You are on page 1of 4

Analytical Report

Meningioma with hemorrhagic onset: Two


case reports
ABSTRACT Mukul Vij,
Haemorrhage is a rare complication of meningiomas that can occur spontaneously, after embolization, stereotactic radiation and Sushila Jaiswal1,
perioperatively. Our first case was a 16 year old male, admitted with spastic quadriparesis, and retention of urine. Magnetic Resonance Awadhesh Kumar
Imaging (MRI) revealed anteriorly placed cervical intradural extramedullary mass. Patient underwent emergency surgery following Jaiswal2,
sudden worsening of neurological symptoms and intratumoral bleed was noted peroperatively. Tumor was labeled as angiomatous Sheo Kumar3,
meningioma with hemorrhage. The second case was of a 45 year female who presented with history of sudden onset weakness in Sanjay Behari2
right upper and lower limb followed by unconsciousness. MRI revealed heterogeneous lesion in left parasagittal area with intratumoral Department of
bleed. Left frontal craniotomy with tumour decompression was performed. Tumour was labelled as meningothelial meningioma with Pathology, Global
haemorrhage. Meningiomas with hemorrhagic onset remain rare, and pathophysiology is still incompletely understood. Prevention and Hospital and Health
outcome of intratumoral haemorrhage highly depends on early diagnosis and adequate treatment. City, Chennai,
Departments
of 1Pathology,
2
Neurosurgery and
KEY WORDS: Meningioma, intracranial, spinal, haemorrhage 3
Radio Diagnosis,
Sanjay Gandhi
Postgraduate Institute
INTRODUCTION of right upper limb, left upper, left lower and right of Medical Sciences,
Lucknow, India
lower limb was 2/5, 1/5, 3/5, and 4/5 respectively.
Intracranial tumours presenting with haemorrhage All deep tendon reflexes were exaggerated. Bilateral For correspondence:
constitute 1.5 to 5.4% of all tumours, more in planters were extensor. Sensory loss was 50-70% Dr. Mukul Vij,
malignant pathology such as metastatic tumours for all modalities below C5. The clinical possibility Department of
Pathology, Global
or gliomas. [1] Haemorrhage is a an unusual of neurofibroma or meningioma was kept. MRI
Hospital and Health
presentation of benign tumours except in cases of showed an anteriorly placed dural based lesion City, Chennai, India.
pituitary adenoma.[2] Meningiomas are benign, from C2 to C5 levels which was isointense lesion E-mail: mukul.vij.
slow-growing, and highly vascularised tumours; it on T1 and T2 weighted images with enhancement path@gmail.com
is extremely rare that their onset is apoplectiform, on contrast administration [Figure 1A-C]. The lesion
mimicking cerebrovascular incidents and thus was compressing the cord. Radiological impression
affecting diagnostic workup, treatment, and was anteriorly placed intradural extramedullary
outcome.[3] Intratumoral haemorrhage (ITH) can meningioma. After admission, he had sudden onset
occur spontaneously, after embolization, stereotactic worsening of neurological status with tachypnoea. He
radiation and perioperatively.[4,5] Extratumoural was taken for emergency surgery. Via posterior midline
haemorrhage, e.g. subdural, subarachnoid, approach, C2-C5 laminectomy was done. Gentle
intraparenchymal and intraventricular, have internal decompression was done and entire tumor was
also been described. [3,5] Haemorrhage is more removed in piece meal under operating microscope.
common in intracranial meningioma. Only four Tumor was pinkish, firm, partially suckable and
case reports of spinal meningioma, all with vascular [Figure 2]. Evidence of intratumoral bleed was
extratumoral subarachnoid haemorrhage present. Histopathology revealed a cellular tumor with
have been published.[6] We present two cases of prominent congested vessels and areas of hemorrhage
intratumoral bleed in meningioma including first [Figure 3]. The tumor cells were arranged in whorls
Access this article online
case report of spinal meningioma with ITH. with oval nuclei having pseudoinclusions and Website: www.cancerjournal.net
variable eosinophilic cytoplasm [Figure 4]. Tumour DOI: 10.4103/0973-1482.95198
CASE REPORTS was labeled as angiomatous meningioma with PMID: ***
hemorrhage. Patient expired following refractory Quick Response Code:

