorrhagic onset on meningiomas: Systematic review

OBJECTIVE

To review the data published on the subject to create a more comprehensive natural history of the haemorrhagic onset of meningiomas (IVMs).

PATIENTS AND METHODS

A Medline search up to June 2020, using the search term "bleeding meningioma," returned 136 papers. As a first selection step, we adopted the following inclusion criteria: series and case reports about bleeding meningioma. Papers written in other languages but with abstracts written in English were also evaluated.

RESULTS

A total of 190 tumours were evaluated, specifically 109 tumours from female patients and 81 tumours from male patients with a ratio of 1.34 female to 1.0 male (mean age of 54.86 ± 16.1years old). The majority were located in the convexity (129-67.9 %). Among the 190 tumours evaluated, 171 patients (90 %) presented with GI tumours, with a predominance of the meningothelial subtype (32.6 %). Nine patients (4.7 %) presented with grade GII tumours, and 10 (5.3 %) presented with GIII tumours. The most prevalent type was intracerebral haemorrhage (ICH) at 50 %, followed by subdural at 27.36 %; the mortality rate was 13.1 % (25 deaths), the distribution of both location (prevalence of convexity: 18-72 %) and histopathology (grade 1: 22-88 %).

CONCLUSION

These tumours follow the histopathological distribution of meningiomas, in general. The age distribution shows prevalence among the adult population but with a greater proportion in the elderly. The fact that the overwhelming majority of cases involve meningiomas with a benign histological subtype is noteworthy. Another relevant factor observed is that most reports are from Asian origin.

Endovascular Treatment of Intracranial Hypertension Associated with Venous Sinus Stenosis due to Tumor Compression

Objective

We report a patient with intracranial hypertension associated with venous sinus stenosis due to tumor compression. Embolization of tumor feeding blood vessels reduced the tumor volume, improved venous sinus stenosis, and alleviated the symptoms of intracranial hypertension.

Case Presentation

The patient was a 46-year-old woman with chronic headache and blurred vision. Magnetic resonance venography (MRV) revealed stenosis of the right transverse-sigmoid sinus. Intracranial hypertension was diagnosed by lumbar puncture. A high-intensity 2-cm tumor was detected on T2-weighted magnetic resonance imaging (MRI), and the homogenously enhanced tumor was adjacent to the right transverse-sigmoid sinus. Cerebral angiography demonstrated tumor staining mainly from the right occipital artery (OA). Collateral venous flow was minimal. In such cases, resection and reconstruction of the involved sinus segment have a high risk of venous infarction. Accordingly, percutaneous transluminal angioplasty (PTA) was performed, but dilation of the stenosis was poor. Thus, feeder occlusion of the tumor was added and lumboperitoneal (LP) shunt was placed, alleviating the headache and blurred vision. Ten months later, reduction of the tumor volume and improvement of sinus stenosis were observed, and the LP-shunt system was removed. A decrease in tumor volume via feeder occlusion may lead to partial sinus decompression and increased venous flow, resulting in long-term clinical remission.

Conclusion

Transverse-sigmoid sinus stenosis can be a cause of intracranial hypertension, albeit rare. Embolization of the tumor is considered to be a treatment option for patients who cannot undergo resection.

Olfactory Groove Meningiomas: Acute Presentation and Potential : Pitfalls in Management and Functional Restoration

Meningiomas are typically benign, slow-growing lesions that present after an insidious onset of symptoms related to mass effect. The acute presentation of a patient who has suffered a transtentorial herniation event due to a meningioma is rare. There are only few publications describing such a presentation in the absence of hemorrhage [1]. In this case report, a patient with an olfactory groove meningioma presenting with signs and symptoms of transtentorial herniation in the absence of tumor-associated hemorrhage is discussed. This is a unique presentation of such a lesion. The patient developed Anton's syndrome-binocular visual loss with blindness denial. Management considerations for patients with meningiomas that present with acute deterioration are discussed.

An Underlying Pathological Mechanism of Meningiomas with Intratumoral Hemorrhage: Undifferentiated Microvessels

BACKGROUND

Meningiomas usually present with a gradual onset of symptoms, and their acute presentation with a hemorrhagic event appears to be a rare condition. Although many clinical features of such a condition have been characterized, pathophysiological mechanisms underlying the bleeding remain unclear, and some contradictory results have been reported. The value of tumor vascularity as an index for the bleeding propensity of meningiomas is inconsistent. We sought to identify whether meningiomas have different types of blood vessels, and to explore the association of the different tumor vessels with intratumoral hemorrhage.

