Journal of Neuro-Oncology 29:229 238,1996.

© 1996KluwerAcademic Publishers. Printedin the Netherlands.

Radiology of meningiomas

Lawrence E. Ginsberg
The University of Texas M. D. Anderson Cancer Center, Department of Radiology, Houston, TX, USA

Key words: meningiomas, magnetic resonance imaging, computed tomography, atypical features

Abstract

Modern imaging plays an important role in the management of the patient with a meningioma. From initial
diagnosis to postoperative evaluation and follow-up studies, the radiologist must be aware of the various and
sometimes atypical imaging appearances of meningioma. This is often very satisfying since the imaging char-
acteristics of meningioma are usually, but not always, diagnostic. This manuscript will briefly review the his-
torical development of the imaging of meningioma and then describe the typical and atypical imaging appear-
ances of this very common intracranial tumor.

Historical background Basic modalities and imaging features

Since the turn of the century, tremendous advances
have been made in the field of diagnostic imaging,
such that the ability to detect and diagnose menin-
giomas has been considerably improved. The first
radiologic diagnosis of meningioma was made in
1902, only seven years after the discovery of Roent-
gen's ray [1, 2]. In the early 1920s, plain film findings
were first formally described for meningiomas. For
some time thereafter, the radiologic diagnosis of
meningioma required the detection of sclerosis, en-
larged vascular channels, calcification, bone de-
struction, or pneumosinus dilatans on plain films.
Dandy did considerable work with ventriculogra-
phy during the early part of this century, but he
could differentiate an intraaxial from an extraaxial
lesion only when bone changes were detected. In
1927, cerebral arteriography was first described,
and in 1947, Hodges first described the angiograph-
ic features of meningiomas [2]. Computed tomogra-
phy (CT) was introduced by Hounsfield in 1973, and
shortly thereafter, Lauterbur developed the imag-
ing technique now known as Magnetic Resonance
Imaging (MRI)[2].
The imaging modalities typically used today in the
work-up of meningiomas are angiography, CT, and
MRI.
Angiography
Angiography of a meningioma shows the arterial
supply, arterial displacement or encasement, collat-
eral patterns, and dural sinus integrity; in certain
cases, it is useful as a preembolization road map. A
meningioma is supplied by the vessels that normally
supply the meninges at that particular location; the
vessels are usually enlarged and hypertrophied. A
sunburst or radial pattern may be seen during the
arterial phase (Fig. 1). A prolonged homogeneous
vascular blush starts in the mid-to-late arterial
phase and extends into the late venous phase (Fig.
2).
Preoperative embolization is performed to facil-
itate surgical removal by decreasing the tumor vas-
cularity and, hence, reducing operative blood loss.
The likelihood of recurrence may be decreased by
producing necrosis at the site of the dural attach-
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Fig. 1. External carotid ar teriogram, lateral view, arterial phase, showing enlarged branch of the middle meningeal artery (arrows) feeding
a vertex meningioma. Notice the spokewheel or radial pattern of the arterial feeders (brackets). (Case courtesy of Dixon Moody, M.D.,
Winston-Salem, North Carolina).
ment [3]. Despite arguments by some researchers
that the procedure is firmly established, emboliza-
tion of meningiomas is often not requested by neu-
Fig. 2. Cerebral arteriogram, lateral view, venous phase, demon-
strating the homogeneous venous blush of a small tentorial me-
ningioma (arrowhead).
rosurgeons. The reasons may be that small and
moderate-sized lesions are easily removed without
much blood loss, personnel skilled in performing
embolizations are not always available, and lastly,
meningiomas in certain locations may not be ame-
nable to embolization because of the risk to normal
brain.
Computed tomography
On non-contrast CT, meningiomas are typically
sharply demarcated and are isodense (25%) or
slightly hyperdense (75%) to brain [4] (Fig. 3). A
broad-based dural relationship usually forms an ob-
tuse angle with the inner table of the skull. Calcifi-
cation may be present in up to 15-20% of cases and
can take different forms: chunky, rim-like, punctate
(Fig. 4), or diffuse. Edema is often present with me-
ningiomas. The amount of edema varies and has
few predictable correlates: large meningiomas may
have no edema, whereas small meningiomas can
have a huge amount of edema. Edema appears as
low density on CT (Fig. 3). Bone changes occur in

