Intrasellar meningioma: case report and review of the literature

A Case of Suprasellar, Intrasellar, and Infrasellar Meningioma Presenting as a Visual Field Defect in an Obese Female

Bitemporal hemianopia is the most common visual field defect encountered in suprasellar meningiomas compressing the optic chiasma and its vascular supply. It is hard to distinguish between meningioma and tumors that arise from suprasellar, intrasellar, and infrasellar extensions. Clinical findings, hormonal levels, and radiological findings could help in labeling it as meningioma. A 53-year-old obese woman with a history of blurred vision more in the right eye, loss of smell, and a headache was diagnosed with meningioma having suprasellar, intrasellar, and infrasellar extension on neuroimaging. She developed bitemporal hemianopia, which gradually worsened over the course of six months with concomitant headaches and dizziness that was treated with analgesics leading to a delayed diagnosis. As she was symptomatic, it was decided to resect her tumor. The patient underwent an endoscopic transsphenoidal approach for tumor resection. Successful excision of the tumor was accomplished. Postoperatively on further evaluation, the patient’s anosmia and the visual deficit were resolved. This instance shows that meningioma located in the sella can cause symptoms like anosmia and visual field loss, which should not be neglected. It also underlines the significance of visual field evaluation on a regular basis as this might predict radiological and symptomatic progression.

Pure Intrasellar Meningioma Mimicking Pituitary Adenoma：A Novel Neuroradiological Finding

Pure intrasellar meningioma is an extremely rare tumor that is difficult to diagnose as it resembles a pituitary adenoma in its clinical, endocrinological, and radiological presentation; it can only be distinguished through histopathological examination. All previously reported cases of this lesion were considered those of pituitary adenoma at the initial diagnosis. This poses major challenges in clinical diagnosis. We report a case of a pure intrasellar meningioma in a 27-year-old man. A boundary between the tumor and pituitary gland may be evident on magnetic resonance imaging, thus enhancing the diagnosis of pure intrasellar meningioma.

Efficacy of endovascular intratumoral embolization for meningioma: assessment using dynamic susceptibility contrast-enhanced perfusion-weighted imaging

BACKGROUND

In preoperative embolization for intracranial meningioma, endovascular intratumoral embolization is considered to be more effective for the reduction of tumorous vascularity than proximal feeder occlusion. In this study, we aimed to reveal different efficacies for reducing tumor blood flow in meningiomas by comparing endovascular intratumoral embolization and proximal feeder occlusion using dynamic susceptibility contrast-enhanced perfusion-weighted imaging (DSC-PWI).

METHODS

28 consecutive patients were included. DSC-PWI was performed before and after embolization for intracranial meningiomas. Normalized tumor blood volume (nTBV) of voxels of interest of whole tumors were measured from the DSC-PWI data before and after embolization. ΔnTBV% was compared between the cases that received intratumoral embolization and proximal feeder occlusion.

RESULTS

ΔnTBV% in the intratumoral embolization group (42.4±29.8%) was higher than that of the proximal feeder occlusion group (15.3±14.3%, p=0.0039). We used three types of embolic materials and ΔnTBV% did not differ between treatments with or without the use of each material: 42.8±42.4% vs 28.7±20.1% for microspheres (p=0.12), 36.1±20.6% vs 28.1±41.1% for n-butyl cyanoacrylate (p=0.33), and 32.3±37.3% vs 34.1±19.0% for bare platinum coils (p=0.77).

CONCLUSIONS

The flow reduction effect of intratumoral embolization was superior to that of proximal feeder occlusion in preoperative embolization for intracranial meningioma in an assessment using DSC-PWI.

Cushing's disease due to a pituitary adenoma as a component of collision tumor: A case report and review of the literature

Background

The coexistence of two morphologically different tumors attached to each other creates a very rare type of tumor called a collision tumor. Collision tumors containing pituitary adenoma–sellar meningioma have only been described in four cases to date; we discuss a fifth case harboring a collision tumor comprising a pituitary corticotroph adenoma and a sellar meningioma in the same anatomic position.

