ClinicalRadiology (1992) 45, 351 352
Case Report: Acute Subdural Haematoma- An Unusual Presentation of a Meningioma S. A. R E N O W D E N
a n d M. D. H O U R I H A N
Department of Diagnostic Radiology, University Hospital of Wales, Cardiff" Acute subdural haemorrhage is usually the result of a head injury, but when it occurs without a history of trauma, an underlying cause must be suspected. An unusual case is described o f an acute subdural haematoma in association with a parasagittal meningioma. This is a rare but serious complication of a meningioma and outcome depends upon prompt removal of the tumour. R e n o w d e n , S.A. & H o u r i h a n , M . D . (1992). Clinical Radiology 45, 351-352. Case Report: Acute Subdural Haematoma - An Unusual Presentation of a Meningioma
A c u t e s u b d u r a l h a e m o r r h a g e is usually caused by t r a u m a to the h e a d a n d is due to bleeding f r o m tears in veins as they traverse the s u b d u r a l space passing f r o m the cerebral cortex to the m a j o r v e n o u s sinuses. D e t e c t i o n o f a n acute s u b d u r a l h a e m a t o m a in the absence o f t r a u m a necessitates the exclusion o f a vascular a n o m a l y or t u m o u r . S u b d u r a l h a e m o r r h a g e in a s s o c i a t i o n with a m e n i n g i o m a is very u n c o m m o n , there being no e x a m p l e s in the large series o f i n t r a c r a n i a l m e n i n g i o m a s r e p o r t e d by C u s h i n g and E i s e n h a r d t (1938) a n d Hoessly a n d O l i v e c r o n a (1955). I n t r a t u m o r a l h a e m o r r h a g e was r e p o r t e d in six o f the 131 m e n i n g i o m a s reviewed by Russell et al. (1980), with one extension into the sudural space. W a k a i et al. (1982) reviewed t u m o u r - r e l a t e d h a e m o r r h a g e a n d f o u n d that o f their 310 m e n i n g i o m a s , four p r e s e n t e d with h a e m o r r h a g e , three into the t u m o u r and one into the s u b a r a c h n o i d space.
p l a s m s (Ztilch, 1975). They arise f r o m the cells o f the a r a c h n o i d villi a n d therefore are in close a s s o c i a t i o n with the d u r a m a t e r a n d venous sinuses, which they tend to invade. The clinical p r e s e n t a t i o n o f a m e n i n g i o m a generally d e p e n d s u p o n its l o c a t i o n a n d a l t h o u g h they are v a s c u l a r t u m o u r s , s p o n t a n e o u s bleeding is rare. W h e n it occurs, it m a y be confined within the t u m o u r o r extend into the brain, the ventricles, the s u b a r a c h n o i d o r subd u r a l spaces o r a c o m b i n a t i o n o f these. H a e m o r r h a g e into the t u m o u r and s u b a r a c h n o i d extension is the m o s t c o m m o n . S u b d u r a l h a e m o r r h a g e is least frequent occurring in isolation in a p p r o x i m a t e l y 10% o f cases o f bleeding from the t u m o u r (Helle a n d Conley, 1980). In o u r case, the bleeding was into the t u m o u r , extending into the s u b d u r a l space. H a e m o r r h a g e into a m e n i n g i o m a m a y result in an atypical C T a p p e a r a n c e . M e n i n g i o m a s are generally
CASE REPORT A 41-year-old woman, who was previously well, presented with a 5 day history of generalized headache of sudden onset, accompanied by nausea, vomiting and double vision. Physical examination showed her to be fully orientated but drowsy, with a right oculomotor palsy and a right extensor plantar reflex. Her reflexes were symmetrically brisk and she had right-sided ankle clonus. Cranial CT demonstrated an acute right frontal subdural haematoma with mass effect (Fig. 1), and a parasagittal meningioma (Fig. 2) which had an atypically high internal density, suggesting haemorrhage. The acute subdural haematoma was evacuated and a syncytial type meningioma removed via a right frontoparietal craniotomy. The patient made an excellent post-operative recovery.
DISCUSSION H a e m o r r h a g e associated with i n t r a c r a n i a l n e o p l a s m s usually occurs within the t u m o u r itself. A m o n g p r i m a r y i n t r a c r a n i a l t u m o u r s it is m o s t often f o u n d in p i t u i t a r y a d e n o m a s , germ cell t u m o u r s , high g r a d e gliomas and o l i g o d e n d r o g l i o m a s . M e t a s t a t i c t u m o u r s p r o n e to h a e m o r r h a g e include m e l a n o m a , h y p e r n e p h r o m a a n d c h o r i o c a r c i n o m a (Zfilch, 1968; W a k a i et al., 1982). The association o f an acute s u b d u r a l h a e m o r r h a g e with an intracranial t u m o u r is less c o m m o n . M e n i n g i o m a s c o m p r i s e 16% o f i n t r a c r a n i a l t u m o u r s and are the largest g r o u p o f o p e r a b l e i n t r a c r a n i a l neoCorrespondence to: Dr M. D. Hourihan, University Hospital of Wales, Heath Park, Cardiff, Wales.
