269
ClinicalNeurology and Neurosurgery,94 (1992) 269-274 0 1992 Elsevier Science Publishers B.V. All rights reserved 0303-8467/92/$05.00
CLINEU 00211
Case report
Meningioma associated with subdural haematoma: report of two cases and review of the literature C. Chaskis”, C. Raftopoulos”, J. Notermana, J. Flament-Durandb
and J. Brotchi”
Departments of “Neurosurgery and bNeuropathology, Universitk Libre de Bruxelles, Brussels, Belgium (Received 14 October, 1991) (Revised, received 27 May, 1992) (Accepted 2 June, 1992)
Key words:
Meningioma; Subdural haematoma; Intracranial neoplasm
Summary
Subdural haematoma (SDH) caused by meningioma is infrequent. 18 cases are described in the literature. We report 2 new cases. Intratumoural bleeding is a frequent feature of this uncommon association.
Case reports
Intracranial haemorrhage caused by neoplasms is mostly met with brain metastases of malignant melanoma, bronchogenic carcinoma, choriocarcinoma and hypernephroma [l-8], or with oligodendrogliomas and glioblastomas [1,4]. It is unusual in benign tumours [9111. No case is described in large series of meningiomas [ 12,131. However, some anecdotal reports are available [2,9,1427]. Meningioma is most commonly associated with subarachnoid haemorrhage [1,9,21-25,28-301. SDH or intratumoural haematomas (ITH) are reported less frequently [ 1,2,10,11,14-26,3 11. Discovery of focal hemosiderin staining in some cases, or chronic subdural collection as in our first case study, suggests that small intratumoural bleedings may be overlooked because of absence or slightness of the symptoms.
Correspondence to: Cristo Chaskis, MD, Department of Neurosurgery, Erasmus Hospital, Universite Libre de Bruxelles, 808 route de Lennick, B-1070 Brussels, Belgium. Tel.: (322) 5553768; Fax: (322) 555-3755.
Case 1
A 59-year-old woman slumped into her armchair a few hours before admission. She was comatous presenting bilateral flexion of the upper limbs with extensor plantar reflexes in response to painful stimuli. There was a stiff dilated left pupil. The CT scan showed a left-sided subdural haematoma with a huge mass effect associated with a left frontal heterogenous intracerebral lesion (Fig. 1). She was operated upon without delay. At surgery, a chronic subdural haematoma with signs of recent bleeding was evacuated, and a meningiomatous tumour was discovered in the left frontal area, which proved to be the source of haemorrhage by the numerous fresh blood clots around and inside it. The tumour and its dural attachment were removed and a dural plasty graft was performed. Histological examination revealed elongated cells with small regular oval nuclei and a weavy arrangement, well stained by Masson’s trichrome (Fig. 2). Immunohistochemical staining against GFAP was negative. Numerous large blood vessels with thin endothelial lining were present in the tumour, which also contained
270 t Fig. I. Cerebral CT scan showing a left-sided chronic subdural haematoma causing a mass-effect (arrowheads) associated with an hyperdense lesion corresponding to haemorrhagic meningioma (arrow).
hemosiderin
deposits.
angioblastic fication. recovery.
The
meningioma~
The patient
histological
according
made an uneventful
She was intellectually
left brachial
diagnosis
predominant
unimpaired
hemiparesis
ral ptosis. The left pupil remained
was
to the WHO classipost-operative with a mild
and a left palpeb-
dilated
but reacted
light. She was discharged on the 12th post-operative She had fully recovered 2 months later.
to
day.
Cuse .? A 62-year-old man, known as having a right frontal meningioma, was admitted I week before the planned date for surgery because of progressive impairment of consciousness. The tumour had been discovered 3 months earlier on CT scan performed owing to progressive intellectual
Fig. 2. Numerous thin-walled vessels (arrows) in angioblastic-type
meningioma.
impairment
(Fig. 3a). On admission.
the
271
Fig. 3. a: CT scan showing right frontal meningioma 3 months before admission. b: meningioma appears spontaneously on CT scan because of the intratumoural haemorrhage. A SDH is associated (arrows).