Case 1 ventricular fibrillation following hypokalemia on 3rd


The first case is of a 16 year old male admitted with post operative day.
spastic quadriparesis and numbness for 2 months,
straining at micturition for 1 month and retention Case 2
of urine 20 days back. On examination, motor power The second case was of 45 year female who

Journal of Cancer Research and Therapeutics - January-March 2012 - Volume 8 - Issue 1 145
Vij, et al.: Meningioma with hemorrhagic onset

Figure 1: Magnetic resonance imaging images of cervical spinal Figure 2: Intraoperative image showing spinal meningioma with areas
meningioma: T1 image showing isointense (arrow) lesion (A), T2 image of bleed
showing isointense (arrow) lesion (B), enhancement (arrow) following
contrast administration (C)

Figure 4: Meningioma displaying whorls of tumor cells with areas of


hemorrhage
Figure 3: Histopathological examination revealing a cellular tumor
of spinal meningioma with prominent congested vessels and areas
of hemorrhage of haemorrhage [Figure 6A]. Prominent foci of haemorrhage
along with bits of tumour tissue and glial tissue were noted
[Figure 6B]. Psammoma bodies were noted. No necrosis, mitosis
presented with history of sudden onset weakness in right upper and atypia were noted. Tumour was labelled meningothelial
and lower limb followed by unconsciousness for 4 days. On meningioma with organising haemorrhage. Postoperatively
examination, patient was conscious, however not verbalising. patient improved. She became conscious and was following
Pupils were reacting to light. Her Glasgow coma scale was E1, simple commands, however right hemiplegia persisted.
V1, M5. Her deep tendon reflexes were exaggerated on right
side. Computed tomography (CT) scan axial section showed DISCUSSION
hyperdense lesion in the left frontal parasagittal region [Figure
5A]. The lesion was heterogeneously enhancing on contrast. Most cases of haemorrhage associated with meningiomas
MRI axial section T1 image showed iso to hypointense lesion are extratumoural and subarachnoid, whereas subdural,
[Figure 5B], T2 image showing hypointesne lesion [Figure 5C] and intracerebral and ITH are reported less frequently.[3,5] Some
enhancement of lesion following contrast [Figure 5D]. She was reviews suggest that location of meningiomas are unrelated
undertaken for emergency surgery and left frontal craniotomy to the risk of bleeding. Other reports suggests that convexity
with tumour decompression was performed. Intraoperatively, meningioma tend to bleed more.[5] Bosnjak et al., on review of
the tumor was dirty grey soft, vascular with areas of bleed. literature identified that the mortality rate associated with
Histopathology revealed tumour cells as polygonal to oblong bleeding from meningiomas has significantly decreased since
and spindle shaped cells with oval nuclei, displaying nuclear the advent of CT scanning from 21.1 to 13.9%[3] They attributed
pseudoinclusions and moderate eosinophilic cytoplasm areas this decrease to earlier diagnosis, better surgical techniques,

146 Journal of Cancer Research and Therapeutics - January-March 2012 - Volume 8 - Issue 1
Vij, et al.: Meningioma with hemorrhagic onset

Figure 6: (A) Parasagital meningioma with foci of hemorrhage. (B)


