Intraoperative rupture of intracerebral aneurysm immediately after meningioma resection: a case report

Co-occurrence of Meningioma and Intracranial Aneurysm: A Systematic Review

A complete understanding of the rare neurosurgical phenomenon of co-occurring meningioma and intracranial aneurysm is important to improve the quality of life and decrease future complications in these patients. In this review, we searched the literature for cases of this rare phenomenon to highlight the most important historical, investigation, and treatment-related factors to improve the accuracy of intraoperative procedural decisions. We searched the PubMed database for case reports on this neurological rare phenomenon to create organized data for our review. Then, we extracted information from these cases and organized it in a table. We identified 19 cases in the literature. In the published studies, there was a predominance of the female sex (73.68%). The mean age of the patients was 54.11 years, with the cases relatively evenly distributed among patients in their 30s, 40s, 50s, 60s, and 70s. Posterior communicating artery aneurysm was the most common among the 19 cases. For meningioma, the frontal lobe and clinoid were the two most affected locations, and the meningothelial histopathology was the most common. Complete tumor resection and aneurysmal clipping were done for the majority of the cases (57.8%) unless there was a complication that deferred simultaneous intervention. Fortunately, most patients (78.95%) recovered completely after surgery. The coexistence of meningioma and intracranial aneurysm has a very high cure rate, postoperative symptom resolution, and a very low recurrence rate. For most cases, neuroimaging investigations are recommended for simultaneous management. This imaging can also highlight other potentially suspicious findings.

Vascular steal and associated intratumoral aneurysms in highly vascular brain tumors: illustrative case

BACKGROUND

Intratumoral aneurysms in highly vascular brain tumors can complicate resection depending on their location and feasibility of proximal control. Seemingly unrelated neurological symptoms may be from vascular steal that can help alert the need for additional vascular imaging and augmenting surgical strategies.

OBSERVATIONS

A 29-year-old female presented with headaches and unilateral blurred vision, secondary to a large right frontal dural-based lesion with hypointense signal thought to represent calcifications. Given these latter findings and clinical suspicion for a vascular steal phenomenon to explain the blurred vision, computed tomography angiography was obtained, revealing a 4 × 2-mm intratumoral aneurysm. Diagnostic cerebral angiography confirmed this along with vascular steal by the tumor from the right ophthalmic artery. The patient underwent endovascular embolization of the intratumoral aneurysm, followed by open tumor resection in the same setting without complication, minimal blood loss, and improvement in her vision.

LESSONS

Understanding the blood supply of any tumor, but highly vascular ones in particular, and the relationship with normal vasculature is undeniably important in avoiding potentially dangerous situations and optimizing maximal safe resection. Recognition of highly vascular tumors should prompt thorough understanding of the vascular supply and relationship of intracranial vasculature with consideration of endovascular adjuncts when appropriate.

Management principles of cranial base tumor with aneurysm

Skull base tumors are challenging to treat because of their deep location, complex anatomy, and close proximity to important blood vessels and nerves. Furthermore, some patients with cranial tumors are found to have aneurysms, but there is no consensus on how to evaluate the impact of aneurysms on surgery and how to handle the lesions safely and effectively. We retrospectively reviewed our database to identify all patients with a skull base tumor treated in the Department of Neurosurgery of Beijing Tiantan Hospital affiliated with Capital Medical University from 2019 to 2021. The records of patients with skull base tumors associated with aneurysms were analyzed. The operative methods and postoperative follow-up information were collected. We analyzed a total of 481 patients with skull base tumors, comprising 224 males and 257 females with a mean age of 48 ± 14 years. Twenty-four patients (24/481, 5.0%) were diagnosed with aneurysms. For eight patients, it was considered necessary to perform aneurysm treatment before or during the tumor resection surgery. For the other 16 patients, the recommendation was to monitor the aneurysm or perform elective aneurysm treatment after tumor resection. All patients with both skull base tumors and aneurysms benefited from treatment. No severe postoperative complications occurred. We summarized the final treatment plan for all patients with skull base tumors with aneurysms and proposed a protocol to decrease the surgical risk of patients with skull base tumors associated with aneurysms.

Case report and literature review: Treatment of multiple meningiomas combined with multiple unruptured aneurysms in a single operation

Background

Although the incidence of a single meningioma or a single aneurysm is common, cases of multiple meningiomas combined with multiple aneurysms are rarely reported, and surgical treatment of the coexisting situation is also relatively uncommon.

Case presentation

A 38-year-old male patient presented to the neurosurgery department of our center with a headache. Examination revealed only symptoms of headache. Laboratory tests showed only decreased total protein and albumin. Magnetic resonance imaging showed preoccupation with the frontal lobe and the right temple bone. Magnetic resonance angiography and digital subtraction angiography showed two aneurysms in the anterior communicating artery and right anterior cerebral artery. Based on a combination of the patient’s history and imaging, we hypothesized that the patient was simultaneously suffering from meningioma and an aneurysm, and both of them are multiple. The patient underwent tumor resection and clipping procedure based on this hypothesis in one surgery. Intraoperative biopsy proved to be a meningioma. The patient was discharged on the 10th postoperative day, and a postoperative follow-up suggested no complications.

Conclusion

Multiple meningiomas combined with multiple aneurysms are rare to be reported in the same patient. For those unruptured intracranial aneurysms (UIAs) located in the visual field of craniotomy prepared for brain tumorlike meningioma, it is possible to do the clipping as well. When the meningiomas are multiple, fitted with the surgical indication, and located in a position that cannot be treated in one surgery, this may lead to a two-stage operation, no matter where the UIAs are located.