was drowsy and disoriented. Pupils were equal and reacted to light. Brisk tendon reflexes were present with extensor plantar reflexes. The patient also had marked ischemic cardiac insufficiency and a chronic obstructive lung disease. A few hours after admission, the patient’s condition deteriorated. He was comatous with flexion withdrawal and eye opening to painful stimuli. Intubation was necessary. The CT scan revealed a rightsided subdural haematoma associated with a large intratumoural haemorrhage (Fig. 3b). At surgery, a large frontal meningioma was completely removed after evacuation of the subdural haematoma. Histological analysis revealed a syncitial meningioma with fresh intratumoural bleeding. The post-operative course was poor. His cardiopulmonary status deteriorated during the early post-operative period. He remained in coma for 2 weeks. A slight improvement was noted at the beginning of the 3rd week. The patient died on the 27th post-operative day. Necropsy revealed no signs of intracranial rebleeding.
hyperdense
patient
Meningioma associated with SDH is rare. A review of the literature yielded 18 cases. We report 2 new patients (Table 1). In this review, SDH was associated with other haemorrhage localisation in 12 out of 20 cases. ITH was present in 6 cases [20-231. The age range in the present series was 36-77, with a mean age of 60. There was a slight female predominance (11 women and 7 men, ratio of 1.6:1). The age and the sex were not reported in 2 cases [17,24]. Onset of symptoms was frequently sudden. Mortality was high (50%). Surgery was performed in 13 cases. Five of 13 patients had a full post-operative neurological recovery and 3 of 13 retained neurological impairments. Post-operative neurological status was not specified in one case. Syncitial type meningioma was encountered most often. Angioblastic or malignant histological types were found in 37% of cases of the present series (Table l), suggesting an increased risk of tumour-associated bleed-
212 TABLE
1
CLINICAL Case No. 1 2 3 4 5 6 I 8 9 10 11 12 13 14 15 16 17 18 19 20 -
FEATURE
OF 20 PATIENTS
WITH MENINGIOMA
ASSOCIATED
Author
Sex
Age tyrsl
Type
Bingas [ 151 Cusick [26] Modesti 1 [16] Modesti 2 Modesti 3 Modesti 4 Wash [22] Yasargil [23] Skultety [21] Therkelsen [ 171
F F M F F M F F M ns. n.s. M M F M F F F F M
65 41
SD SD SD SD SD SD SD SD SD
Russel [24] Sakai [25] Araki [ 141 Scott 1 [2] Scott 2 Wang [19] Tokugawa [ 181 Jones [20] Case 1 Case 2
59 49 72 69 77 50 58 n.s. n.s. 36 65 77 36 62 61 76 59 62
SD SD SD SD SD SD SD SD SD SD SD
Lot
IC SA IC SA IC SA SA IT IT SA IC IT SA IC 1C
IT 1T IT
cvx skb skb cvx cvx cvx Pfo skb ns ns skb cvx cvx
skb cvx cvx skb cvx cvx
WITH SUBDURAL
HAEMATOMA
Hist.
Surgery
Outcome
syn ns
yes no
norm
syn syn ang syn
yes yes yes yes yes yes yes no no
syn trs fib ns ns syn ns syn syn ns trs syn ang syn
yes no no no yes yes no yes yes
dead norm morb dead norm dead morb ns ns ns dead alive dead dead norm morb dead norm dead
ns.: not specified; SD: subdural; IC: intracerebral; IT: intratumoural; SA: subarachnoid; lot: localisation of the haemorrhage; cvx: convexity; skb: skull base; pfo: posterior fossa; hist: histology; syn: syncitial: ang: angioblastic: trs: transitional; fib:fibrous; norm: normal neurological status; morb: presence of neurological impairments.
