Pathologic quiz case: an 11-year-old boy with intractable seizures. Meningioangiomatosis

Meningioangiomatosis: A review of the variable manifestations and complex pathophysiology

Meningioangiomatosis (MA) is a rare, complex and heterogeneous disease of meningovascular proliferation that is found primarily in the leptomeninges and cerebral cortex but can involve subcortical white matter and other brain regions such as the cerebellum and deep gray matter. MA may be found in pediatric or adult populations and may be sporadic or neurofibromatosis-associated. The presentation of MA is highly variable: it may be associated with other neurological diseases; clinically presents on a spectrum from asymptomatic to seizures or focal deficits; radiologically presents with multifocal, tumor-like, or cystic lesions, or may appear normal; and pathologically may have cellular or vascular predominance. In this article, we review the various manifestations of MA including neurofibromatosis-associated MA, multifocal MA, cystic MA, and MA associated with meningioma, other brain tumors, focal cortical dysplasia, neurodegenerative changes, and post-radiation changes. The treatment of MA is also reviewed. While the pathogenesis of MA remains elusive, we discuss the proposed theories such as developmental, dysplastic, hamartomatous or reactive ethology in given variants. It is important for physicians to be aware of MA as more research on this complex entity is needed and timely diagnosis may benefit outcomes in patients with MA.

Sporadic meningioangiomatosis with and without meningioma: analysis of clinical differences and risk factors for poor seizure outcomes

BACKGROUND

Meningioangiomatosis (MA) is a rare cerebral lesion. Sporadic MA occasionally combines with meningioma (MA-M). The aim of the present study was to clarify whether MA-M and pure MA have clinical differences and to determine risk factors for unsatisfactory seizure outcomes in sporadic MA.

METHODS

We reported 14 sporadic MA cases in our center and conducted a literature review. We compared the demographic, clinical, imaging, electrophysiological and pathological features and surgical outcomes. Logistic regression analysis was performed to evaluate the risk factors for poor seizure outcomes.

RESULTS

MA-M cases showed a more prominent male predilection (4.2 times vs. 1.6 times, p = 0.04), a shorter duration of symptoms (2.8 ± 0.8 years vs. 5.2 ± 0.6 years, p = 0.02), and a lower seizure incidence (53.6 % vs. 89.3 %, p < 0.001) as compared to pure MA. A gyriform alteration on imaging was exclusively associated with pure MA. The Ki-67 was higher in the meningioma component than in the MA component in MA-M (1.2 ± 0.3 % vs. 6.1 ± 1.1 %, p < 0.001). Lesions located in the temporal lobe predicted poor seizure outcomes (p = 0.02, OR = 4.4, 95 % confidence interval, 1.24-15.89).

CONCLUSION

Clinical differences may be caused by the different biological natures. MA-M seems to be a neoplastic lesion, while pure MA seems to be a non-neoplastic lesion. Long-term follow-up is required for MA-M. Because the coexistence of hippocampal sclerosis may explain the poor seizure outcomes of MA located in the temporal lobe, it is important to identify underlying hippocampal sclerosis and to perform complete resection.

Sporadic meningioangiomatosis: imaging findings with histopathologic correlations in seven patients

INTRODUCTION

Meningioangiomatosis (MA) is a rare benign cerebral lesion. We aimed to evaluate the CT and MR features of sporadic MA, with a focus on the correlation between imaging and histopathologic findings.

METHODS

CT (n = 7) and MR (n = 8) images of eight patients (6 men and 2 women; mean age, 12.8 years; range, 4-22 years) with pathologically proven MA were retrospectively reviewed. After dividing the MA lesions according to their distribution into cortical and subcortical white matter components, the morphologic characteristics were analyzed and correlated with histopathologic findings in seven patients.

RESULTS

CT and MR images showed cortical (n = 4, 50%) and subcortical white matter (n = 7, 88%) components of MA. All four cortical components revealed hyperattenuation on CT scan and T1 isointensity/T2 hypointensity on MR images, whereas subcortical white matter components showed hypoattenuation on CT scan and T1 hypointensity/T2 hyperintensity on MR images. Two cortical components (25%) demonstrated enhancement and one subcortical white matter component demonstrated cystic change. Seven cases were available for imaging-histopathologic correlation. In all seven cases, the cortex was involved by MA and six patients (86%) showed subcortical white matter involvement by MA. There were excellent correlations between the imaging and histopathologic findings in subcortical white matter components, and the accuracy was 100% (seven of seven); whereas there were poor correlations in cortical components, and the accuracy was 43% (three of seven).