Case presentation

A 34-year-old Caucasian woman presented with menstrual irregularity, severe weakness of the proximal muscles, and 10–15 kg weight gain within a year. Basal plasma cortisol and adrenocorticotrophic hormone levels were 17.7 mg/dL and 58 pg/mL, respectively. Her diurnal cortisol rhythm was impaired (plasma cortisol at 23:00, 18.2 mg/dL) and after a 48-hour, 2-mg dexamethasone suppression test, plasma cortisol level was 13.6 mg/dL. The results were consistent with a diagnosis of Cushing’s syndrome. We then performed a nocturnal 8-mg dexamethasone suppression test and the suppression of cortisol was not greater than 50% (21.4 to 19.3). A pituitary magnetic resonance imaging revealed a tuberculum sellae meningioma arising from within the sellar region. An operation was chosen in order to examine whether the tumor was an adrenocorticotrophic hormone/corticotropin-releasing hormone-secreting lesion or if there were any microadenomas that could be observed during the operation. Via an extended endoscopic endonasal approach the meningioma was resected successfully. Unexpectedly, our patient complained of nausea and vomiting postoperatively. Plasma cortisol was 2.6 mg/dL and orally administered hydrocortisone treatment was initiated immediately. Histopathological examination revealed that the tumor generally consisted of a pituitary corticotroph adenoma infiltrated by meningioma. Our patient maintained hydrocortisone treatment for 11 months. At the latest visit, she had lost 12 kg, and her hypertension, menstrual irregularity, and weakness of the proximal muscles had disappeared. Her mental and physical wellbeing were restored.

Conclusions

To the best of our knowledge, this is the first report of Cushing’s disease due to a pituitary corticotroph adenoma adjacent to a meningioma. Even if a high-dose dexamethasone suppression test fails to suppress basal cortisol level, the importance of considering a suprasellar/sellar meningioma a possible component of a collision tumor presenting as adrenocorticotrophic hormone-dependent Cushing’s syndrome is highlighted here.

Pure Intrasellar Meningioma Mimicking Pituitary Macroadenoma: Magnetic Resonance Imaging and Review of the Literature

Intrasellar meningioma originating from the sellar floor is extremely rare and is often indistinguishable from pituitary macroadenoma, both clinically and radiologically. Here, we report a case involving a 68-year-old patient with intrasellar meningioma possibly originating from the sellar floor and present a brief review of all previous cases reported in the English literature.

Malignant intrasellar meningioma presenting as an invasive pituitary macroadenoma: A rare case report and literature review

Intrasellar meningiomas are rare tumors that have the ability to mimic non-functioning pituitary adenomas. The majority of meningiomas are slow-growing and benign, therefore an intrasellar meningioma with malignant histological features is extremely rare. The present study describes the case of a malignant diaphragm meningioma that was controlled through combined chemotherapy, following subtotal surgical resection. The patient's symptoms ceased and no tumor recurrence was detected at the 3-year follow-up. Hormone levels were also observed as normal. Further investigation of similar cases may aid in achieving an accurate pre-operative diagnosis. This would prove particularly beneficial in regards to intrasellar meningiomas due to their specific location and surgical treatment. The present study analyzes the requirement of chemotherapy for the treatment of these unique tumors.

Clinical features of sellar and suprasellar meningiomas

Meningiomas account for about 1% of sellar masses. Although they can mimic pituitary adenomas, they are more vascularized and invasive. To gain insights that would enhance our ability to establish a pre-surgical diagnosis of meningioma, we performed a retrospective study of these tumors. Query of the surgical pathology database identified 1,516 meningiomas operated at out institution between January 2000 and May 2012. Cases were matched to the radiology database to identify a strictly defined sellar and/or suprasellar location. We identified 57 meningiomas. F:M ratio was 6:1. The mean age was 52 years (median 50, range 30-78). The most common symptoms were visual disturbance (58%), headache (16%) and incidental finding (12%). The mean duration of symptoms was 13 months. Hyperprolactinemia was found in 36%, with mean value of 51.6 ng/ml (median 41.8, range 22.5-132). Mean maximal diameter was 2.9 cm (median 2.7, range 0.9-6.8), and most tumors enhanced homogeneously on MRI after gadolinium. A "dural tail" sign was reported in a third. The radiologist reported "likely meningioma" in 65%, "possible meningioma" in 8.7%, and pituitary adenoma in 11%. After surgery, visual disturbances improved in most patients (80%) but headache only in 7%. Post-operative complications at 1 and 3 months occurred 38.6 and 33.3% respectively. There was no mortality. Sellar/suprasellar meningiomas represent 4% of all meningiomas, and have a particularly high female predominance. The diagnosis is suggested by the radiologist in approximately 2/3 of the cases. An improved method to differentiate preoperatively these tumors from adenomas would be desirable.