ing in these histological subtypes. By comparison, in the series of 1197 surgically verified intracranial and intraspinal meningiomas reported by Jellinger and Slowik [32]. only 5.2% of angioblastic type and 1.2% of malignant type were observed. The site of the meningioma did not seem to influence the occurrence of haemorrhage. Modesti [16] reported 2 cases occurring in patients presenting essential hypertension but without associated intracerebral haemorrhage. No other patient with a history of significant hypertension was found. Blood dyscrasia or anticoagulant therapy was not reported in any patient. Trauma to the head is considered as playing no part in the production of a haemorrhage into a tumour [3]. However, head injury is described as a precipitating factor in one case [22]. Askenazy and Behmoaram [33] hypothesized that blood vessels supplying a meningioma undergo compensatory enlargement with parietal weakening and so enhance the potential for tumour associated haemorrhage. Stretching of subdural bridging veins by expansion of the meningioma may make them more susceptible to rupture from minor trauma [1,16,19,31]. The
vascular network, which can be considered as the source of bleeding, is the dominant feature of the angioblastic meningioma [34]. On the other hand, more than one tissue pattern can exist in the same tumour [24], and foci of abnormal blood vessels have been already reported in a number of non-angioblastic meningiomas with associated haemorrhage [9,10,16,35,36]. In addition, cerebral edema and venous obstruction which are commonly associated with meningiomas can cause infarction and subsequent haemorrhage [37,38]. The frequent association of SDH with intratumoural bleeding in the present review suggests a cause-effect relationship [ 16,18,20,21,233 251. Our hypothesis is that the pathological mechanism most likely is a primary haemorrhage in foci of abnormal vessels at the periphery or centre of the tumour, followed by rupture of the resulting haematoma into the subdural space. The same hypothesis could explain the occurrence of ‘intracerebral haematoma’ when haemorrhage occurs in a pia mater-eroding meningioma. The factor initializing this mechanism remains however undefined.
213 In conclusion,
meningioma
with SDH. The clinical only effective treatment neous evacuation
feature
is exceptionally is frequently
is tumour
of subdural
removal
associated sudden.
The
with simuita-
haematoma.
References 1 Mandybur, T.I. (1977) Intracranial hemorrhage caused by metastatic tumors. Neurology, 27: 650-655. 2 Scott, M. (1975) Spontaneous intracerebral hematoma caused by cerebral neoplasms, Report of eight verified cases. J. Neurosurg., 42: 3388342. 3 Globus, J.H. and Sapirstein, M. (1942) Massive hemorrhage into brain tumors. JAMA, 120: 348-352. 4 Ztilch, K.J. (1968) Neuropathology of intracranial hemorrhage. Prog. Brain Res., 30: 151-165. 5 Browder, J. (1943) A resume of the principal diagnostic features of subdural hematoma. Bull. N.Y. Acad. Med., 19: 168-176. 6 Strang, R.R. and Ljungdahl, T.I. (1962) Carcinoma of the lung with a cerebral metastasis presenting as subarachnoid hemorrhage. Med. J. Aust., 1: 90-91. 7 Garin, C., Plauchu, M. and Masson, P. (1932) Naevocarcinome de la joue avec metastases cerebrales se traduisant par un tableau neurologique a allure paroxystique. Lyon Med. 149: 803-807. 8 Vaugham, H.G. and Howard, R.G. (1962) Intracranial hemorrhage due to metastatic chorioepithelioma. Neurology, 1962; 12: 771-777. 9 Goran, A., Ciminello, V. and Fischer, R.G. (1965) Hemorrhage into meningiomas, Arch. Neurol., 13: 65-69. 10 Kholi, CM. and Crouch, R.L. (1984) Meningioma with Intracerebral hematoma, Neurosurgery, 15: 237-240. 11 Lazaro, R.P., Messer, H.D. and Brinker, R.A. (1981) Intracranial hemorrhage associated with meningioma, Neurosurgery, 8: 96-101. 12 Cushing, H. and Eisenhardt, L. (1938) Meningiomas, Their Classification, Regional Behavior, Life History, and Surgical End Results, Charles C. Thomas, Springfield, IL. 13 Hoessly, G.F. and Olivecrona, H. (1955) Report on 280 cases of verified parasagittal meningiomas. J. Neurosurg., 12: 614626. 14 Araki, C. (1974) Pathology of chronic subdural hematoma and hydroma. In: Sano, K. et al. (Eds.), Recent Progress in Neurological Surgery, New York, American Elsevier Publishing, Excerpta Medica, Amsterdam, 14-17. 15 Bingas, B. and Meese, M. (1966) Subdurales Hamatom seltener Etiologie (Fallmitteilung). Nervenarzt, 37: 175-177. 16 Modesti, L.M., Binet, E.F. and Collins, G.H. (1976) Meningiomas causing spontaneous intracranial hematomas, J. Neurosurg., 45: 437441. 17 Therkelsen, J. (1963) The diagnostic value of cerebral angiography in patients with apoplectic symptoms. Acta Psychiatr. Stand., (Suppl. 150) 36: 129-132.