CONCLUSIONS

The cerebral cortex and subcortical white matter were concomitantly involved by MA. Subcortical white matter components of MA were more apparent than cortical components on CT and MR imaging.

Meningioangiomatosis: a case report and literature review emphasizing diverse appearance on different imaging modalities

Purpose. Meningioangiomatosis (MA) is a rare, benign lesion that commonly mimics other intracranial malformations in clinical presentation and appearance on imaging. The case presented and the literature review performed highlight the importance of combining MRI and CT results to better characterize intracranial lesions and including MA on the list of differential diagnoses of patients presenting with seizures. Methods. The case described is of a 19-year-old male with a 10-year history of worsening seizures refractory to multiple drug regimens. MRI revealed an atypical vascular malformation. The patient underwent surgical resection of the epileptogenic cortex. Results. Although the radiologic impression of the lesion was a vascular malformation, pathological examination revealed MA. A literature search performed highlights the variability of the appearance of MA on CT and MRI and suggests the utility of the T2 GRE sequence in illustrating the presence of calcification and, in a lesion with other characteristic features, the diagnosis of MA. Conclusion. MA can be a difficult diagnosis to make based on imaging findings alone. However, in a patient with a characteristic history and presentation, the presence of a calcified mass on CT and MRI brain susceptibility artifact on a T2 GRE sequence may suggest MA.

Meningioangiomatosis associated with neurofibromatosis: report of 2 cases in a single family and review of the literature

BACKGROUND

Meningioangiomatosis (MA) is a rare benign disorder. It may occur sporadically or in association with neurofibromatosis (NF). The sporadic type typically presents with seizures, whereas that associated with NF is often asymptomatic. Of the 100 cases reported, only 14 are associated with NF. We now report 2 additional cases of MA associated with neurofibromatosis 2 (NF2) in a single family, with one occurring in the cerebellum. The etiology, pathology, and imaging features of MA are presented.

CASE DESCRIPTION

A 38-year-old woman (patient 1) presented with a 4-month history of ataxia. She had been diagnosed previously with NF2. Magnetic resonance imaging (MRI) scans of the brain revealed bilateral acoustic neuromas and multiple calcified intracranial lesions. Her 13-year-old daughter (patient 2) presented with complex partial seizures. MRI scans of the brain revealed bilateral acoustic neuromas and a right parietal mass. Patient 1 underwent a suboccipital craniotomy to resect the right-sided acoustic neuroma. A small portion of normal-appearing cerebellar cortex was resected to avoid undue retraction. Histopathologic examination showed the presence of a lesion consistent with MA. Patient 2 underwent a right temporal-parietal craniotomy to remove the enhancing epileptogenic right posterior temporoparietal lesion. Histopathologic analysis showed a lesion consistent with meningioma and MA.

CONCLUSIONS

MA has been reported infrequently in association with NF2. We now report 2 cases of MA associated with NF2 in one family, and we add the cerebellum to possible locations of occurrence. MA should be considered in the differential diagnosis of cortical lesions, particularly in patients with NF2.

Insights into meningioangiomatosis with and without meningioma: a clinicopathologic and genetic series of 24 cases with review of the literature

Meningioangiomatosis (MA) is a rare seizure-associated lesion of presumed hamartomatous or developmental origin. It is occasionally combined with a neoplasm, most commonly meningioma (MA-M). In the current study, we examined 24 cases (14 pure MA, 10 MA-M) using immunohistochemistry for merlin, protein 4.1 B, progesterone receptor (PR), and MIB-1, as well as FISH for NF2 and 4.1B gene dosages. Nine cases of MA-M (90%) had gene deletions (NF2/4.7B), protein losses (merlin/protein 4.1B), and/or PR positivity, with a similar or identical phenotype in both components. No PR positivity or gene deletions were seen in pure MAs, though merlin and/or protein 4.1B were immunonegative in six cases. Our data suggest that in most MA-Ms, the MA component is neoplastic, likely representing an exuberant perivascular pattern of spread from the meningioma, rather than an underlying hamartoma. This pattern of spread may be facilitated by meningiomas that are predominantly leptomeningeal or intracerebral in origin. It remains important to distinguish this pattern from true brain invasion, given the more ominous prognostic significance of the latter. In contrast, most perivascular spindled cells of pure MA are genetically and immunohistochemically similar to non-neoplastic meningothelial cells, consistent with current histogenetic theories.