Natoral bray oes ARATE Nstna rts of Hath |Asian Journal of Neurosurgery Asian J Newrosug, TO) 132734 ‘Multiple spinal and cranial meningiomas: A case report and review of literature 'S.K Jain |. Vijay Sundar, Vinod Sharma, Ravishankar S. Goel K.L. Prasanna Deparinet of Newesupery. SUS Kea Colege,Japu, Rash, inde [Addres for corrapondence! Or § Jan, 220, Hinat Naga, Gopapurs Mode, Tonk Rese, Jii-202 01, Rajasthan, nds E-al:shashinealyaton com ‘Ap asian Journal or Neurosurgery Abstract Though meninglonas are common neapiasmns of e nervous system, he occurrence of mulple meringionas in afereet neural comparinens rather are. We reper a Case of 62-year od female who presented wth spas paraparetsm both aver ims, and was found fo have mune homagenusy enhancing tn of orsokanesr Spine. Cranial magnete resonance imaging (VR) revealed mulipe biateral sipatentoal meningiomas She Underwent multe level laminectomy anata removal tna {mors afer whch poner mproved in bot over ims. Histopaology revealed peanmomatous meringoma. Onl around 19 cases of mullpio cranial and spinal meningiomas nave been reported, of mien only Wve cases have move tan one spinal meningioma. The mplcaion oe Iedence ot sich mulple meningiomas the same patent th relevanee io inestigallons and decision making ae dscussed along wh a bet evew of erate of cases wid mulpe spinal and canal meningiomas. Introduction [Meningiomas ae the most common primary non-gal brain turiors and comprise 13-19% of allpimay intacranial neoplasm [3] Spinal canal meningiomas account toabout 25% of al spinal cord tumors 2] Mutiple spinal meningiomas are rarer than mukiple cranial meningiomas [3] Multiple meningiomas occurring in ciferent ‘eurasial compartments are distinct are, wit any 19 well dacumented cases reported in world erature [4] ofthese, only sx cases had more than one spiral tor. ‘Occurence of such mutiple meningiomas of spinal and cranial cistbution in absence of neurofibramatosis is quite rare Case Report ‘A.62.year-old female presented with backache, pain radiating to both lower ims, and cfficuty in waking. On examination, she had grade 3 power ataljins in both lower lmbs and increased tone. She had no history of sezues, headache, or anyother symptom atinbulable o inacranal pathology. There were no mutiple Fypopigmented macules, neuroibromas, or other stigmata of neuolibromatas's. Magnetic resonance imaging (MR) of the dorsolumbar spine was performed [Fae || wach revealed four well defined, oval rradural exramecullary, hamogenausiy enhancing sold lesions at 7-8, D11-12, and at D121 levels causing core ‘compression at allevels, An intial dlagnosis of muiple thoracolumbar meningiomas was made, and he patient was subjected to a contrast enhanced MR ofthe brain. MRI ofthe bran revealed multiple extra axial, well defined, homogenously enhancing lesions inthe ight ronal endl parietal region [Escute 2]. A final ‘agnosis of multiple cranial and spinal meningiomas was made. The paient underwent mutipe evel laminectomy and complete removal ofall tumors far ‘dorsolumbar region Post operatively, the panents pawer Improved ard she was able to wak wih suppor afer 2 week. A cenrast eananced MRI ofthe spine showed ‘complete removal of tumors and decompression of cor [gu 3] Histopathology revealed psammomatous meningioma [Figure 4], Despite our detaled counseling, the patient and ter elaives steadfast refused surgery for nacranial tumors. Patient was discharged on artiepllepics and is under close folow-up. losers Figure 1. corrstemnced Mt spine showing matte wel ened emancing lesions ij arta Figure 2. conrstemance Ml ban showing mute enhancing sions in bah carb