Professional Documents
Culture Documents
• Meningiomas are slowly growing neoplasms thought to arise from meningothelial cells found
within arachnoid granulations. Concentrated in the walls of the major venous sinuses, these
structures, which contain “arachnoid cap cells,” account for the dural localization of most
meningiomas within the cranium and spinal cord. Meningiomas may originate in any location
where arachnoidal cells are present, including the choroid plexus (intraventricular
meningioma). Meningiomas may also occur as a flattened sheath of tumor, taking the shape
of the underlying bone. This so-called meningioma en plaque is more common in the area of
the sphenoid bone.
• Most meningiomas are well-defined, lobulated, firm masses that compress the underlying
brain. Gross total resection is usually curative. Invasion of brain parenchyma is associated
with a greater likelihood of recurrence. In contrast, invasion through the dura into the
overlying cranial bone is quite common in low-grade (WHO grade I) meningioma.
• Arachnoid
• The arachnoid and the pia mater form the leptomeningeal, or thin layer of meninges.
Immediately deep to the dural border cell layer sits the arachnoid barrier cell layer. This layer
consists of tightly packed large fibroblasts with minimal extracellular space and absence of
collagen. There is a unique abundance of cell junctions. Tight junctions among cells
strengthen the arachnoid barrier cell layer and render it impermeable to fluids, large
molecular weight substance, and even some ions. In addition, a continuous basement
membrane lines the inner surface of the arachnoid, abutting the subarachnoid CSF space.
Arachnoid trabecular cells are specialized fibroblasts with long processes and attachment to
the arachnoid barrier layer. They bridge the subarachnoid space with their long, flattened,
irregular processes and may form cellular attachments with pial cells. Collagen may be found
within the trabecular matrix created by the processes in the subarachnoid space.
ARACHNOID VILLI/GRANULATIONS
• Arachnoid villi are specialized segments of the meninges that project into the sinuses and
major venous structures. They are essential in the absorption of CSF through both passive
and active mechanisms. Whereas arachnoid villi are microscopic, arachnoid granulations are
visible to the naked eye, and Pacchionian bodies are especially large, elaborate complexes.
• Arachnoid cap cells are derived from the outer portions of the endomeninx and are
considered the cells of origin of meningiomas. Although they can be located throughout the
central nervous system, including within the ventricles, the sylvian fissure, and the pineal
region, they are found in greatest concentration adjacent to the major sinuses, large cerebral
veins, and basilar plexus, and around the crista galli, over the cribriform plate, and at the exit
foramina of cranial nerves II through VII and IX through XII.
EPIDEMIOLOGY
• Meningiomas account for 20% of all intracranial tumors in males and 38% in
females, yet little is known regarding the risk factors associated with these
lesions. Data from the Central Brain Tumor Registry of the United States
(CBTRUS) reveal an age-adjusted incidence rate (per 100,000 person-years) of
8.36 and 3.61 for females and males.
• Age-Specific Incidence Rates for Meningioma in the United States (2002–
2006)
Age 0–19 20–34 35–44 45–54 55–64 65–74 75–84 85+
Rate 0.11 1.05 3.72 7.62 12.39 20.58 29.40 34.94
ETIOLOGY / RISK FACTORS
• Ionizing Radiation
In one of the most well-known studies to date of IR and meningioma risk, children who were
given radiation therapy for scalp ringworm in Israel between 1948 and 1960 (the Tinea Capitis
Cohort) were observed to have a relative risk of almost 10 for meningioma. Radiation therapy
for intracranial tumors has also been linked to meningioma risk, and animal studies support the
contention that IR can induce intracranial tumors, including meningiomas, by damaging DNA.
Several studies have linked the number of full-mouth dental radiographs to risk of meningioma,
although the sample sizes are limited, and most later studies (also small in size) did not confirm
these findings. The most recent casecontrol study of 200 meningioma patients reported that the
full-mouth series was associated with a significantly increased risk of meningioma although
evidence for a dose response relation was lacking.
• Hormones
The presence of estrogen, progesterone, and androgen receptors on some meningiomas; an
association between breast cancer and meningiomas; indications that meningiomas change in size
during the luteal phase of the menstrual cycle and pregnancy; and in vitro proliferation of
meningioma-cell lines in culture after exposure to estrogens has been observed.
• Head trauma
Head trauma has been suggested as a risk factor for meningioma, although the results across
studies are not consistent. Although several small case-control studies from the early 1980s report
an increased risk of meningioma associated with head trauma for both males and females, other
studies report no such association. A cohort study of 228,055 Danish residents hospitalized for
concussion, skull fracture or other head injury between 1977 and 1992 did not find any significant
increase in the incidence of meningioma, although the mean follow-up was only 8 years.
• Viruses
Some researchers have looked into a possible viral cause of meningiomas. One strong contender
is the Inoue-Melnick virus (IMV), a DNA virus linked to subacute myelo-opticoneuropathy. In
work reported by Inoue,77 IMV was isolated from six of seven human meningioma-derived cell
cultures but was not isolated from six other brain tumor cell cultures. The prevalence of the IMV
antibody in healthy Japanese adults was 17.3%. Of 26 patients with meningioma, 22 (84.6%)
were positive for the IMV antibody. Based on their review of the subject, however, Rachlin and
Rosenblum78 stated that “although there is strong biochemical evidence associating DNA tumor
viruses with human meningiomas, the role of the virus in the development of the tumor
remains undefined.”
• Other risk factors
- Cell phone use
- Breast cancer
- Industry/occupation/diet/allergy
- Family history of meningioma
RADIOLOGY FINDINGS
Chordoid meningioma
WHO Grade II Clear cell meningioma
(Atypical)
Atypical meningioma
Papillary meningioma
WHO Grade Rhabdoid meningioma
• The distribution of intracranial meningiomas is approximately as follows:
convexity (35%), parasagittal (20%), sphenoid ridge (20%), intraventricular (5%),
tuberculum sellae (3%), infratentorial (13%), and others (olfactory groove,
cerebellopontine angle, etc) (4%).
OBSERVATION FOR MENINGIOMAS
• It is our practice to monitor patients with asymptomatic meningiomas (including those at the
skull base) and reserve treatment for patients who develop symptoms or whose tumors are
shown to grow progressively. Our follow-up strategy involves first imaging at 3 months to
exclude rapidly enlarging tumors and then at 9 months, and yearly thereafter. If the patient
remains stable for 5 years, imaging can be spread out to a biannual schedule. As part of this
strategy, it is critical to compare follow-up scans with the earliest images possible rather than
with immediately subsequent scans, to avoid missing significant changes that have occurred
over time. If at any time during this period the patient becomes symptomatic or the tumor
grows progressively, we believe that he or she should be treated with maximal surgical
resection.
OBSERVATION FOR MENINGIOMAS
Grade Description
I Macroscopically complete tumor removal with excision of the tumor's
dural attachment and any abnormal
bone
• Simpson
II Grading System
Macroscopically complete tumor removal with coagulation of its dural
attachment
III Macroscopically complete removal of the intradural tumor without
resection or coagulation of its dural
attachment or extradural extensions
IV Subtotal removal of the tumor
V Simple decompression of the tumor
LOCATION
Parasagittal meningioma
• Sphenoid wing meningioma
• Falcine meningioma
• Suprasellar meningioma