islands of meningothelial cells with extensive hemorrhage

malformation or aneurysm may influence the hemodynamics


of the meningioma.
Figure 5: Radiological images of parasagittal meningioma: computed
tomography scan axial section showing hyperdense lesion in the left CONCLUSION
frontal parasagittal region (A), Magnetic resonance imaging axial
section T1 image showing iso to hypointense lesion (B), T2 image Meningiomas with hemorrhagic onset remain rare, and
showing hypointesne lesion (C) and enhancement of lesion following pathophysiology is still incompletely understood. Prevention
contrast (D) and outcome of intratumoral bleeding highly depend on early
diagnosis and adequate treatment. As spinal meningiomas
with haemorrhage are extremely rare, neurosurgeons should
and advancement in monitoring of patients. The proportions
be aware of this complication to reduce mortality.
of angiomatous (16%) and malignant (5.7%) hemorrhagic
variants of meningiomas were found to be higher in the study
REFERENCES
by Bosnjak et al., than in meningiomas overall.[3] Bruno et al.,
also suggested that angiomatous and malignant meningioma 1. Kondziolka D, Bernstein M, Resch L, Tator CH, Fleming JF,
tends to bleed more frequently.[5] Pitkethly et al., however Vanderlinden RG, et al. Significance of haemorrhage into brain
did not document any cases of bleeding in 81 patients with tumors: Clinicopathological study. J Neurosurg 1987;67:852-7.
angiomatous meningiomas.[7] 2. Wakai S, Fukushima T, Teramoto A, Sano K. Pituitary apoplexy: Its
incidence and clinical significance. J Neurosurg 1981;55:187-93.
3. Bosnjak R, Derham C, Popovic M, Ravnik J. Spontaneous intracranial
The mechanisms of spontaneous ITH in meningiomas are not meningioma bleeding: Clinicopathological features and outcome. J
yet understood, and several hypotheses have been proposed. Neurosurg 2005;103:473-84.
The most common hypothesis is the rupture of the abnormal 4. Kallmes DF, Evans AJ, Kaptain GJ, Mathis JM, Jensen ME, Jane JA, et al.
vasculature of tumor. This is based on findings such as weak Hemorrhagic complications in embolization of a meningioma: Case
thin-walled vessels on morphology or peritumoral vascular report and review of the literature. Neuroradiology 1997;39:877-80.
5. Bruno MC, Santangelo M, Panagiotopoulos K, Piscopo GA, Narciso
erosion by the tumor directly.[3] In our first case, multiple thin
N, Del Basso De Caro MI, et al. Bilateral chronic subdural hematoma
walled congested vessels were identified in histopathology. associated with meningioma: Case report and review of the literature.
Gruskiewicz et al., mentioned that necrosis of the tumor J Neurosurg Sci 2003;47:215-27.
can cause direct breakdown of the tumor vessels and 6. Morimoto T, Tokunaga H, Hoshida T, Tsunoda S, Sakaki T. Thoracic
subsequent haemorrhage.[8] Jones reported noted granulation meningioma presenting subarachnoid haemorrhage. Acta Neurochir
(Wien) 1996;138:886-7.
tissue around a central area of necrosis and hypothesized
7. Pitkethly DT, Hardman JM, Kempe LG, Earle KM. Angioblastic
that bleeding is derived from neovasculature.[9] Another meningiomas: Clinicopathologic study of 81 cases. J Neurosurg
hypothesis suggests that enlarged, tortuous feeding arteries 1970;32:539-44.
are less resistant to blood pressure changes and susceptible 8. Gruszkiewicz J, Doron Y, Gellei B, Peyser E. Massive intracerebral
to rupture. Rupture of the bridging veins secondary to their bleeding due to supratentorial meningioma. Neurochirurgia (Stuttg)
stretch is also a probable cause of haemorrhage. Kim et 1969;12:107-11.
9. Jones NR, Blumbergs PC. Intracranial haemorrhage from meningiomas:
al., identified infarction of the meningioma in cases with A report of five cases. Br J Neurosurg 1989;3:691-8.
haemorrhage.[10] Blood dyscrasias, anticoagulation therapy, 10. Kim DG, Park CK, Paek SH, Choe GY, Gwak HS, Yoo H, et al.
seizures, trauma, malignant transformation, have also been Meningiomas manifesting intracerebral haemorrhage: A possible
considered as possible causes of haemorrhage.[3] Minor head mechanism of haemorrhage. Acta Neurochir (Wien) 2000;142:165-8.
trauma may tear stretched subdural bridging veins overlying
slow-expanding meningiomas. This may be true in some Cite this article as: Vij M, Jaiswal S, Jaiswal AK, Kumar S, Behari S.
parasagittal or convexity meningiomas in which pure subdural Meningioma with hemorrhagic onset: Two case reports. J Can Res Ther
2012;8:145-7.
hemorrahge occur. In cases with pure intratumoral bleeding,
Source of Support: Nil, Conflict of Interest: None declared.
head injury is unlikely to be causative. Concomitant vascular

Journal of Cancer Research and Therapeutics - January-March 2012 - Volume 8 - Issue 1 147
Copyright of Journal of Cancer Research & Therapeutics is the property of Medknow Publications & Media
Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the
copyright holder's express written permission. However, users may print, download, or email articles for
individual use.