Fig. 3. 44-year-old woman with a right frontal meningioma.
(A) Noncontrast axial CT image showing edema related to this
meningioma (arrowheads). Anterior to the edema, the isodense
meningioma can barely be seen (asterisk).
(B) Postcontrast image, same level, shows the fairly dense, ho-
mogeneous enhancement typical of meningioma.
231
Fig. 4. Noncontrast axial CT image showing numerous punctate
and several more chunky calcifications in a right-sided cerebello-
pontine angle meningioma (arrowheads).
approximately 20 to 25% of meningiomas. Such
changes may take the form of mild blistering or hy-
perostosis, or they may be very flagrant or even de-
structive (Figs 5 and 6). Bone changes are best seen
with CT.
With intravenous contrast administration, homo-
geneous dense enhancement is generally the rule
(Fig. 3). Occasionally, the enhancement is only
modest, and if the tumor is densely calcified, no ap-
preciable enhancement may be detected.
Magnetic resonance imaging
On noncontrast Tl-weighted images, the typical
meningioma is isointense (60-65 %) or hypointense
(30-35%) relative to brain [4] (Fig. 7). On proton
density and T2-weighted images, approximately
50% of meningiomas remain isointense, 40% be-
come hyperintense (Fig. 7), and 10% become by-
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Fig. 5. Hyperostosing "en-plaque" sphenoid wing meningioma
in a 50-year-old man who presented with painless loss of visual
accuity.
(A) Axial CT image, "bone window" demonstrating gross
hyperostosis of the right greater sphenoldwing/lateral orbital
wall (arrows).
(B) Noncontrast CT, soft tissue window, same level shows the
soft tissue component of the tumor in the orbit (arrowheads).
The middle cranial fossa component is difficult to see without
contrast (arrow).
pointense relative to brain [4]. Heterogeneity is of-
ten seen on T2-weighted images (Fig. 7).
The relationship between T2 signal and histolog-
ic subtype is controversial. Although a high correla-
tion between T2 signal and histologic subtype has
been reported in one study [5], other studies have
found no correlation [6]. In practice, predicting tu-
Fig. 6. Large malignant central skull base meningioma in a 46-
year-old woman.
(A) Midline sagit tal noncontrast Tl-weighted MR image shows a
large mass filling the sphenoid sinus and replacing the clivus (as-
terisk). The sella turcica is enveloped by tumor and is very hard
to identify. There is extension into the posterior fossa and appar-
ent compression of the pons (arrow).
(B) Coronal postcontrast Tl-weighted MR image shows bright
contrast enhancement of the lesion. Note the large inward pro-
jection of tumor into the right middle cranial fossa (arrow), a sign
which has been associated with aggressive or "malignant" be-
havior. There is involvement of both cavernous sinuses and en-
casement of both cavernous carotid arteries (the black "flow-
voids" marked by arrowheads represent the patent arteries).
 233

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Fig. 7. Left-sided CP angle meningioma in a 67-year-old woman.