18 Tokugawa, T., Kuboyama, M., Kojo, N., Mitsuo, H., Shigemori, M. and Kuramoto, S. (1988) A case of acute subdural hematoma associated with convexity meningioma, Noshinkeigeka, 16: 1389-1393. C.E., O’Reilly, G.V. and 19 Wang, A.-M., Chinwuba, Kleefield, J. (1985) Subdural hematoma in patients with brain tumor: CT evaluation. J. Comp. Ass. Tomogr., 9: 511-513. 20 Jones, N.R. and Blumbergs, P.C. (1989) Intracranial haemorrhage from meningiomas: a report of five cases, Br. J. Neurosurg., 6: 691-698. 21 Skultety, F.M. (1968) Meningioma simulating ruptured aneurysm: case report, J. Neurosurg., 28: 380-382. 22 Walsh, J.W., Winston, K.R. and Smith, T. (1977) Meningioma with subdural hematoma, Surg. Neurol., 8: 293-295. 23 Yasargil, M.G. and So, S.C. (1976) Cerebellopontine angle meningioma presenting as subarachnoid haemorrhage, Surg. Neurol., 6: 3-6. 24 Russel, D.S. and Rubinstein, L.J. (1977) Pathology of tumours of the nervous system, Williams and Wilkins, Baltimore, MD, p. 72. 25 Sakai, N., Ando, T., Yamada, H., Ikeda, T., Shimokawa, K. (1981) Meningioma associated with subdural hematoma Report of case and review of 15 reported cases, Neurol. Med. Chir. (Tokyo), 21: 329-336. 26 Cusick, J.F. and Baily, O.T. (1972) Association of ossified subdural hematomas and a meningioma. Case report, J. Neurosurg., 37: 731-714. 27 Mutlu, N., Berry, R.G. and Alpers, B.J. (1963) Massive cerebral hemorrhage. Arch. Neurol., 8: 644661. Blutung. 28 Yasargil, M.G. (1969) Die subarachnoidale Schweiz. Med. Wochenschr., 99: 162991632. 29 Smith, R.V., Stein, P.S. and MacCarty, C.S. (1975) Subarachnoid hemorrhage due to lateral ventricular meningiomas. Surg. Neurol., 4: 241-243. 30 Rosenberg, G.A., Herz, D.A., Leeds, N. and Strully, K. (1975) Meckel’s cave meningiomas with subarachnoid hemorrhage. Surg. Neurol., 4: 241-243. 31 Helle, T.L. and Conley, F.K. (1980) Haemorrhage associated with meningioma: a case report and review of the literature, J.N.N.P., 43: 725-729. 32 Jellinger, K. and Slowik, F. (1975) Histological subtypes and prognostic problem in meningiomas. J. Neurol., 208: 279-298. 33 Askenazy, H.M. and Behmoaram, A.D. (1960) Subarachnoid hemorrhage in meningiomas of the lateral ventricle. Neurology, 10: 484489. 34 Nakao, S., Sato, S., Ban, S., Inutsuka, N., Yamamoto, T. and Ogata, M. (1977) Massive intracerebral hemorrhage caused by angioblastic meningioma. Surg. Neurol., 7: 245248. 35 Fukumitsu, T., Yoshida, Y. and Yamashita, J. (1973) Massive intracerebral haemorrhage due to parasagittal meningioma. Brain Nerve (Tokyo), 25: 911-914.
274 36 Budny, J.L., Glasauer, F.E. and Sil, R. (1977) Rapid recurrence of meningioma causing intracerebral haemorrhage. Surg. Neurol., 8: 323-325. 37 El-Banhawy, A. and Walter, W. (1962) Meningioma with acute onset. Acta Neurochir. (Wien), 10: 194-206.
38 Gruszkiewicz, J., Doron, Y., Gellei, B. and Peyer, E. (1969) Massive intracerebral bleeding due to supratentorial meningioma. Neurochirurgia (Stuttg.), 12: 107-I 11.