Fig. 1 Unenhanced cranial CT: an acute subdural haematoma is seen in the right frontal region compressing the right lateral ventricle and displacing the midline structures to the left.
352
CLINICAL RADIOLOGY
Parasagitt_al meningiomas had a relatively low and spinal meningiomas the least bleeding potential. The mechanisms of haemorrhage from meningiomas are not fully understood but three factors may be involved. First, meningiomas, particularly the angioblastie variety, contain foci ~of thin-walled angiomatous vessels and endothelial channels (Modesti et al., 1976; Budny et al., 1977), which are thought to be the source of haemorrhage. Second, the vessels supplying a meningioma may also undergo enlargement and weakening of their walls. Third, Koos et al. (1971) noted that there may be a high content of plasminogen activators in meningiomas, indicating local fibrinolysis. Acknowledgements. We would like to thank Dr Richard Clements, Royal Gwent Hospital, Newport, for referring this case. We would also like to thank Mr Peter Braithwaite, Consultant General Surgeon, for his advicc in this manuscript. He must now know more about meningiomas than any other general surgeon in the country!
REFERENCES
Fig. 2 Unenhanced cranial CT: a right parasagittal meningioma contains areas of high density suggesting haemorrhage, and is associated with blood in the subdural space on the right of the interhemispheric fissure.
slightly hyperdense with respect to cerebral grey matter, though some (11-19%) are iso- or slightly hypodense (New et al., 1980; Stevens et al., 1983). Recent bleeding into a tumour may result in partial or sometimes complete hyperdensity of the lesion, while old haemorrhage may result in hypodense areas. Cysts, areas of necrosis and lipomatous infiltration may also complicate the CT appearances of a meningioma, causing areas of low density (Russell et al., 1980; Stevens et al., 1983). In a review of 43 meningiomas complicated by haemorrhage, Helle and Conley (1980) found the average age of the patient at the time ofhaemorrhage to be 50 years. The presentation was acute in half of the cases and more insidious in the remainder. Malignant meningiomas, followed by the angioblastic variety were most often associated with haemorrhage, while syncytiat meningiomas appeared to have a low bleeding potential. Intraventricular meningiomas had a much greater tendency to Need than meningiomas in other sites.
Budny, JL, Glasauer, FE & Sil, R (1977). Rapid recurrence of meningioma causing intracerebral haemorrhage. Surgical Neurology, 8, 323-325. Cushing, H & Eisenhardt, L (1938). Meningiomas Their Classification, Regional Behaviour, Life History and Surgical End Results, p. 785. Charles C. Thomas, Springfield. Helle, TL & Conley, FK (1980). Haemorrhage associated with meningioma; a case report and review of the literature. Journal oJ' Neurology, Neurosurgery and Psychiatry, 43, 725 729. Hocssly, GF & Olivecrona, H (1955). Report on 280 cases of verified parasaginal meningioma. Journal of Neurosurgery, 12, 614 626. Koos, W, Valencak, E, Kraus, H, Blumel, G &Bock, S (1971). L'activit6 fibrinolytique r616v6e dans les tumeurs intra-craniennes. Neurochirurgie, 17, 549 558. Modesti, LM, Binet, EF & Collins, GH (1976). Meningiomas causing spontaneous intracranial hematomas. Journal of Neurosurgery, 45, 437-441. New, PJF, Aronow, S & Hesselink, JR (1980). National Cancer Institute Study. Evaluation of computed tomography in the diagnosis of intracranial neoplasms: meningiomas. Radiology, 136, 665-675. Russell, EJ, George, AE, Kricheff, l & Budzilovich, G (1980). Atypical computed tomographic features of intracranial meningioma. Radiology, 135, 673 -682. Stevens, JM, Ruiz, JS & Kendall, BE (1983). Observations on peritumoral oedema in meningioma. II. Mechanism of oedema production. Neuroradiology, 25, 125-131. Wakai, S, Yamakawa, K, Manaka, S & Takakura, K (1982). Spontaneous intracranial hemorrhage caused by brain tumour: its incidence and clinical significance. Neurosurgery, 10, 437-444. Zfilch, KJ (1968). Neuropathology of intracranial haemorrhage. Progress in Brain Research, 30, 151-165. Z/ilch, KJ (1975). Atlas of Gross Neurosurgical Pathology, pp. 113 135. Springer-Verlag, New York.
