Journal of Medical Sciences

CASE REPORT
Year
: 2016  |  Volume : 36  |  Issue : 4  |  Page : 158--161

Meningioma with purely intratumoral hemorrhage mimicked intracerebral hemorrhage: Case report and literature review


Ruei-Hong Lin, Chiung-Chyi Shen 
 Department of Minimally Invasive Skull Base Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Section 4, Taichung, Taiwan 40705, Republic of China

Correspondence Address:
Chiung-Chyi Shen
Department of Minimally Invasive Skull Base Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Section 4, Taichung 40705, Taiwan
Republic of China

Abstract

Meningiomas are the most common non-glial intracranial tumor with an incidence of 2.3-5.5/100,000 people, accounting for 20-30% of all primary adult brain tumor diagnoses. Meningiomas associated with hemorrhage are rare; the reported incidence is 0.5-2.4%. We share a case experience of meningioma with purely intratumoral hemorrhage. The initial image study of the intratumoral hemorrhage mimicked intracerebral hemorrhage. A 63-year-old woman with initial presentation of headache, dizziness, nausea, and vomiting has brought to the emergent department. The brain computed tomography showed a 5.3 cm hyperdense lesion over the left occipitotemporal area. Under the impression of intracerebral hemorrhage with unknown etiology, the brain magnetic resonance imaging was done for tumor survey and showed lobulated enhanced mass over left T-O area. Tumor with bleeding with skull bone invasion was first considered. The surgical pathology revealed atypical meningioma with focal clear cell change (World Health Organization Grade II), which is separated with the brain by pia meter. Meningiomas associated with hemorrhage are rare; the reported incidence is 0.5-2.4%. The clinical features about increasing bleeding tendency: (i) age >70 years old or <30 years old; (ii) the location of meningiomas locate at intraventricle or convexity; (iii) histopathalogical type: Meningotheliomatous, malignant, fibrous, and angioblastic type. Most reported intracranial hemorrhages associated with meningiomas are found in the subarachnoid and subdural spaces. There are several hypotheses for the possible mechanism of tumoral bleeding. The tumoral bleeding in meningioma is a rare event. The incidence depended on the location and the histopathological finding. There might be other indicators but still need more research.



How to cite this article:
Lin RH, Shen CC. Meningioma with purely intratumoral hemorrhage mimicked intracerebral hemorrhage: Case report and literature review.J Med Sci 2016;36:158-161


How to cite this URL:
Lin RH, Shen CC. Meningioma with purely intratumoral hemorrhage mimicked intracerebral hemorrhage: Case report and literature review. J Med Sci [serial online] 2016 [cited 2021 Nov 27 ];36:158-161
Available from: https://www.jmedscindmc.com/text.asp?2016/36/4/158/188901


Full Text

 Introduction



Meningiomas are the most common nonglial intracranial tumor with an incidence of 2.3-5.5 per 100,000 people, [1],[5],[6] accounting for 20-30% of all primary adult brain tumor diagnoses. [8],[9] They are mostly benign, slow-growing, and highly vascular tumors. Spontaneous intracranial hemorrhage occurs in 5.1% of all brain tumors, [13] mostly in pituitary adenomas, highly vascularized tumors such as medulloblastoma, neuroblastoma, ependymoma, oligodendroglioma, or metastatic tumors. [2],[11],[13],[14],[18] Meningiomas associated with hemorrhage are rare; the reported incidence is 0.5-2.4%. [10],[11],[12],[13] Most reported intracranial hemorrhages associated with meningiomas are found in the subarachnoid and subdural spaces. [10],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[20],[31],[32]

Purely, intratumoral hemorrhage was much rarer event. In this report, we share a case experience of meningioma with purely intratumoral hemorrhage. The initial image study of the intratumoral hemorrhage mimicked intracerebral hemorrhage.