(A) Noncontrast axial Tl-weighted MR image shows the mass as
hypointense relative to brain (arrowhead). There is brainstem
compression. Note the hypointense CSF cleft at the posterior
margin of the lesion (arrow), which helps establish its extraaxiaI
location.
(B) Axial T2-weighted MR image showing the lesion to be heter-
ogeneously hyperintense.

mor subtype may be of little value since other fac-

tors (e.g., tumor size, location, and clinical status)
are ultimately more likely to determine the course
of treatment.
There is usually a sharp demarcation between the
tumor and brain, and the extra-axial nature of the
lesion is usually apparent due to displacement of
blood vessels, the presence of CSF clefts between
the lesion and brain (Fig. 7), or inward displace-
ment of the gray-white junction ("white matter
buckling"). Calcifications that are large and chunky
can usually be seen on MRI, whereas small punc-
rate or rimlike calcifications may not be discernible.
Calcium is typically hypointense on both T1-
weighted images (rarely hyperintense) and T2-
weighted images. T2 is more sensitive than T1 in the
detection of calcification. Bone changes that are
subtle may not be detected on MRI, but those that
are flagrant (e.g. bone destruction/invasion or gross
hyperostosis) can be seen. Bone changes are best
seen on Tl-weighted MR images as replacement of
the normally hyperintense marrow fat by lower, hy-
pointcnse signal representing either tumor within
the marrow space (Fig. 6) or simply dense hyperos-
totic bone. Edema is seen quite easily on MR imag-
es as hypointense on Tl-weighted images and hype-
rintense on T2-weighted images (Fig. 8).
With administration of Gadolinium-DTPA, the
vast majority of meningiomas will enhance brightly
and homogeneously (Figs 9 and 10). A "dural tail"
may be seen in association with meningiomas, and
is much better seen with MRI. The dural tail is an
area of thickened, enhancing dura that extends
away from the lesion (Fig. 9). It may represent a re-
action to the meningioma or an actual invasion of
the dura by tumor. Initially, the dural tail was
thought to be specific for meningioma, but subse-
quent studies have demonstrated them in a wide va-
234

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Fig. 8. Metastatic sarcoma to the dura in a 35-year-old female.

(A) Axial T2-weighted M R image demonstrates a heterogene-
ously hyperintense mass in the left parietooccipital region (ar-
rows). Note the striking resemblence to the lesion in Fig. 7B.
There is extensive edema anterior to the lesion (arrowheads),
which appears to be probably extraaxial.
(B) Coronal postcontrast Tl-weighted M R image shows bright
enhancement and extension across the falx into the right hemi-
sphere (arrow), a feature commonly seen in meningiomas. How-
ever, this patient had a known intraabdominal sarcoma and a
metastasis to the skull base. For these reasons (as well as her be-
ing somewhat young for a meningioma), the diagnosis of metas-
tasis was favored. Notice the flow void within the superior sagit-
tal sinus indicating patency (arrowhead).

riety of lesions, including superficial intraaxial ma-

lignancies and other nonmeningioma lesions such
as dural metastases and even acoustic neuromas [7].
Nevertheless, if a dural tail is detected, the most
likely diagnosis is meningioma.
Contrast-enhanced MR imaging is the single
most sensitive test in the detection of meningiomas
and is useful in detecting small lesions such as mul-
tiple meningiomas (and acoustic neuromas), which
may be seen in type II Neurofibromatosis (Fig. 10).
MRI is very useful for determining the integrity
of dural venous sinuses, which may be compressed
or thrombosed by a meningioma. In most cases, du-
ral patency can be assessed with routine images,
but, occasionally, more advanced techniques such
as MR Angiography (MRA) or, more specifically,
MR Venography (MRV), are necessary.

Atypical features and diagnostic difficulty

Meningiomas demonstrating all the typical imaging

features seldom pose a diagnostic problem. How-
ever, the radiologist may be challenged by a lesion
that proves to be a meningioma but has atypical fea-
tures. Atypical imaging features occur in about 15 %
of meningiomas [81 and include cystic change or ne-
crosis, hemorrhage, or, rarely, fatty change. In the
case of cystic meningioma, there should be a solid
component that displays more typical meningioma
features (Fig. 11). In cases which do not clearly sug-
gest meningioma because of unusual imaging find-
 235

