Case

Presentation:
PGI Tang, Jeremy Gina Joy
General Data

o M.M
o 43/F/Married
o P-6 Sagpon, Daraga, Albay
o Roman Catholic
o Informant: Patient
o Good Reliability
o Admitted for the 1st time in our
institution
Chief Complaint:
Generalized body weakness
History of Present Illness
6 months PTA,
(+) generalized body weakness
(+) intermittent generalized headache
accompanied by photosensitivity
(-) vomiting,
(-) nausea, Few hours prior to admission, patient
prompted consult to an ophthalmologist noted increased sleeping time. Hence,
where patient was requested for CT-Scan consult and was subsequently
and revealed a space occupying lesion admitted.
at the temporoparietal area, left.
Cranial MRI with contrast was further
requested revealing a left middle
cranial fossa meningioma approx. 8 x
5 x 5.5 with subfalcine uncal torsion,
herniation right, midline shift and
right ventriculomegaly.
Past Medical History
o (+) Hypertension – Amlodipine, unrecalled dose
o (-) Diabetes Mellitus
o (-) PTB
o (-) Cardiac Problem
o (-) Renal Problem
o (-) Asthma/COPD
o (-) Stroke
o (-) Cancer
o No known Allergies
o No previous surgeries/admissions
Family History
o (+) Hypertension – Maternal side
o (+) Stroke – Maternal Side
o (-) Diabetes Mellitus
o (-) PTB
o (-) Cardiac Problem
o (-) Renal Problem
o (-) Asthma/COPD
o (-) Cancer
Personal and Social History
o Non-smoker
o Non-Alcoholic beverage drinker
o Denies Illicit drug use
o Denies exposure to radiation
o Claims to use mefenamic acid for headache
o Occupation: Housewife
Review of Systems
o General: No weight loss. (+) increased sleeping time
o Skin: No rash, lumps and sores. No flaking and itchiness
o Head and Neck: (+) headache, No dizziness, No lightheadedness
o Eyes: No visual changes, tearing, redness, pain.
o ENT: No redness, itchiness and discharge. No bleeding and sore.
o Respiratory: (-) productive cough, No shortness of breath. No hemoptysis
o Cardiovascular: No palpitation, chest pain/tightness, orthopnea
o GIT: No difficulty of swallowing. No constipation. No diarrhea. (-) melena
o Urinary: No urinary incontinence. No change in urine color. No nocturia.
o Musculoskeletal: (-) painful back/ joints, (-) swollen joints, (-) pain during ambulation.
o Neuro: No loss of consciousness, dizziness/syncope, balance and gait abnormality
Physical Examination
o General: Patient is awake, coherent, and not in cardiorespiratory Vital Signs:
distress
o Skin: No rash, (-) pallor, warm to touch, good skin turgor BP: 100/70 mmHg
o HEENT: Normocephalic, atraumatic, Anicteric sclera, pink palpebral HR: 62 bpm
conjunctiva, (+) nystagmus, Pupils 4-5mm ERTL, Symmetric, non- RR: 22 cpm
erythematous pinnae. No external ear discharge, Non distended neck Temp: 36.30C
vein. No visible mass. No cervical lymphadenopathy. O2 sat: 99% at room air
o Chest and Lungs: Symmetric chest expansion, No retractions, No
deformities, (-) Crackles, Symmetric tactile fremitus
o Cardiovascular: Adynamic precordium, Normal Rate Regular
Rhythm, PMI on 5th ICS, MCL Left, no murmur. Ht: 160cm
o Abdomen: Flat, soft, non distended, normoactive bowel sounds at 8 Wt: 55kg
clicks per minute, Tympanitic in all quadrants. No organomegaly. Liver BMI: 21.48kg/m² (Normal)
span = 8cm, No palpable mass
o Extremities: No gross deformities, pink nailbeds, Full Pulses,
Capillary refill time <2s
Physical Examination
o Neurologic: GCS 15, Oriented to person, place, time and date Vital Signs:
o CN I – able to smell coffee BP: 100/70 mmHg
o CN II – 2-3mm pupil equally reactive to light HR: 62 bpm
o CN III, IV, VI – intact extraocular muscles RR: 22 cpm
o CN V – able to clench teeth equally on both sides, (+) tactile Temp: 36.30C
sensation on the forehead, cheeks, and mandibular area O2 sat: 99% at room air
o CN VII – no facial asymmetry
o CN VIII – intact gross hearing bilaterally
o CN IX, X – uvula at midline, intact gag reflex, able to swallow
o CN XI – can shrug shoulders Ht: 160cm
o CN XII – tongue at midline, able to protrude, no fasciculations Wt: 55kg
BMI: 21.48kg/m² (Normal)
o Motor: 5/5 on all extremities
o Sensory: 100% on all extremities
Diagnostics
CHEMISTRY