Case Report: Acute Subdural Haematoma- An Unusual Presentation of a Meningioma S. A. R E N O W D E N
a n d M. D. H O U R I H A N
Department of Diagnostic Radiology, University Hospital of Wales, Cardiff" Acute subdural haemorrhage is usually the result of a head injury, but when it occurs without a history of trauma, an underlying cause must be suspected. An unusual case is described o f an acute subdural haematoma in association with a parasagittal meningioma. This is a rare but serious complication of a meningioma and outcome depends upon prompt removal of the tumour. R e n o w d e n , S.A. & H o u r i h a n , M . D . (1992). Clinical Radiology 45, 351-352. Case Report: Acute Subdural Haematoma - An Unusual Presentation of a Meningioma
A c u t e s u b d u r a l h a e m o r r h a g e is usually caused by t r a u m a to the h e a d a n d is due to bleeding f r o m tears in veins as they traverse the s u b d u r a l space passing f r o m the cerebral cortex to the m a j o r v e n o u s sinuses. D e t e c t i o n o f a n acute s u b d u r a l h a e m a t o m a in the absence o f t r a u m a necessitates the exclusion o f a vascular a n o m a l y or t u m o u r . S u b d u r a l h a e m o r r h a g e in a s s o c i a t i o n with a m e n i n g i o m a is very u n c o m m o n , there being no e x a m p l e s in the large series o f i n t r a c r a n i a l m e n i n g i o m a s r e p o r t e d by C u s h i n g and E i s e n h a r d t (1938) a n d Hoessly a n d O l i v e c r o n a (1955). I n t r a t u m o r a l h a e m o r r h a g e was r e p o r t e d in six o f the 131 m e n i n g i o m a s reviewed by Russell et al. (1980), with one extension into the sudural space. W a k a i et al. (1982) reviewed t u m o u r - r e l a t e d h a e m o r r h a g e a n d f o u n d that o f their 310 m e n i n g i o m a s , four p r e s e n t e d with h a e m o r r h a g e , three into the t u m o u r and one into the s u b a r a c h n o i d space.
p l a s m s (Ztilch, 1975). They arise f r o m the cells o f the a r a c h n o i d villi a n d therefore are in close a s s o c i a t i o n with the d u r a m a t e r a n d venous sinuses, which they tend to invade. The clinical p r e s e n t a t i o n o f a m e n i n g i o m a generally d e p e n d s u p o n its l o c a t i o n a n d a l t h o u g h they are v a s c u l a r t u m o u r s , s p o n t a n e o u s bleeding is rare. W h e n it occurs, it m a y be confined within the t u m o u r o r extend into the brain, the ventricles, the s u b a r a c h n o i d o r subd u r a l spaces o r a c o m b i n a t i o n o f these. H a e m o r r h a g e into the t u m o u r and s u b a r a c h n o i d extension is the m o s t c o m m o n . S u b d u r a l h a e m o r r h a g e is least frequent occurring in isolation in a p p r o x i m a t e l y 10% o f cases o f bleeding from the t u m o u r (Helle a n d Conley, 1980). In o u r case, the bleeding was into the t u m o u r , extending into the s u b d u r a l space. H a e m o r r h a g e into a m e n i n g i o m a m a y result in an atypical C T a p p e a r a n c e . M e n i n g i o m a s are generally
CASE REPORT A 41-year-old woman, who was previously well, presented with a 5 day history of generalized headache of sudden onset, accompanied by nausea, vomiting and double vision. Physical examination showed her to be fully orientated but drowsy, with a right oculomotor palsy and a right extensor plantar reflex. Her reflexes were symmetrically brisk and she had right-sided ankle clonus. Cranial CT demonstrated an acute right frontal subdural haematoma with mass effect (Fig. 1), and a parasagittal meningioma (Fig. 2) which had an atypically high internal density, suggesting haemorrhage. The acute subdural haematoma was evacuated and a syncytial type meningioma removed via a right frontoparietal craniotomy. The patient made an excellent post-operative recovery.
DISCUSSION H a e m o r r h a g e associated with i n t r a c r a n i a l n e o p l a s m s usually occurs within the t u m o u r itself. A m o n g p r i m a r y i n t r a c r a n i a l t u m o u r s it is m o s t often f o u n d in p i t u i t a r y a d e n o m a s , germ cell t u m o u r s , high g r a d e gliomas and o l i g o d e n d r o g l i o m a s . M e t a s t a t i c t u m o u r s p r o n e to h a e m o r r h a g e include m e l a n o m a , h y p e r n e p h r o m a a n d c h o r i o c a r c i n o m a (Zfilch, 1968; W a k a i et al., 1982). The association o f an acute s u b d u r a l h a e m o r r h a g e with an intracranial t u m o u r is less c o m m o n . M e n i n g i o m a s c o m p r i s e 16% o f i n t r a c r a n i a l t u m o u r s and are the largest g r o u p o f o p e r a b l e i n t r a c r a n i a l neoCorrespondence to: Dr M. D. Hourihan, University Hospital of Wales, Heath Park, Cardiff, Wales.