METHODS

Six patients with meningioma with acute onset due to intratumoral hemorrhage were identified, and 12 nonhemorrhagic meningiomas were matched according to specific clinical data. The characteristics of tumor vessels were examined through immunohistochemical staining of CD31, CD34, and smooth muscle actin (SMA). The number of stained vessels was counted and compared between the 2 groups.

RESULTS

Two distinct types of blood vessels were determined in all meningiomas: undifferentiated (CD31⁺/CD34^-) and differentiated (CD31⁺/CD34⁺) vessels, and most differentiated vessels were covered by pericytes marked by SMA. However, only the mean number of undifferentiated vessels in hemorrhagic meningiomas was significantly higher than that in controls (15.3 ± 4.9 vs. 6.4 ± 3.6; P < 0.01). Neither the number of differentiated vessels nor the total number of tumor vessels were significantly different between the 2 groups (P > 0.05).

CONCLUSIONS

Our results suggest that tumor vasculature in meningiomas is heterogeneous, and that the undifferentiated vessels may play a pivotal role in the spontaneous intratumoral hemorrhage from meningiomas.

Benign Sphenoid Wing Meningioma Presenting with an Acute Intracerebral Hemorrhage - A Case Report

BACKGROUND AND STUDY OBJECT

We report an unusual case of a benign lateral sphenoid wing meningioma that presented with, and was masked by, an acute intracerebral hemorrhage.

CASE REPORT

A 68-year-old woman was admitted after sudden onset of coma. Computed tomography (CT) revealed an intracerebral hemorrhage, without any underlying vascular pathology on CT angiography. During the surgery, we found a lateral sphenoid wing meningioma with intratumoral bleeding that extended into the surrounding brain parenchyma.

RESULTS

We removed the hematoma and resected the tumor completely in the same session. The histopathological classification of the tumor was a WHO grade I meningothelial meningioma. The patient recovered very well after surgery, without significant neurological sequelae. CONCLUSIONS: Having reviewed the relevant references from the medical literature, we consider this event as an extremely rare presentation of a benign sphenoid wing meningioma in a patient without any predisposing medical factors. The possible mechanisms of bleeding from this tumor type are discussed.

Intracranial hypertension due to meningioma of the unique transverse sinus

We describe a 28-year-old woman with intracranial hypertension due to a meningioma invading the unique transverse sinus (with absent contralateral sinus). Clinical remission and normalization of orbital echography were obtained by resection of the intradural tumor and peeling of the dural attachment. In such cases, resection and reconstruction of the involved sinus segment is at high risk of venous infarction. Endovascular stenting of the obstructed sinus is a valid alternative when the stenosis is not remarkable. Single tumor removal may lead to partial sinus decompression and increased venous flow, resulting in long-term clinical remission.

Bilateral chronic subdural haematomas in a patient with meningioma of the superior sagittal sinus - case report and pathophysiological study

Bilateral chronic subdural haemorrhage accompanying meningioma is a very rare clinical condition. We present a case of a 69-year-old female patient with large meningioma completely obliterating the posterior third part of the superior sagittal sinus with accompanying bilateral chronic subdural haematomas. Three anatomical zones of venous collateral circulation were revealed by the preoperative digital subtraction angiography. The tumour and haematomas were removed completely with no major complications. The most likely pathomechanism of the development of bilateral chronic subdural haematomas was venous hypertension caused by an occlusion of major cerebral venous trunks. As a result of a minor thrombotic incident or insignificant head injury, the distended veins of collateral circulation that were volumetrically burdened could have been damaged. Patients with large tumours occluding the superior sagittal sinus, who did not qualify for or refused surgery, should be carefully monitored clinically and neuroradiologically because of possibly increased risk of an intracranial haemorrhage.

