Meningioma with radiosurgery

Case contributed by A.Prof Frank Gaillard

Presentation

Headache

Patient Data

Age: 80 Years
Gender: Female
CT

No intra or extraaxial haemorrhage. There is a calcified extraaxial mass measuring 1.6 cm adjacent to the falx at the midline. There is a further extraaxial isodense mass measuring 1.4 cm adjacent to the anterior falx projecting towards the right. No mass effect. The parenchyma is normal. No hydrocephalus. Basal cisterns unremarkable. The imaged orbits, mastoid air cells and paranasal air cells are unremarkable.

Conclusion: Multiple incidental meningiomata.

MRI

MRI brain

Homogeneously enhancing extraaxial lesions abutting the falx in the paramedian right frontal and parietal lobes measure up to 1.6 cm each. A small component is seen penetrating through the falx to the other side. Both are T1 and FLAIR isointense with the mild diffusion restriction. The parietal lesion contains minor susceptibility. No significant mass effect or adjacent oedema. Ventricles, sulci cisterns are within age-appropriate limits. Mild supra and infratentorial small vessel ischaemic change.

Conclusion: Findings are most in keeping with two small parafalcine meningiomas.

MRI

MRI 1 year later

There has been significant increase in the size of right frontal parafalcine meningioma. The small component of the tumour protruding through the falx into the contralateral hemisphere has also marginally increased in size compared to the previous study. 

There has also been marginal increase in the size of the right parietal parafalcine meningioma.

There is no abnormal T2 FLAIR hyperintensity in the brain parenchyma adjacent to the meningiomata. Small ill-defined patchy foci of T2 and FLAIR hyperintensity in the periventricular and subcortical white matter reflects chronic small vessel ischaemic change. No other abnormality of the brain parenchyma is demonstrated.

The patient went on to have radiosurgery to the anterior meningioma, the one that had grown the most rapidly. Months later the patient developed increased headache and left sided weakness. 

MRI

MRI months later

The anterior frontal parafalcine meningioma has become heterogeneous with less enhancement and is surrounded by striking vasogenic oedema and enhancement in the adjacent parenchymal contrast enhancement. 

Case Discussion

This is a good example of the sometimes dramatic oedema that results from radiosurgery

Patient went on to have surgery.

Histology

MICROSCOPIC DESCRIPTION: The sections show a moderately cellular meningioma. The tumour forms whorls and fascicles. The tumour cells have ovoid nuclei with no nuclear pleomorphism. Mitoses are inconspicuous. There are large areas of necrosis. No brain parenchyma is included. No evidence of atypical or malignant meningioma is identified. About 20% of the tumour cells are progesterone receptor positive. The topoisomerase index is about 3%.

FINAL DIAGNOSIS: Meningioma (WHO Grade I).

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Case information

rID: 42516
Case created: 24th Jan 2016
Last edited: 17th Apr 2016
Inclusion in quiz mode: Excluded

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