Meningioma

Associated

with

-Case

Subdural

Hematoma

Report

Shuji NIIKAWA, Masahiro KAWAGUCHI, Shingo SUGIMOTO, Tatsuaki HATTORI and Akio OHKUMA Department of Neurosurgery, Prefectural Gifu Hospital, Gifu

Abstract The case of a 49-year-old female with a left parietal convexity meningioma associated with an acute subdural hematoma is described. She was admitted because of sudden onset of severe headache accom panied by nausea and vomiting. She was also confused, and 6 hours after admission she developed lethargy, right hemiplegia, and left mydriasis with no pupillary reaction to light. Computed tomogra phy disclosed a round, extra-axial mass in the left parietal region; it was heterogeneously enhanced. Emergency craniotomy, performed after carotid angiography, revealed a tumor with a massive underlying subdural hematoma. The histological diagnosis was meningotheliomatous meningioma, and there were many meningothelial cells within the hematoma. Key words:

meningioma,

tumor

hemorrhage,

subdural

was heterogeneously enhanced, and there was no surrounding edema or ischemic change (Fig. 1). About 6 hours after admission, she suddenly became lethargic, with urinary incontinence. Neurological evaluation at this time disclosed right decorticate posture and complete mydriasis of the left pupil, with no reaction to light. Cerebral angiography showed a left parietal tumor blush (Fig. 2). The tumor was supplied by the superficial temporal, occipital, and middle menin geal arteries, and underlying the tumor was a large, avascular area. Under a diagnosis of atypical me ningioma of the left parietal convexity, emergency craniotomy was performed. The left parietal tumor was found to have penetrated the dura mater and destroyed the bone. Beneath the tumor was a massive, dark red, coagulated subdural hematoma, which was confined to the parietal region (Fig. 3). After removal of the tumor and hematoma, no cerebral hematoma was noted, although yellow pigmentation resembling hemosiderin was observed around the cortical veins. The histological diagnosis was meningotheliomat

Introduction Although malignant brain tumors, such as glio blastoma and metastatic tumors, are known to spon taneously hemorrhage, 11,16. 17)bleeding from benign intracranial tumors is rare. However, there have been reports of hemorrhage associated with meningi omas.2-6,8,10,12-15,17-19) The mechanism of hemorrhage from benign tumors, such as meningioma, is un known. We present a case, in which there appeared to have been a direct relationship between the me ningioma and the hemorrhage. Case

Report

A 49-year-old female was hospitalized with a chief complaint of sudden onset of headache, nausea, and vomiting. On admission, she was confused and exhibited right hemiparesis and mild anisocoria, although both pupils were reactive to light. A skull x-ray revealed osteolytic erosion in the left parietal region. Computed tomographic (CT) scans revealed a round mass in the left parietal region. The mass Received Author's

September present

12, 1989;

address:

Accepted

S. Niikawa, Japan.

M.D.,

January Department

hematoma

16, 1990 of Neurosurgery,

School

of Medicine,

Gifu

University,

Gifu,

Fig. 1

A,B: Pre (A) and postcontrast (B) CT scans obtained on admission, revealing a round, extra-axial mass in the left parietal region, with heterogeneous enhancement. C: Destruction of the parietal bone is seen adjacent to the round mass.

Fig. 2

Left

carotid

and middle

angiograms, meningeal

showing arteries,

a parietal beneath

tumor

which

ous meningioma containing multiple hemorrhagic foci and thin-walled vessels. Throughout the hema toma specimen there were meningioma cells and hemosiderin deposits (Fig. 4). The postoperative course was good, and she was discharged on the 24th postoperative day with only mild dysesthesia of the right hand. During subse quent outpatient visits, this symptom disappeared as well.

supplied

is a large,

by the superficial avascular

temporal,

occipital,

area.

Discussion In a large series of meningiomas reported in 1955, Hoessly and Olivecrona9) found none to have been associated with hemorrhage. However, there have been a number of reports of meningioma associated with subarachnoid hemorrhage (SAH) and intra cerebral and subdural hematoma.2-6,8,10,12-15,17-19) In the series reviewed by Kohli and Crouch,") most

Fig. 3

Illustration of the operative findings. The left parietal tumor (T) had penetrated the dura mater (arrowhead) and destroyed the overlying bone. A massive subdural hematoma lay beneath the tumor.

hemorrhages from meningiomas were extracerebral; SAH was the most common and subdural hematoma was rare. In most cases, histological examination

Fig. 4

disclosed meningotheliomatous tumors, the angio blastic type being rare, although the latter type of tumor would seem to be the more prone to bleed because of its high vascularity.1 ' Several authors,',', 10,12-14,17) in describing meningo theliomatous meningiomas with associated hemor rhage, have noted the presence of an angiomatous capillary network composed of thin-walled vessels, which may well predispose a tumor to hemorrhage. Other possible causes of hemorrhage include: erosion of the draining veins surrounding the meningioma or weakening of the walls of the feeding arteries2'14); other concomitant diseases, such as arteriosclerosis, hypertension, or blood dyscrasia, in which cases the hemorrhage is not related to the meningioma 14,16); tumor expansion within the subdural space, stretch ing the communicating veins and rendering them susceptible to rupture"); and a malignant process within the meningioma, causing hemorrhage secon darily to necrosis.') It is generally accepted that the cause of bleeding in a malignant tumor is weakness of the neoplastic vessels and the tendency of the mural endothelium to proliferate, leading to destruc tion and necrosis.7'11,14,19) Yasargil and So19) con