The role of preoperative embolization for intracranial meningiomas

Object

As endovascular techniques have become more advanced, preoperative embolization has become an increasingly used intervention in the management of meningiomas. To date, however, no consensus has been reached on the use of this technique. To clarify the role of preoperative embolization in the management of meningiomas, the authors conducted a systematic review of case reports, case series, and prospective studies to increase the current understanding of the management options for these common lesions and complications associated with preoperative embolization.

Methods

A PubMed search was performed to include all relevant studies in which the management of intracranial meningiomas with preoperative embolization was reported. Immediate complications of embolization were reported as major (sustained) or minor (transient) deficits, death, or no neurological deficits.

Results

A total of 36 studies comprising 459 patients were included in the review. Among patients receiving preoperative embolization for meningiomas, 4.6% (n = 21) sustained complications as a direct result of embolization. Of the 21 patients with embolization-induced complications, the incidence of major complications was 4.8% (n = 1) and the mortality rate was 9.5% (n = 2).

Conclusions

Preoperative embolization is associated with an added risk for morbidity and mortality. Preoperative embolization may be associated with significant complications, but careful selection of ideal cases for embolization may help reduce any added morbidity with this procedure. Although not analyzed in the authors' study, embolization may still reduce rates of surgical morbidity and mortality and therefore may still have a potential benefit for selected patients. Future prospective studies involving the use of preoperative embolization in certain cases of meningiomas may further elucidate its potential benefit and risks.

Sellar meningiomas: an endocrinologic perspective

To review the clinical manifestations and outcomes of those with sellar meningiomas treated surgically at Mayo Clinic between 1975 and 2003. This is a retrospective chart and pathology review of 17 patients with a diagnosis of purely or largely intrasellar meningiomas treated surgically at our institution. Data in regards to presentation, endocrine hormonal status, surgical approach, pathology findings, outcome and adjunctive treatment were abstracted from the medical records. The majority of patients present with visual disturbances. All 17 tumors were WHO grade I. Surgical cure was achieved in 53 % after initial surgery. Postsurgical hypopituitarism occurred with high frequency. A substantial proportion of patients required subsequent surgical intervention or adjunctive treatment with external beam radiation. Sellar meningiomas are technically challenging and carry a high risk for visual disturbance and pituitary hormonal abnormalities. Many patients experience persistent disease requiring further intervention. These patients require long-term follow-up for evaluation of recurrence or development of new pituitary hormonal insufficiencies.

Pure intrasellar meningioma located under the pituitary gland: case report

Most intrasellar meningiomas are located in the subdiaphragmatic and supraglandular region because they originate from the diaphragma sellae. Subglandular meningiomas located under the pituitary gland are extremely rare. Intrasellar meningiomas in the subdiaphragmatic and subglandular region probably originate from the dura in the sellar floor. We report a case of a subglandular meningioma along with a review of the literature.

Further data favouring hormonal dependency of cerebral meningiomas: evidence from a patient treated with cabergoline

OBJECTIVE

To explore the role of cabergoline, a dopamine agonist, in the progression of meningiomas.

DESIGN

Case report.

SETTING

Teaching hospital in Barcelona, Spain (Gynecology, Obstetrics and Neonatology Clinical Institute, Hospital Clínic).

PATIENT(S)

Women with a history of meningioma underwent surgery via right pterional craniotomy. During the follow-up, at 18 months after the operation the patient developed a progressive hyperprolactinemia with amenorrhea and galactorrhea. An MR examination revealed a recurrence of the neoplasm.

INTERVENTION(S)

Cabergoline treatment.

MAIN OUTCOME MEASURE(S)

Progression of meningioma.