ClinicalNeurology and Neurosurgery,94 (1992) 269-274 0 1992 Elsevier Science Publishers B.V. All rights reserved 0303-8467/92/$05.00
CLINEU 00211
Case report
Meningioma associated with subdural haematoma: report of two cases and review of the literature C. Chaskis”, C. Raftopoulos”, J. Notermana, J. Flament-Durandb
and J. Brotchi”
Departments of “Neurosurgery and bNeuropathology, Universitk Libre de Bruxelles, Brussels, Belgium (Received 14 October, 1991) (Revised, received 27 May, 1992) (Accepted 2 June, 1992)
Key words:
Meningioma; Subdural haematoma; Intracranial neoplasm
Summary
Subdural haematoma (SDH) caused by meningioma is infrequent. 18 cases are described in the literature. We report 2 new cases. Intratumoural bleeding is a frequent feature of this uncommon association.
Case reports
Intracranial haemorrhage caused by neoplasms is mostly met with brain metastases of malignant melanoma, bronchogenic carcinoma, choriocarcinoma and hypernephroma [l-8], or with oligodendrogliomas and glioblastomas [1,4]. It is unusual in benign tumours [9111. No case is described in large series of meningiomas [ 12,131. However, some anecdotal reports are available [2,9,1427]. Meningioma is most commonly associated with subarachnoid haemorrhage [1,9,21-25,28-301. SDH or intratumoural haematomas (ITH) are reported less frequently [ 1,2,10,11,14-26,3 11. Discovery of focal hemosiderin staining in some cases, or chronic subdural collection as in our first case study, suggests that small intratumoural bleedings may be overlooked because of absence or slightness of the symptoms.
Correspondence to: Cristo Chaskis, MD, Department of Neurosurgery, Erasmus Hospital, Universite Libre de Bruxelles, 808 route de Lennick, B-1070 Brussels, Belgium. Tel.: (322) 5553768; Fax: (322) 555-3755.
Case 1
A 59-year-old woman slumped into her armchair a few hours before admission. She was comatous presenting bilateral flexion of the upper limbs with extensor plantar reflexes in response to painful stimuli. There was a stiff dilated left pupil. The CT scan showed a left-sided subdural haematoma with a huge mass effect associated with a left frontal heterogenous intracerebral lesion (Fig. 1). She was operated upon without delay. At surgery, a chronic subdural haematoma with signs of recent bleeding was evacuated, and a meningiomatous tumour was discovered in the left frontal area, which proved to be the source of haemorrhage by the numerous fresh blood clots around and inside it. The tumour and its dural attachment were removed and a dural plasty graft was performed. Histological examination revealed elongated cells with small regular oval nuclei and a weavy arrangement, well stained by Masson’s trichrome (Fig. 2). Immunohistochemical staining against GFAP was negative. Numerous large blood vessels with thin endothelial lining were present in the tumour, which also contained
270 t Fig. I. Cerebral CT scan showing a left-sided chronic subdural haematoma causing a mass-effect (arrowheads) associated with an hyperdense lesion corresponding to haemorrhagic meningioma (arrow).
hemosiderin
deposits.
angioblastic fication. recovery.
The
meningioma~
The patient
histological
according
made an uneventful
She was intellectually
left brachial
diagnosis
predominant
unimpaired
hemiparesis
ral ptosis. The left pupil remained
was
to the WHO classipost-operative with a mild
and a left palpeb-
dilated
but reacted
light. She was discharged on the 12th post-operative She had fully recovered 2 months later.
to
day.
Cuse .? A 62-year-old man, known as having a right frontal meningioma, was admitted I week before the planned date for surgery because of progressive impairment of consciousness. The tumour had been discovered 3 months earlier on CT scan performed owing to progressive intellectual
Fig. 2. Numerous thin-walled vessels (arrows) in angioblastic-type
meningioma.
impairment
(Fig. 3a). On admission.
the
271
Fig. 3. a: CT scan showing right frontal meningioma 3 months before admission. b: meningioma appears spontaneously on CT scan because of the intratumoural haemorrhage. A SDH is associated (arrows).