hemispheres M1 Figure 3. Pact sprains contac eohancad UR pine showing complete eal of mening arr Figure 4. Hisipatosgy shown psarmanious menirgjons Discussion ‘Muttple meningiomas are defined as a least two spatially separated meningiomas occuring a the same time, or more tan two meningiomas arising sequentially ftom two clearly distinc regions [5] “Tne incidence of multiple itracranal meringiomas in the post-CT era has been reparted io be between 5.4 and 8 9%. The maj of these are located ina hemicrarial distribution [6] Multiple spinal moningicmas are rarer than multiple cranial moringiomas. Mutiple meningiomas occuring in cifferont nouraxial ‘compartments are distinct rare, wit only six cases having mutiple spinal and maliple cranial meningiomas [Table 1], The premous oldest reported case was a 50- year-old male, hus making our case ihe oldest reported. Faw of he six cases were aged 35 years or less and allexcept one thal was a female =a ‘Table 1. Lis of epated cases f mule meningomas wih mate than ane spinal mening ‘The pathogenesis of multiple meningiomas can be explained in two ways, ether these tumors arse independently as evidenced bythe histological and cytogenetic differences between mutipe tumors from the same patent, ofa single transforming event occurs and the criginal clone of cels spreads throughout the meninges in the formation of muple, clonal related tumors [15] ‘The relationship between isolated mutiple meningiomas and neurcfibromatosis is ursetied ‘Meningiomas are found in about half the patients with Neuroibromatosis type 2 (NF2) and sporadic meningiomas often have Somabc mutations in the NF2 gone. NF2 Is ofen the undarying isoaso in young paople who present with meningioma, but aduts wth multslo moningiomas andne ether signs of NF2 aro usually not considered tobe at high nskfor NF2_[1] ofthe intracranial meningiomas, one percent are multiple, usualy in nevrofbromatosis. The most common locations are: Falx and parasagita, convexity, sphenoid, ‘and olfactory groove [Z| Inthe spinal canal, the preferred locaton of meningiomas is atthe thoracic level folewed by the Ceracal region, and aly, the kmnbar region a ‘The clinical feature is characterized by a motor det, varying rom a slg impaimentto paralysis, wih pyramidal iberation signs, sphincter disturbances and signs Coffunicular or radicular impairment. Ordinarily, the syripiomatology is resticted toa oat or 1s associated fo several sansiive and mator neurological rs [2] The radiological features are similar to isolated meningiomas. Well descrived featues ince well defined esta axial lesions that enhance uniformly on contrast ‘adminstation, enhancement ofthe dural atachment and ite or na periesional edema, Operative management of muticle meningiomas occupying both cranial and spinal compartments poses special problems, A decision is made regarding which lesion, or lesions shauld be removed intially Keeping in mind hat hstologcaly. each of hese tumors may be a diferent variant of meninglama. Smal ot asymptomatic tumors may be folowed-up wit seral maging “The majity of mutiple meningiomas (80-906) are benign and classified as World Heath Organization (WHO) grade 1 [5] Regarding the cases of spinal canal "muttple meningiomas, the psarmomatous type predominate. Usually, mile meningiomas are cicumscnbed and show slow growth and have a good post surgical ‘prognosis. On the oer hand, the meningiomas Pal occu in younger paienis might have an aggressive behavior and an unfavorable prognosis. Conclusion ‘Athough meningiomas are one of the most common tumors encounered in neurological practice, multiple meningiomas sill remain a rare