RESULT(S)

Long-standing cabergoline treatment in this patient with meningioma relapse early after surgery and subsequent hyperprolactinemia resulted in absence of progression of the neoplasm many years after the dopamine agonist initiation.

CONCLUSION(S)

These data suggest that cabergoline, a dopamine agonist, had an antiproliferative effect on the growth of meningiomas. Thus, one can hypothesise that the proliferation of cerebral meningiomas may be under dopaminergic control and that dopamine agonists such cabergoline may have a potential role in the medical treatment of patients with meningiomas.

Clinical features of nonpituitary sellar lesions in a large surgical series

CONTEXT

Pituitary adenomas are the most common lesions in the sellar region, but other pathologies need to be considered in the differential diagnosis.

OBJECTIVE

To assess the prevalence of unusual sellar masses in a large series of patients and identify clinicopathological factors that may aid the pre-operative diagnosis.

DESIGN

Retrospective case series.

PATIENTS

We analysed the records of 1469 transsphenoidal procedures performed between 1998 and 2009. One hundred sixteen cases (7·9%) were not pituitary adenomas.

MEASUREMENTS

Final pathological diagnosis.

RESULTS

One hundred sixteen patients (45 men, 71 women; mean age (±SD): 45 ± 17 years) with nonadenomatous lesions were divided into four major aetiological groups: cystic lesions (CYS) (53%); benign neoplasms (BEN) (22%); malignancies (MAL) (16%) and inflammatory lesions (INF) (9%). Rathke's cysts, the most common lesions, represented 42% of all cases. Twenty-five per cent of malignant lesions were metastases, and some of the MAL (e.g., fibrosarcoma, lung metastasis) had a radiographical appearance suggestive of a pituitary adenoma. The most common presenting symptoms were visual field impairment (51%) and headache (34%). Pre-operative pituitary dysfunction was present in 58% of cases, with hyperprolactinaemia (35%), hypogonadism (23%) and hypocortisolism (23%) found most frequently. Postoperative resolution of headache and visual symptoms occurred in 63% and 65% of patients, respectively. Hyperprolactinaemia resolved in 77% of cases.

CONCLUSIONS

A substantial minority of sellar masses are not pituitary adenomas. While they frequently present with the symptoms, hormone abnormalities and radiographical appearance typical of pituitary tumours, the possibility of a nonadenomatous lesion needs to be considered in the differential diagnosis.

Imaging of sellar and parasellar lesions

The sellar and parasellar region is an anatomically complex area where a number of neoplastic, infectious, inflammatory, developmental and vascular pathologies can occur. Differentiation among various etiologies may not always be easy, since many of these lesions may mimic the clinical, endocrinologic and radiologic presentations of pituitary adenomas. The diagnosis of sellar lesions involves a multidisciplinary effort, and detailed endocrinologic, ophthalmologic and neurologic testing are essential. CT and, mainly, MRI are the imaging modalities to study and characterise normal anatomy and the majority of pathologic processes in this region. We here provide an overview of the most relevant MRI and CT characteristics together with clinical findings of pituitary tumors, vascular, inflammatory and infectious lesions found in the sellar/parasellar region in order to propose an appropriate differential diagnosis.

MRI in the differential diagnosis of a sellar mass

Whilst pituitary adenomas are the commonest cause of a sellar mass, there are a number of other neoplastic, infectious, inflammatory, developmental and vascular aetiologies that should be considered by the radiologist. We discuss and illustrate these lesions and indicate the various magnetic resonance imaging features that are helpful in formulating an appropriate differential diagnosis.