CBC TSH 0.52

WBC 12.52 FT3 2.15

HGB 4.16 FT4 21.17

HCT 0.38 HDL 1.65

PC 378 Total Chole 6.30

Sputum GSCS P. Algaligenes (mod. growth)

PLAIN CRANIAL CT SCAN
Isodense mass in the left middle cranial fossa extending
to the parietal lobe involving the insular cortex measuring
approx. 4.6 x 4.4 x 5.9 cm in cc x w x ap. No calcification
is noted. Very minimal surround edema is seen. Mass
effect on the ipsilateral and 3rd ventricles are noted with
mild dilatation of the contra-lateral ventricle. Consequent
rightward subfalcine herniation is noted measuring 1.0cm
and beginning uncal herniation.

No intra or exra-axial hemorrhage noted.

Fluid density is seen in the ethmoid and maxillary

sinuses.

Orbits have normal appearance, and the rest of the

paranasal sinuses and mastoid air cells are clear.
No bony abnormality seen.
Salient Features
o 43 y/o, Female
o (+) Intermittent generalized headache
o (+) Photosensitivity
o (+) Generalized body weakness
o (+) Increased sleeping time
o (+) Nystagmus
o CT Scan result
o Cranial MRI with contrast result
Diagnosis:
Left Sphenoid Wing Meningioma,
Medial Third
Procedure done:
o Frontotemporoparietal craniotomy, Left; Excision of meningioma Left
Spenoid Wing (Medial Third)
 Differential Diagnosis
Fibrous Tumor of the
Meningioma MALT Lymphoma
Dura
Rare
Most common in middle-aged
Epidemiology/ Common in women. Occur in middle aged
individuals
Demographics Uncommon before the age of 40. individuals (Average: 47-56)
More common in females.
More common in females

Headache Symptoms depend on the size

Clinical Usually indolent with symptoms
Paresis of the mass.
Presentation related to mass effect: Headache
Change in mental status Headache most common CC.

Surgical excision. If only

incomplete resection is possible,
Surgical resection. If
then external-beam radiation Surgical resection and/or
incomplete or recurrence
Treatment therapy can be used. No radiation with or without
occurs, then radiotherapy may
widespread chemotherapy.
be employed.
chemotherapeutic/systemic therapy
has been proven to be efficacious.
 Differential Diagnosis
Fibrous tumor of the
Meningioma MALT Lymphoma
Dura

CT:
Plain films: Well-circumscribed and isodense
No longer have a role in the diagnosis or to hyperdense compared to
management. adjacent brain. May demonstrate
CT: calcifications and may erode
CT: Due to high cellularity, these tumors bone.
Non contrast: are typically somewhat hyperdense
compared to brain. MRI:
Radiologic Hyperdense to normal brain, rest are more
MRI: Appears as extra-axial well-
findings isodense; have some calcification, • T1 – isointense to grey matter circumscribed masses.
variable edema, and Hyperostosis • T2 – iso- to hypointense to grey • TI – typically, intermediate
matter, edema common in adjacent signal similar to brain.
MRI: brain • T2 – iso-to hypointensity (best
Extra-axial masses with broad dural base. clue to the diagnosis)
Homogenous and well-circumscribed. • Heterogenous signal: ‘Yin-
yang” appearance of separate
areas
 Differential Diagnosis
Fibrous tumor of the
Meningioma MALT Lymphoma
Dura