enti. Afhough the Incidence of mubiple mening‘amas may not be suficieni to warrant a complete evaluation of the rain and spine inal cases where a solar maingioma is lagnosed, features that should alert the surgeon include early age of onset, female sex, mubiple spina tumors, and presence of neurfibromatosis. When silent ‘meningiomas are discovered in a neuraxaial compartment ferent from the one causing the symptoms careful decision making is needed taking into Consideration te presenting features, age, sx. uno olgy, asso diseases and patetsexpectaons fom supe Regardless oe evertual managemetdecsio, sich pallents must be kept under close fallow-up. Footnotes Source of Suppor i Confit of inert None dscaed Atces from Asian Journal of Neurosurgery ate provided here couttesy of Medknow Publications PMC Copyright tice ‘The atiessylate fom the PMC ate ae pleted by copyght vn though acess ies. Copyght it hld by the respective asta or publishes he provde these aces to PMC. User of PMC re responsi for empjng whe em nd condos Gained bythe copyright Woe User oul scumatha land capynght pretation spe ails PMC, ples an atc artane an cage lance stalaan that gor 2 sot ater ruce ar ederon fights. PIC coos na alow eromatedulkdonloaing fails that Rave sandard copy prtecion Soe the copigt nie on the PMC st, ht noi om ih goancislceoii fo uth deals and spec exceptions, References White, Smith C,NavooP, Cale, authors. Monngomas sma. Lancat. 2000963 16365645, Bute Roux FX, Natt. Pinay M, Soe G, Desi. Vader JF. sitar Iraspinal meningiomas: Review of 4 cases with cussion of or rognise, factors and moda therapatic ‘management Sug Heal 196 48458864. asa, Luesserhep autos, Schmid HH, edtor Mtpe Meningomes. eningiomas andthe sual maragemen 192 Phieelphia: WS Saundes Co, p THEN ‘Bhatoe HS, auto. Simulaneaus occurence of muligle mengorras in dflrent news campatments. Newlin 21C3 51 2684€ [Pied Spale A, Neve’ M, Ge Raut Muli shall ase meningiomas: Case reput. SuxgHewal 199951 2748680, [Pabhied) Domenicuc M, Sartor A, O9€™Onsals OM, Oni R Coto GP, Gael B,suthors Mientras menngiras. J Hewesug HES 70-S1664. [Pulled] oda JM, Banscosma JA, Peeztiguras A. Fra M.athrs. Siutanous muti inacranal and spl menngomas. Nowe (Sti) T8523 S2H€4. [Eat] ‘Stathosice Sorel, Sjatiowice A Bln E Adamo Dozynska . Wyberalsa Ditanewce M, Salers A. authors. lil primary cano-snal tumours m 2 13;yar-ldhmae vwthneuftromatos type 2 managem at suategy Cis Ney Spot 2011 27-1598 (Puna 40. Shukla SK, Tava A Shama V. Singh K autos. Coexsting canal end mile sna meringoma in aciéeport oa cas. J Newroancal. 20111021846 [Pus +1. Evans OG, Walon C King A. Wllace A, Baber ME, autor, Mule maringomay: Dfsretal mobement othe NE2 gene ia chidan and ada. Mad Genet, 2005250 (Euittoe) 12 Balachandran G, author A Gace ef Mile Meningoms. tome J Rail 2010; 11 Number 1 DOV 10 880/8beFigure 3. Post operasac Table 1. Ut of rp cases of mutps meningiomas wth mar than one spn mexingora Yesrreported | Author ‘Aec/eox | Gronilloeston Spinal location oor Sedzimiret al ‘alm Tuberculumselae Conical Dorsal Craniabnat resected ‘Spinal-psammomatous og Roda et a soln Suprasellar®Faeine®® Dosa Crasialand spinal- meningotheliomatous 2003 Bhatoe Hs asf MukiplesupraandinfaDorsat Cravial-transtional, meninootheia tertorat Spina-foroslarti, spice sows Seachowice-sencelT yf Mukiplesupraand infa Lumbosacral Crasial-psaramomatous erat tentoriat rmultisle Spinalmeringioms poss Shukla etal! gif Left trortoparital Dorsal Lumbar? Spinal-predaminantly meringotheiomatous poss Present case Golf Multiple bilateral owsah Lumbar! Spina psammamatous me font ference nue ners pertaes fn cael cola ndcas narbor of trond