Fig. 1 Unenhanced cranial CT: an acute subdural haematoma is seen in the right frontal region compressing the right lateral ventricle and displacing the midline structures to the left.
352
CLINICAL RADIOLOGY
Parasagitt_al meningiomas had a relatively low and spinal meningiomas the least bleeding potential. The mechanisms of haemorrhage from meningiomas are not fully understood but three factors may be involved. First, meningiomas, particularly the angioblastie variety, contain foci ~of thin-walled angiomatous vessels and endothelial channels (Modesti et al., 1976; Budny et al., 1977), which are thought to be the source of haemorrhage. Second, the vessels supplying a meningioma may also undergo enlargement and weakening of their walls. Third, Koos et al. (1971) noted that there may be a high content of plasminogen activators in meningiomas, indicating local fibrinolysis. Acknowledgements. We would like to thank Dr Richard Clements, Royal Gwent Hospital, Newport, for referring this case. We would also like to thank Mr Peter Braithwaite, Consultant General Surgeon, for his advicc in this manuscript. He must now know more about meningiomas than any other general surgeon in the country!
REFERENCES
Fig. 2 Unenhanced cranial CT: a right parasagittal meningioma contains areas of high density suggesting haemorrhage, and is associated with blood in the subdural space on the right of the interhemispheric fissure.
slightly hyperdense with respect to cerebral grey matter, though some (11-19%) are iso- or slightly hypodense (New et al., 1980; Stevens et al., 1983). Recent bleeding into a tumour may result in partial or sometimes complete hyperdensity of the lesion, while old haemorrhage may result in hypodense areas. Cysts, areas of necrosis and lipomatous infiltration may also complicate the CT appearances of a meningioma, causing areas of low density (Russell et al., 1980; Stevens et al., 1983). In a review of 43 meningiomas complicated by haemorrhage, Helle and Conley (1980) found the average age of the patient at the time ofhaemorrhage to be 50 years. The presentation was acute in half of the cases and more insidious in the remainder. Malignant meningiomas, followed by the angioblastic variety were most often associated with haemorrhage, while syncytiat meningiomas appeared to have a low bleeding potential. Intraventricular meningiomas had a much greater tendency to Need than meningiomas in other sites.
Budny, JL, Glasauer, FE & Sil, R (1977). Rapid recurrence of meningioma causing intracerebral haemorrhage. Surgical Neurology, 8, 323-325. Cushing, H & Eisenhardt, L (1938). Meningiomas Their Classification, Regional Behaviour, Life History and Surgical End Results, p. 785. Charles C. Thomas, Springfield. Helle, TL & Conley, FK (1980). Haemorrhage associated with meningioma; a case report and review of the literature. Journal oJ' Neurology, Neurosurgery and Psychiatry, 43, 725 729. Hocssly, GF & Olivecrona, H (1955). Report on 280 cases of verified parasaginal meningioma. Journal of Neurosurgery, 12, 614 626. Koos, W, Valencak, E, Kraus, H, Blumel, G &Bock, S (1971). L'activit6 fibrinolytique r616v6e dans les tumeurs intra-craniennes. Neurochirurgie, 17, 549 558. Modesti, LM, Binet, EF & Collins, GH (1976). Meningiomas causing spontaneous intracranial hematomas. Journal of Neurosurgery, 45, 437-441. New, PJF, Aronow, S & Hesselink, JR (1980). National Cancer Institute Study. Evaluation of computed tomography in the diagnosis of intracranial neoplasms: meningiomas. Radiology, 136, 665-675. Russell, EJ, George, AE, Kricheff, l & Budzilovich, G (1980). Atypical computed tomographic features of intracranial meningioma. Radiology, 135, 673 -682. Stevens, JM, Ruiz, JS & Kendall, BE (1983). Observations on peritumoral oedema in meningioma. II. Mechanism of oedema production. Neuroradiology, 25, 125-131. Wakai, S, Yamakawa, K, Manaka, S & Takakura, K (1982). Spontaneous intracranial hemorrhage caused by brain tumour: its incidence and clinical significance. Neurosurgery, 10, 437-444. Zfilch, KJ (1968). Neuropathology of intracranial haemorrhage. Progress in Brain Research, 30, 151-165. Z/ilch, KJ (1975). Atlas of Gross Neurosurgical Pathology, pp. 113 135. Springer-Verlag, New York.