Radiologic
findings
Discussion
Meningioma
• Meningiomas are tumors that start in the
layers of tissue (meninges) that cover
the brain and spinal cord. Most
meningiomas are not cancerous
(benign).
• The meninges are membranes that
support and protect the brain and spinal
cord. A clear fluid called cerebrospinal
fluid (CSF) travels in the spaces formed
by the meninges.
Meningioma
• Usually extra axial tumors and the most common
tumor of the meninges.
• Non-glial neoplasm that originates from the
meningocytes or arachnoid cap cells of the meninges
and are located anywhere that meninges are found.
• There are 15 subtypes with variable imaging features
• Most are entirely asymptomatic.
• May become clinically apparent due to mass effect
depending on the location:
o Supratentorial: 85-90%
 Seizures and hemiparesis
 Anosmia, Foster Kennedy syndrome
 Visual field defects, cranial nerve deficits
o Infratentorial: 5-10%
o Miscellaneous: <5%
 Parinaud syndrome
Meningioma
• Types of Meningioma
• Convexity Meningioma
• Falcine and Parasagittal
• Intraventricular
• Skull base meningioma
• Sphenoid Wing meningioma
• Olfactory Groove
meningioma
• Posterior fossa/Petrous
• Suprasellar
• Recurrent
Grading:
Meningiomas are graded from grade 1 to 3 based on histological features (e.g. mitotic index) some
histological subtypes (e.g. chordoid meningiomas and clear cell meningiomas) and molecular features

Grade 2 Criteria: Grade 3 Criteria:

• Increased mitotic figures • Increased mitotic figures
• Brain invasion • Homozygous deletion of CDKN2A/B
• Chordoid or clear cell histological subtype • Sarcoma or carcinoma or melanoma-like
• Three or more of the following:
appearance
o Increased cellularity
• TERT promoter mutation
o Prominent nucleoli
o Necrosis
o Sheet-like growth
o Small cells with high nuclear to cytoplasmic
ratio
Diagnostics
• MRI Scan or CT Scan
• A Biopsy (Confirmation)
• Blood tests (Elevated Serum Caspase-3 Levels)
• Neurological Examination
• Brain Angiogram
Radiographic Features
• Best imaged with MRI with contrast, as this most accurately delineates the tumor,
presence of intra- and trans-osseous extension and relationship to the underlying brain.
• CT is useful if bony anatomy is required, when patients cannot have MRI, and especially
when the meningioma is entirely ossified/calcified.
SPECIAL EXAMPLES OF
MENINGIOMAS
BURNT-OUT
MENINGIOMA
CYSTIC MENINGIOMA
INTRAOSSEUS
MENINGIOMA
- Term used to denote a meningioma Meningiomas with intratumoral Does not include those intradural
which has become completely degenerative cyst formation as well as meningiomas which present with an
calcified/ossified. those with peritumoral arachoid cysts intraosseous extension even when the
intracranial (non-osseous component) is
a minor feature of the mass.
SPECIAL EXAMPLES OF
MENINGIOMAS
INTRAVENTRICULAR OPTIC NERVE SHEATH
Rare tumors and they classically present
as vividly enhancing solid mass at the
trigone of the lateral ventricles.
RADIATION-INDUCED
Benign tumors. More frequently multiple and have a
Typically appear as masses within the very long latency period.
optic nerve. Isointense on to grey matter
on both T1 and T2 weighted imagine.
“Tram trach-sign”
 Thanks!
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