Diagnosis, treatment, and outcome of pituitary tumors and other abnormal intrasellar masses. Retrospective analysis of 353 patients

We reviewed the clinical features, essential laboratory data, pituitary imaging findings (computerized tomography and magnetic resonance imaging), management, and outcome of 353 consecutive patients with the presumptive diagnosis of pituitary tumor investigated from January 1984 through December 1997 at University Hospital, Lausanne, Switzerland. In 18 cases primary empty sella turcica was diagnosed, and in 13 cases of pseudacromegaly there were no endocrine abnormalities. The remaining 322 patients disclosed abnormal pituitary masses, including 275 pituitary adenomas, 18 craniopharyngiomas, 6 cases of primary pituitary hyperplasia, 6 intrasellar meningiomas, 6 cases of distant metastases, 4 intrasellar cysts, 2 chordomas, 1 primary lymphoma, and 1 astrocytoma. Biologic data and immunohistochemical analysis of the excised tissues demonstrated that prolactinomas and nonsecreting adenomas (NSAs) were the most frequent pituitary tumors (40% and 39%, respectively), followed by somatotropic adenomas with acromegaly (11%) and Cushing disease (6%). In contrast with the vast majority of NSAs, which significantly expressed glycoprotein hormones in tissue without secreting them, there was a small group of glycoprotein hormone-secreting adenomas (2%), which had a more severe clinical course after surgery. Thirty-eight pituitary masses were incidentally discovered, most of them NSAs. The expansion of pituitary adenomas into the right cavernous sinus was twice as frequent as to the left cavernous sinus. For the differential diagnosis of hyperprolactinemia, basal prolactin (PRL) levels above 85 micrograms/L, in the absence of renal failure and PRL-enhancing drugs, and a PRL increment of less than 30% after thyrotropin-releasing hormone (TRH) accurately ruled out functional hyperprolactinemia due to NSA, and were typical of prolactinomas. For screening and follow-up of acromegaly, basal growth hormone (GH) and insulin-like growth factor 1 (IGF-1) levels, as well as the paradoxical GH response to TRH (present in 2/3 acromegalic patients), could be used as convenient tools, but the most accurate test for diagnosis and prediction of outcome after therapy was GH (lack of) suppression during oral glucose tolerance test. In Cushing disease, single evening plasma cortisol was as good as the overnight dexamethasone suppression test for screening, and a combined dexamethasoneovine corticotropin-releasing hormone (oCRH) test was as accurate as the long dexamethasone suppression test to confirm the diagnosis. Bilateral inferior petrosal sinus catheterization coupled with oCRH test confirmed the pituitary origin of excess adrenocorticotropic hormone (ACTH) in all patients, including those with normal pituitary on magnetic resonance imaging (50% of the cases). However, this procedure failed to predict tumor localization correctly within the pituitary in 21% of patients. Pituitary cysts, meningiomas, and craniopharyngiomas with an intrasellar component were correctly diagnosed based on pituitary imaging in 75%, 67%, and 44% of cases, respectively. The remainder, as well as the cases of pituitary hyperplasia, metastases, and other less frequent pathologies, were initially diagnosed as NSAs or as masses of unknown nature. When surgery was indicated, pituitary adenomas and other intrasellar masses were operated on by the transsphenoidal route, with the exception of 100% of meningiomas, 83% of craniopharyngiomas, and 10% of NSAs, which were operated on by the transcranial route. Favorable late surgical outcome of prolactinomas could be predicted by a restored PRL response to TRH. However, dopamine agonist (DA) therapy, usually resulting in satisfactory control of PRL levels and in tumor shrinkage, progressively displaced surgery as primary treatment for prolactinomas throughout the study period. After full-term pregnancy, the size of prolactinoma decreased in 7 of 9 patients, and PRL was normal in 2. Surgery was the first treatment for NSAs, with a tumor rela

Differential diagnosis of sellar masses

The differential diagnosis of nonpituitary sellar masses is broad; differentiating among potential etiologies may not always be straightforward because many of these lesions, tumorous and nontumorous, may mimic the clinical, endocrinologic, and radiologic presentations of pituitary adenomas. This article provides an overview of the clinical and radiographic characteristics of both pituitary tumors and the nonpituitary lesions found in the sellar/parasellar region and discusses, in detail, the specific nonpituitary origins of the sellar masses.

Imaging of sellar and parasellar pathology

This article reviews the complex anatomic relationships between structures in the sellar and parasellar regions. Normal anatomy and the normal imaging spectrum are reviewed, with emphasis on the diversity of pathology that originates from this region. Both CT and MR imaging may be used to evaluate the sellar and parasellar regions. This article discusses how modern imaging techniques enable characterization of the many lesions that alter the structure and function of normal sellar and parasellar anatomy.