 Case Report



A 63-year-old woman visited our emergent department due to acute onset of headache. Otherwise, dizziness, nausea, and vomiting were also complained. Her vital signs were within normal limit and the neurologic examination showed no abnormalities. She only took medication for Type II diabetes mellitus control since 5 years ago. At the emergent department, the brain computed tomography showed a 5.3 cm hyperdense lesion over the left occipitotemporal area [Figure 1]a with partial skull bone erosion [Figure 1]b. Under the impression of intracerebral hemorrhage with unknown etiology, she was admitted to intensive care unit for further survey.{Figure 1}

Because of skull bone erosion, the possibility of tumor involvement was considered initially. After discussion with the patient and the family, pre- and post-contrast brain computed tomography was repeated in the next day after admission. The brain computed tomography revealed huge mass lesion about 5.3 cm in size at left T-O junction with adjacent skull bone erosion, and partial enhancement and partial hemorrhage were noted [Figure 1]a and c. Tumor growth with bleeding was favored. The brain magnetic resonance imaging was done for tumor survey and showed lobulated enhanced mass with isointensity in T1-weighted (T1W) and T2W series and acute hemorrhage [Figure 2]a-c. Tumor with bleeding with skull bone invasion was suspected, and hemangiopericytoma, metastasis, or other intra- or extra-axial tumor was considered. There was difficult to differentiate which kind of tumor is.{Figure 2}

After discussion with the patient, an elective operation for left T-O craniotomy with removal of the brain tumor was planned. During operation, the skull bone was involved by the tumor and sent for pathology. The tumor was attached to the dura and tumor biopsy was done for frozen section. The frozen section report favored meningioma, and malignant meningioma might be considered. Due to the highly possibility of malignancy, en-bloc resection with some brain parenchyma was performed smoothly. After the operation, the patient recovered smoothly, and no neurological deficit was noted.

The surgical pathology revealed atypical meningioma with focal clear cell change (World Health Organization Grade II), and the labeled index of immunohistochemical stain for Ki-67 is about 10%. No psammoma body is seen, and brain tissue is also seen, which is separated with tumor by pia meter. No intratumoral necrosis is identified.

The patient discharged after radio-oncologist consultation on the postoperative day 12.

 Discussion



Spontaneous intracranial hemorrhage occurs in 3.9% of all brain tumors, [14] mostly in pituitary adenomas, highly vascularized tumors such as medulloblastoma, neuroblastoma, ependymoma, oligodendroglioma, or metastatic tumors. [11],[13],[14],[18] Meningiomas associated with hemorrhage are rare; the reported incidence is 0.5-2.4%. [10],[11],[12],[13] However, in another clinical study, 2 of 126 meningiomas showed radiological macroscopic hemorrhages and 9 of 126 meningiomas showed microscopic hemorrhages. [33] The clinical features about increasing bleeding tendency: [3] (i) Age >70 years old or <30 years old; (ii) the location of meningiomas locate at intraventricle or convexity; (iii) histopathological type: Meningotheliomatous, malignant, fibrous, and angioblastic type. In this case, the meningioma located at convexity and the histopathological type is atypical meningioma.

Most reported intracranial hemorrhages associated with meningiomas are found in the subarachnoid and subdural spaces. [10],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31] There is association between the location of meningioma and the hemorrhage type. Subdural hemorrhage was present in 49.2% of convexity meningioma. Subarachnoid hemorrhage was present in 67.4% of tumor locations other than the convexity, parasagittal, and falcine regions. [3] Purely, intratumoral hemorrhage was much rarer event. In this case, the intact pia meter separated the brain parenchyma and the tumor. No subarachnoid hemorrhage or subdural hemorrhage was noted.

The characteristics in magnetic resonance imaging might provide some information about the risk of tumoral bleeding. Hyperintensity on T2W magnetic resonance imaging might be an indicator but had not been fully established. [10] Hyperintensity on T2W magnetic resonance imaging also indicate the tumor's soft consistency [34],[35] and high proliferative nature. [7],[36] The signal on T2W is not an independent indicator, and there is doubt in some situations. For example, the fibrous meningioma had hemorrhage tendency but presents relatively hypointense in T2W magnetic resonance imaging. [34]

The mechanism of tumoral bleeding is unclear. There are several hypotheses for the possible mechanism: [4],[14] (1) Tumor grows rapidly and the abnormal newborn vessel is too fragile to rupture because of the extension and distortion by tumor. [13] (2) Inadequate proliferation of tumoral vessels results in necrosis and bleeding. (3) The peritumoral normal vessels are invaded by tumor. (4) The degeneration, thrombosis, cell embolus of tumoral vessels lead to bleeding. (5) Other factors: Vessel occlusion by radiotherapy, abnormal blood coagulation, hepatopathy and anti-coagulation treatment and trauma might result in tumoral bleeding.