Meningiomas of the transverse--sigmoid sinus junction area

Meningiomas with exclusive or prevalent dural attachment over the transverse-sigmoid sinus junction area represent a well-defined subgroup of posterior fossa meningiomas. This study reports 13 cases of this localisation (10.8% of all infratentorial meningiomas). In this series, six patients (46%) were discovered as an incidental MR finding. One patient with a small (1.5 cm) meningioma presented with an intracranial hypertension syndrome due to severe obstruction of the unique transverse-sigmoid sinus junction. A MR angiography was performed in 11 patients; it showed intraluminal tumour in two cases with dominant and unique transverse sinus, respectively. Tumour removal with excision of the outer dural layer and coagulation of the dural attachment (Simpson II) was performed in 11 cases; in two others with focal sinus invasion, removal of the small intravenous tumour fragment was not performed (Simpson III). No post-operative complications occurred. Remission of pre-operative symptoms was obtained in all symptomatic cases. The management of the transverse-sigmoid sinus junction is the main problem of meningiomas of this region. Excision of the outer dural layer and coagulation of the dural attachment are in our opinion sufficient in most cases, even when there is tumour invasion of the patent venous lumen. The resection of the sinus wall should be reserved to cases with a totally obstructed segment and symmetrical or asymmetrical but present transverse and sigmoid sinuses.

Acute haemorrhage into a microcystic meningioma leading to cerebral herniation

Low-grade (WHO level I) meningiomas are slow-growing, benign tumours typically presenting with unspecific symptoms (e.g. headache), seizures, cranial nerve compression and neuropsychological symptoms determined by location and size of the lesion. Haemorrhagic onset and sequelae are rare, and have been described infrequently. This is a case of a 50-year-old male presenting with signs of tentorial herniation secondary to hyperacute intratumoural haemorrhage (ITH) into a previously undiagnosed meningioma. Emergency surgical decompression and exstirpation of the lesion helped to achieve a favourable outcome. ITH has been described in all including benign intracranial neoplasms. Factors associated with a higher risk for haemorrhage in meningiomas are discussed. Though haemorrhages associated with meningiomas have been reported, ITH into low-grade meningiomas leading to herniation remains a rarity. Bearers of known lesions and their treating physicians who opt for conservative or delayed treatment should be aware of this remote complication.

Peritumoural haematoma and meningioma: a common tumour with an uncommon presentation

Spontaneous peritumoural haemorrhage in meningiomas is a rare but serious complication with a grave prognosis. It occurs at the interface between the tumour and the parenchyma, either from the tumour surface or the cortical vessels in association with it. Although several pathophysiologic mechanisms for this complication have been proposed, they all remain speculative. We report a 72-year-old female who presented with sudden onset of headache and a left homonymous hemianopia. Neuroimaging revealed a parasagittal meningioma at the posterior third of the superior sagittal sinus with peritumoural intracerebral haematoma, 1 cm away from the tumour. An uncomplicated gross total excision of the meningioma and aspiration of the haematoma was achieved through a craniotomy. The postoperative course was uneventful with an excellent clinical outcome. Possible mechanisms for this unusual complication are discussed. We emphasise the importance of prompt diagnosis and simultaneous excision of the tumour and aspiration of the haematoma as prerequisites for a favourable outcome.

Intratumoral haemorrhage: a clinical study

Although the incidence of spontaneous intracranial haemorrhage associated with meningioma is 1.3%, the incidence of intratumoral haemorrhage could not be determined. The authors report on 11 patients, six men and five women, with meningiomas that presented as spontaneous intratumoral haemorrhage, among 126 meningioma cases which were evaluated radiologically and histopathologically. The average age of patients was 58.9 years (range 45-72 years). Two (1.5%) cases showed radiological, and nine cases (7.9%) showed microscopic bleeding. Most of these cases also showed microcysts (9.7%) and necrosis (6.3%). The location, histopathological types, sex, age, blood dyscrasia, hypertension do not influence the occurrence of intratumoral haemorrhages in meningiomas. We concluded that microcysts and necrosis are important in the occurrence of intratumoral haemorrhage in meningiomas.

Reversible non-thrombotic occlusion of the superior sagittal sinus caused by metastatic malignant lymphoma--case report

A 57-year-old female presented with intracranial hypertension secondary to non-thrombotic superior sagittal sinus occlusion manifesting as acute onset of headache, vomiting, and disorientation. She had a history of intrapelvic malignant lymphoma. Neuroimaging and tumor biopsy revealed that both the superior sagittal sinus and the straight sinus were occluded by metastatic deposits of malignant lymphoma. Her clinical symptoms were remarkably improved by irradiation and chemotherapy, and the affected sinuses were angiographically recanalized.