Fig. 9. Right-sided cavernous sinus meningioma. Contrast-enhanced axial Tl-weighted MR image shows a large enhancing mass in the
right cavernous sinus (asterisk). Notice the narrowing of the cavernous carotid artery (arrow). The "dural tail" of enhancement can be
seen extending posterolaterally from the lesion (arrowheads).

ings, other differential diagnoses are usually consid-
ered, including other neoplasms.
Other factors that complicate making the diag-
nosis of meningioma are lesion size, location, and
other aspects of lesion appearance such as difficulty
in determining whether the lesion is extra- or intra-
axial. The distinction between intra- or extraaxial is
not always easy, and, therefore, the differentiation
between meningioma and superficially-situated in-
traaxial neoplasms may not always be possible pre-
operatively.
Very large lesions, especially skull base masses or
those associated with gross bone destruction, may
not at first suggest the diagnosis of meningioma
(Fig. 6); nevertheless, meningioma should be con-
sidered. For lesions in certain anatomic locations
such as the suprasellar cistern, cavernous sinus (Fig.
9), orbit, pineal region, and within the ventricle
(Fig. 12), meningioma should be considered as part
of a thorough differential diagnosis, even if a specif-
ic diagnosis cannot be made preoperatively in every
case. Finally, a lesion that closely resembles menin-
gioma on imaging may be something else, such as a
dural based metastasis, a fact that should be kept in
236
Fig. 10. Type II Neurofibromatosis in a 42-year-old man.
(A) and (B) Postcontrast axial Tl-weighted MR images showing
bilateral acoustic neuromas (arrowheads) and multiple menin-
glomas of varying sizes (arrows).
Fig. 11. Cystic right parafalcine meningioma in a 35-yearoold man
presenting with left leg weakness.
(A) Noncontrast CT image showing bean-shaped cystic struc-
ture in the right parietal lobe (asterisk) with a suggestion of a
medially-situated solid component (arrowheads).
(B) Postcontrast CT image, same level, shows the enhancing sol-
id component (arrowhead), which looks more typical of a me-
ningioma.
 237

Fig, 12, Intraventricular meningioma in a 46-year-old woman.

(A) Sagittal noncontrast Tl-weighted M R image shows a large
slightly hypointense mass within the atrium of the left lateral
ventricle (arrowhead).
(B) Postcontrast axial Tl-wmghted M R image shows intense
contrast enhancement. This is the most common intraventricular
location for a meningioma, and the imaging characteristics are
those of a meningioma elsewhere in terms of signal intensity and
enhancement.
238
m i n d w h e n p e r f o r m i n g imaging tests on the cancer
patient (Fig. 8).
Malignant meningiomas
Classic histologic features of malignancy (e.g., nu-
clear p l e o m o r p h i s m , necrosis, and mitotic figures)
do not always correlate with aggressive b e h a v i o r in
m e n i n g i o m a s and, therefore, the t e r m " m a l i g n a n t "
m a y not have the precise implication it has for tu-
m o r s located elsewhere. T h o u g h there are no radio-
logic features that can predict with certainty the fu-
ture b e h a v i o r of meningiomas, certain imaging fea-
tures m a y be associated with aggressive behavior.
These include gross b o n e destruction, central areas
of necrosis or n o n e n h a n c e m e n t , indistinct t u m o r
margins at the brain surface, and irregular inward
projections of t u m o r t o w a r d the brain [9] (Fig. 6).
Conclusion
M o d e r n imaging plays a crucial role not only in the
p r e o p e r a t i v e evaluation of a m e n i n g i o m a , but also
in assessing the efficacy of t r e a t m e n t and ruling out
recurrences. This r e p o r t was a i m e d at introducing
the basic imaging features of m e n i n g i o m a s and fa-
miliarizing the r e a d e r with s o m e of the difficulties
e n c o u n t e r e d during the radiologic evaluation of
these patients.
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Address for offprints: L. E. Ginsberg, Department of Radiology,
Box 57,M.D. Anderson Cancer Center, 1515 Holcombe, Hous-
ton, Texas 77030, USA