Tumoral bleeding is associated with higher morbidity and mortality rates. Mortality rates of hemorrhagic meningiomas have been found to be 21.1% overall and 9.5% in surgically treated patients. [3] The mortality rate is different between the types of tumoral bleeding, but no statistical significance was noted. [3] There was no comparison between pure intratumoral bleeding and other types of tumoral bleeding. We suppose the pure intratumoral bleeding might result in better clinical outcomes, because of (1) limited amount of hematoma, and (2) no brain parenchymal injury. Massive tumoral bleeding must lead to extra-tumoral hematoma. There was no established evidence, and the hypothesis still needs large study to discuss.

 Conclusion



The tumoral bleeding in meningioma is rare event. The incidence depended on the location and the histopathological finding. There might be other indicators but still need more research.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Mangubat EZ, Byrne RW. Major intratumoral hemorrhage of a petroclival atypical meningioma: Case report and review of literature. Skull Base 2010;20:469-74.
2Agazzi S, Burkhardt K, Rilliet B. Acute haemorrhagic presentation of an intracranial meningioma. J Clin Neurosci 1999;6:242-5.
3Bosnjak R, Derham C, Popovic M, Ravnik J. Spontaneous intracranial meningioma bleeding: Clinicopathological features and outcome. J Neurosurg 2005;103:473-84.
4Yuguang L, Meng L, Shugan Z, Yuquan J, Gang L, Xingang L, et al. Intracranial tumoural haemorrhage - a report of 58 cases. J Clin Neurosci 2002;9:637-9.
5Kurland LT, Schoenberg BS, Annegers JF, Okazaki H, Molgaard CA. The incidence of primary intracranial neoplasms in Rochester, Minnesota, 1935-1977. Ann N Y Acad Sci 1982;381:6-16.
6Sutherland GR, Florell R, Louw D, Choi NW, Sima AA. Epidemiology of primary intracranial neoplasms in Manitoba, Canada. Can J Neurol Sci 1987;14:586-92.
7Niiro M, Yatsushiro K, Nakamura K, Kawahara Y, Kuratsu J. Natural history of elderly patients with asymptomatic meningiomas. J Neurol Neurosurg Psychiatry 2000;68:25-8.
8McGregor JM, Sarkar A. Stereotactic radiosurgery and stereotactic radiotherapy in the treatment of skull base meningiomas. Otolaryngol Clin North Am 2009;42:677-88.
9McGovern SL, Aldape KD, Munsell MF, Mahajan A, DeMonte F, Woo SY. A comparison of World Health Organization tumor grades at recurrence in patients with non-skull base and skull base meningiomas. J Neurosurg 2010;112:925-33.
10Niiro M, Ishimaru K, Hirano H, Yunoue S, Kuratsu J. Clinico-pathological study of meningiomas with haemorrhagic onset. Acta Neurochir (Wien) 2003;145:767-72.
11Kondziolka D, Bernstein M, Resch L, Tator CH, Fleming JF, Vanderlinden RG, et al. Significance of hemorrhage into brain tumors: Clinicopathological study. J Neurosurg 1987;67:852-7.
12Martínez-Lage JF, Poza M, Martínez M, Esteban JA, Antúnez MC, Sola J. Meningiomas with haemorrhagic onset. Acta Neurochir (Wien) 1991;110:129-32.
13Wakai S, Yamakawa K, Manaka S, Takakura K. Spontaneous intracranial hemorrhage caused by brain tumor: Its incidence and clinical significance. Neurosurgery 1982;10:437-44.
14Kim DG, Park CK, Paek SH, Choe GY, Gwak HS, Yoo H, et al. Meningioma manifesting intracerebral haemorrhage: A possible mechanism of haemorrhage. Acta Neurochir (Wien) 2000;142:165-8.