was drowsy and disoriented. Pupils were equal and reacted to light. Brisk tendon reflexes were present with extensor plantar reflexes. The patient also had marked ischemic cardiac insufficiency and a chronic obstructive lung disease. A few hours after admission, the patient’s condition deteriorated. He was comatous with flexion withdrawal and eye opening to painful stimuli. Intubation was necessary. The CT scan revealed a rightsided subdural haematoma associated with a large intratumoural haemorrhage (Fig. 3b). At surgery, a large frontal meningioma was completely removed after evacuation of the subdural haematoma. Histological analysis revealed a syncitial meningioma with fresh intratumoural bleeding. The post-operative course was poor. His cardiopulmonary status deteriorated during the early post-operative period. He remained in coma for 2 weeks. A slight improvement was noted at the beginning of the 3rd week. The patient died on the 27th post-operative day. Necropsy revealed no signs of intracranial rebleeding.
hyperdense
patient
Meningioma associated with SDH is rare. A review of the literature yielded 18 cases. We report 2 new patients (Table 1). In this review, SDH was associated with other haemorrhage localisation in 12 out of 20 cases. ITH was present in 6 cases [20-231. The age range in the present series was 36-77, with a mean age of 60. There was a slight female predominance (11 women and 7 men, ratio of 1.6:1). The age and the sex were not reported in 2 cases [17,24]. Onset of symptoms was frequently sudden. Mortality was high (50%). Surgery was performed in 13 cases. Five of 13 patients had a full post-operative neurological recovery and 3 of 13 retained neurological impairments. Post-operative neurological status was not specified in one case. Syncitial type meningioma was encountered most often. Angioblastic or malignant histological types were found in 37% of cases of the present series (Table l), suggesting an increased risk of tumour-associated bleed-
212 TABLE
1
CLINICAL Case No. 1 2 3 4 5 6 I 8 9 10 11 12 13 14 15 16 17 18 19 20 -
FEATURE
OF 20 PATIENTS
WITH MENINGIOMA
ASSOCIATED
Author
Sex
Age tyrsl
Type
Bingas [ 151 Cusick [26] Modesti 1 [16] Modesti 2 Modesti 3 Modesti 4 Wash [22] Yasargil [23] Skultety [21] Therkelsen [ 171
F F M F F M F F M ns. n.s. M M F M F F F F M
65 41
SD SD SD SD SD SD SD SD SD
Russel [24] Sakai [25] Araki [ 141 Scott 1 [2] Scott 2 Wang [19] Tokugawa [ 181 Jones [20] Case 1 Case 2
59 49 72 69 77 50 58 n.s. n.s. 36 65 77 36 62 61 76 59 62
SD SD SD SD SD SD SD SD SD SD SD
Lot
IC SA IC SA IC SA SA IT IT SA IC IT SA IC 1C
IT 1T IT
cvx skb skb cvx cvx cvx Pfo skb ns ns skb cvx cvx
skb cvx cvx skb cvx cvx
WITH SUBDURAL
HAEMATOMA
Hist.
Surgery
Outcome
syn ns
yes no
norm
syn syn ang syn
yes yes yes yes yes yes yes no no
syn trs fib ns ns syn ns syn syn ns trs syn ang syn
yes no no no yes yes no yes yes
dead norm morb dead norm dead morb ns ns ns dead alive dead dead norm morb dead norm dead
ns.: not specified; SD: subdural; IC: intracerebral; IT: intratumoural; SA: subarachnoid; lot: localisation of the haemorrhage; cvx: convexity; skb: skull base; pfo: posterior fossa; hist: histology; syn: syncitial: ang: angioblastic: trs: transitional; fib:fibrous; norm: normal neurological status; morb: presence of neurological impairments.