Photomicrographs of tumor specimens. A,B: The histological diagnosis was meningo theliomatous meningioma with multiple hemorrhagic foci (A) and thin-walled vessels (B) . C: The hematoma contained meningioma cells. D: A hematoma specimen containing a piece of tumor with thin-walled vessels. HE stain, x 100.

cluded that the factors responsible for hemorrhage in malignant tumors also exist, albeit very rarely, in some benign tumors. In our case, the meningioma contained thin-walled vessels and multiple foci of hemorrhage, and the hematoma harbored meningi oma cells throughout. In addition, there were many hemosiderin deposits in both the tumor and hema toma. These findings strongly indicate that the hemorrhage occurred within the meningioma itself, perhaps from the thin-walled intratumoral vessels; the presence of hemosiderin deposits suggests recur rent hemorrhage. Only one previous case report 18) mentions a finding of possible meningioma cells within the hematoma. If the bleeding were from draining veins, feeding arteries, or communicating veins or were caused by another underlying disease, the hematoma would not be expected to contain me ningioma cells. The most common symptoms of meningioma are severe headache, a change in the level of conscious ness and, to varying degrees, neurological deficits.") The symptoms are the same whether or not there is hemorrhage,") although they may be exacerbated by hemorrhage, ischemia, or edema.5°10) In our case, CT revealed only a heterogeneously enhanced mass, without ischemia or edema. Why the subdural hema toma was enhanced is unclear. Artmann et al.') noted similar enhancement in a case involving a ruptured aneurysm and speculated that minor bleeding during scanning had caused extravasation of the contrast material. This phenomenon can lead to a misdiag nosis; in our case, for example, the subdural hema toma was not suspected preoperatively. There is a greater likelihood of hemorrhage from a meningioma located in the parasagittal area, on the convexity or in the ventricle.") We feel that even when a relatively small meningioma, such as our pa tient had, is found in a region prone to hemorrhage and CT or angiography reveals abundant vascula ture, if the patient is relatively young and otherwise healthy, prophylactic surgery should be considered. Acknowledgment The authors wish to thank Professor Hiromu Yamada, Department of Neurosurgery, School of Medicine, Gifu University, for his valuable advice. References 1) Artmann H, Vonofakos D, Muller H, Grau H: Neuroradiologic and neuropathologic findings with growing giant intracranial aneurysm. Surg Neurol 21: 391-401, 1984

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Askenasy HM, Behmoaram AD: Subarachnoid hemorrhage in meningiomas of the lateral ventricle. Neurology (Minneap) 10: 484-489, 1960 Budny JL, Glasauer FE, Sil R: Rapid recurrence of meningioma causing intracerebral hemorrhage. Surg Neurol 8: 323-325, 1977 Cusick FJ, Bailey OT: Association of ossified sub dural hematomas and a meningioma. Case report. J Neurosurg 37: 731-734, 1972 El-Banhaway A, Walter W: Meningiomas with acute onset. Acta Neurochir (Wien) 10: 194-206, 1962 Everett BA, Kusske JA, Pribram HW: Anticoagu lants and intracerebral hemorrhage from an unsus pected meningioma. Surg Neurol 11: 233-235, 1979 Glass B, Abbott KH: Subarachnoid hemorrhage con sequent to intracranial tumors. Arch Neurol Psychiat 73: 369-379, 1955 Goran A, Ciminello VJ, Fisher RG: Hemorrhage i nto meningiomas. Arch Neurol (Chicago) 13: 65-69, 1965 Hoessly GF, Olivecrona H: Report on 280 cases of verified parasagittal meningiomas. J Neurosurg 12: 614-626, 1955 Kohli CM, Crouch RL: Meningioma with intracere bral hematoma. Neurosurgery 15: 237-240, 1984 Little JR, Dial B, Belanger G, Carpenter S: Brain hemorrhage from intracranial tumor. Stroke 10: 283 288, 1979 Modesti LM, Binet EF, Collins GH: Meningiomas causing spontaneous intracranial hematomas. J Neurosurg 45: 437-441, 1976 Nakao S, Sato S, Ban S, Inutsuka N, Yamamoto T, Ogata M: Massive intracerebral hemorrhage caused by angioblastic meningioma. Surg Neurol 7: 245 248, 1977 Pluchino F, Lodrini S, Savoiardo M: Subarachnoid haemorrhage and meningiomas. Report of two cases. Acta Neurochir (Wien) 68: 45-53, 1983 Sakai N, Ando T, Yamada H, Ikeda T, Shimokawa K: Meningioma associated with subdural hematoma. Report of a case and review of 15 reported cases. Neurol Med Chir (Tokyo) 21: 329-336, 1981 (in Japanese) Scott M: Spontaneous intracerebral hematoma caused by cerebral neoplasms. Report of eight veri fied cases. J Neurosurg 42: 338-342, 1975 Tokunaga T, Kuboyama M, Kojo N, Matsuo H, Shigemori M, Kuramoto S: A case of acute subdural hematoma associated with convexity meningioma. No Shinkei Geka 16: 1389-1393, 1988 (in Japanese) Walsh JW, Winston KR, Smith T: Meningioma with subdural hematoma. Surg Neurol 8: 293-295, 1977 Yasargil MG, So SC: Cerebellopontine angle me ningioma presenting as subarachnoid haemorrhage. Surg Neurol 6: 3-6, 1976

Address ment

reprint of

University,

requests Neurosurgery,

to:

S. Niikawa, School

40 Tsukasa-machi,

of Gifu

M.D.,

Depart

Medicine, 500, Japan.

Gifu

Meningioma associated with subdural hematoma--case report.

The case of a 49-year-old female with a left parietal convexity meningioma associated with an acute subdural hematoma is described. She was admitted b...
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