15Helle TL, Conley FK. Haemorrhage associated with meningioma: A case report and review of the literature. J Neurol Neurosurg Psychiatry 1980;43:725-9.
16Sunada I, Nakabayashi H, Matsusaka Y, Yamamoto S. Meningioma associated with acute subdural hematoma - case report. Radiat Med 1998;16:483-6.
17Jones NR, Blumbergs PC. Intracranial haemorrhage from meningiomas: A report of five cases. Br J Neurosurg 1989;3:691-8.
18Waga S, Shimizu T, Shimosaka S, Tochio H. Intratumoral hemorrhage after a ventriculoperitoneal shunting procedure. Neurosurgery 1981;9:249-52.
19Yapor WY, Gutierrez FA. Cocaine-induced intratumoral hemorrhage: Case report and review of the literature. Neurosurgery 1992;30:288-91.
20Roux-Vaillard S, Mercier P, Fournier HD, Hayek G, Menei P, Guy G. Intracranial meningiomas revealed by hemorrhage. Report of three cases and literature review. Neurochirurgie 1999;45:407-12.
21Lazaro RP, Messer HD, Brinker RA. Intracranial hemorrhage associated with meningioma. Neurosurgery 1981;8:96-101.
22Bloomgarden GM, Byrne TN, Spencer DD, Heafner MD. Meningioma associated with aneurysm and subarachnoid hemorrhage: Case report and review of the literature. Neurosurgery 1987;20:24-6.
23Chaskis C, Raftopoulos C, Noterman J, Flament-Durand J, Brotchi J. Meningioma associated with subdural haematoma: Report of two cases and review of the literature. Clin Neurol Neurosurg 1992;94:269-74.
24Pluchino F, Lodrini S, Savoiardo M. Subarachnoid haemorrhage and meningiomas. Report of two cases. Acta Neurochir (Wien) 1983;68:45-53.
25Okuno S, Touho H, Ohnishi H, Karasawa J. Falx meningioma presenting as acute subdural hematoma: Case report. Surg Neurol 1999;52:180-4.
26Lieu AS, Howng SL. Intracranial meningioma with hemorrhage. Kaohsiung J Med Sci 1999;15:69-74.
27Russell EJ, George AE, Kricheff II, Budzilovich G. Atypical computed tomography features of intracranial meningioma: Radiological-pathological correlation in a series of 131 consecutive cases. Radiology 1980;135:673-82.
28Koumtchev Y, Petkov S, Gozmanov G. Meningioma accompanied by a subdural hematoma. A case report. Review of 17 cases in the literature. Folia Med (Plovdiv) 1993;35:61-3.
29Kim JH, Gwak HS, Hong EK, Bang CW, Lee SH, Yoo H. A case of benign meningioma presented with subdural hemorrhage. Brain Tumor Res Treat 2015;3:30-3.
30Munivenkatappa A, Shukla DP. Atypical meningioma and acute subdural hemorrhage. J Neurosci Rural Pract 2014;5:203-4.
31Hambra DV, Danilo de P, Alessandro R, Sara M, Juan GR. Meningioma associated with acute subdural hematoma: A review of the literature. Surg Neurol Int 2014;5 Suppl 12:S469-71.
32Timothy J, Lafuente D, Chakrabarty A, Saxena A, Marks P. Meningioma recurrence at a different site masquerading as a subdural hematoma. Case report. J Neurosurg 1999;91:496-8.
33Kuzeyli K, Cakir E, Usul H, Karaarslan G, Yazar U, Baykal S, et al. Intratumoral haemorrhage: A clinical study. J Clin Neurosci 2004;11:490-2.
34Soyama N, Kuratsu J, Ushio Y. Correlation between magnetic resonance images and histology in meningiomas: T2-weighted images indicate collagen contents in tissues. Neurol Med Chir (Tokyo) 1995;35:438-41.
35Yamaguchi N, Kawase T, Sagoh M, Ohira T, Shiga H, Toya S. Prediction of consistency of meningiomas with preoperative magnetic resonance imaging. Surg Neurol 1997;48:579-83.
36Kuratsu J, Kochi M, Ushio Y. Incidence and clinical features of asymptomatic meningiomas. J Neurosurg 2000;92:766-70.