ing in these histological subtypes. By comparison, in the series of 1197 surgically verified intracranial and intraspinal meningiomas reported by Jellinger and Slowik [32]. only 5.2% of angioblastic type and 1.2% of malignant type were observed. The site of the meningioma did not seem to influence the occurrence of haemorrhage. Modesti [16] reported 2 cases occurring in patients presenting essential hypertension but without associated intracerebral haemorrhage. No other patient with a history of significant hypertension was found. Blood dyscrasia or anticoagulant therapy was not reported in any patient. Trauma to the head is considered as playing no part in the production of a haemorrhage into a tumour [3]. However, head injury is described as a precipitating factor in one case [22]. Askenazy and Behmoaram [33] hypothesized that blood vessels supplying a meningioma undergo compensatory enlargement with parietal weakening and so enhance the potential for tumour associated haemorrhage. Stretching of subdural bridging veins by expansion of the meningioma may make them more susceptible to rupture from minor trauma [1,16,19,31]. The
vascular network, which can be considered as the source of bleeding, is the dominant feature of the angioblastic meningioma [34]. On the other hand, more than one tissue pattern can exist in the same tumour [24], and foci of abnormal blood vessels have been already reported in a number of non-angioblastic meningiomas with associated haemorrhage [9,10,16,35,36]. In addition, cerebral edema and venous obstruction which are commonly associated with meningiomas can cause infarction and subsequent haemorrhage [37,38]. The frequent association of SDH with intratumoural bleeding in the present review suggests a cause-effect relationship [ 16,18,20,21,233 251. Our hypothesis is that the pathological mechanism most likely is a primary haemorrhage in foci of abnormal vessels at the periphery or centre of the tumour, followed by rupture of the resulting haematoma into the subdural space. The same hypothesis could explain the occurrence of ‘intracerebral haematoma’ when haemorrhage occurs in a pia mater-eroding meningioma. The factor initializing this mechanism remains however undefined.
213 In conclusion,
meningioma
with SDH. The clinical only effective treatment neous evacuation
feature
is exceptionally is frequently
is tumour
of subdural
removal
associated sudden.
The
with simuita-
haematoma.
References 1 Mandybur, T.I. (1977) Intracranial hemorrhage caused by metastatic tumors. Neurology, 27: 650-655. 2 Scott, M. (1975) Spontaneous intracerebral hematoma caused by cerebral neoplasms, Report of eight verified cases. J. Neurosurg., 42: 3388342. 3 Globus, J.H. and Sapirstein, M. (1942) Massive hemorrhage into brain tumors. JAMA, 120: 348-352. 4 Ztilch, K.J. (1968) Neuropathology of intracranial hemorrhage. Prog. Brain Res., 30: 151-165. 5 Browder, J. (1943) A resume of the principal diagnostic features of subdural hematoma. Bull. N.Y. Acad. Med., 19: 168-176. 6 Strang, R.R. and Ljungdahl, T.I. (1962) Carcinoma of the lung with a cerebral metastasis presenting as subarachnoid hemorrhage. Med. J. Aust., 1: 90-91. 7 Garin, C., Plauchu, M. and Masson, P. (1932) Naevocarcinome de la joue avec metastases cerebrales se traduisant par un tableau neurologique a allure paroxystique. Lyon Med. 149: 803-807. 8 Vaugham, H.G. and Howard, R.G. (1962) Intracranial hemorrhage due to metastatic chorioepithelioma. Neurology, 1962; 12: 771-777. 9 Goran, A., Ciminello, V. and Fischer, R.G. (1965) Hemorrhage into meningiomas, Arch. Neurol., 13: 65-69. 10 Kholi, CM. and Crouch, R.L. (1984) Meningioma with Intracerebral hematoma, Neurosurgery, 15: 237-240. 11 Lazaro, R.P., Messer, H.D. and Brinker, R.A. (1981) Intracranial hemorrhage associated with meningioma, Neurosurgery, 8: 96-101. 12 Cushing, H. and Eisenhardt, L. (1938) Meningiomas, Their Classification, Regional Behavior, Life History, and Surgical End Results, Charles C. Thomas, Springfield, IL. 13 Hoessly, G.F. and Olivecrona, H. (1955) Report on 280 cases of verified parasagittal meningiomas. J. Neurosurg., 12: 614626. 14 Araki, C. (1974) Pathology of chronic subdural hematoma and hydroma. In: Sano, K. et al. (Eds.), Recent Progress in Neurological Surgery, New York, American Elsevier Publishing, Excerpta Medica, Amsterdam, 14-17. 15 Bingas, B. and Meese, M. (1966) Subdurales Hamatom seltener Etiologie (Fallmitteilung). Nervenarzt, 37: 175-177. 16 Modesti, L.M., Binet, E.F. and Collins, G.H. (1976) Meningiomas causing spontaneous intracranial hematomas, J. Neurosurg., 45: 437441. 17 Therkelsen, J. (1963) The diagnostic value of cerebral angiography in patients with apoplectic symptoms. Acta Psychiatr. Stand., (Suppl. 150) 36: 129-132.
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