ANGIOBLASTIC MENINGIOMA WITH INTRAPARENCHYMALHEMORRHAGE

ismail H. Tekkok. M.D .. Mehmet Turgut. M.D .. Kadir Tabta. M.D .. Siileyman Saglam. M.D ..

Department of Neurosurgery, Hacettepe University school of Medidne,

Slhhiye 06100, Ankara, TURKiYE

Turkish Neurosurgery 2 : 165 - 169. 1992

ABSTRACT

We report the case of a 37-year-old female patient harboring a right tentorial meningioma with bicom­partmental growth who deteriorated while awaiting elective surgery. Both radiological and operativefindings demonstrated intratumoral and intracerebellar hemorrhage. The tumor was removed totallyin two sessions and was an angioblastic type. We discuss the frequency. presentation and outcomeof such patients and point out to precautions that need to be taken.

KEY WORDS:

Angioblastic. Hemorrhage. Intracerebellar. Meningioma

INTRODUCTION

Meningiomas are slowly growing benigntumors having a gradual onset with a relative­ly chronic but progressive course (2). Hemor­rhage. vascular changes. cerebral edema. highrate of malignancy and necrosis are factors heldresponsible of acute presentation of men­ingiomas (2,6.8). Acute presentation of a men­ingioma is so unexpected that most often ityields poor results (8).The purpose of this paperis to present a case who have bled whileawaiting surgery for a recurrent tentorial men­ingioma and to discuss the etiology. precautionsto be taken and outcome with a brief reviewof the literature.

CASE HISTORY:

A 37-year old female patient was first admit­ted in March 1988 with persistent headache oftwo months duration and a history of fourseizures. Concomittantly she had experiencedblurred vision. CT scan demonstrated an enhan­

dng mass of 5 em diameter at right parietotem­poral region. On March 3, 1988 a craniotomywas performed. A pink mass with moderate

consistency which was found to originate fromthe tentorium was removed gross totally. Thetumor bed was coagulated by bipolar and C02laser. The histopathological diagnosis was ameningioma with sarcomatous degeneration.The patient made an uneventful recovery. Toexclude any possibility of recurrence 50 Gy ofradiotherapy by a C060 source was also given.The patient stayed symptom- and recurrencefree at 6-monthly clinical and yearly CTfollowups.

In June 1991,while the neurological examina­tion was completely normal. a contrast enhanc­ed CT scan as well as an MR scan showedrecurrence on both sides of the tentorium.

Supratentorial growth measured 15x15mm andinfratentorial extension was 30x15 mm (Fig.1a).She was then hospitalized for surgery. Whileawaiting her operation day scheduled for 2 dayslater. she deteriorated suddenly with intensesweating, bradykardia and with decreased sen­sorium. A repeat CT scan with no contrast show­ed enlarging hyperdensity measuring 45x35 mm.in the posterior fossa. The fourth ventricle wasdistorted markedly towards left (Fig. 1b).

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Fig. I-a.; Postcontrast CT scan demonstrates an infratentorialrecurrence with marked enhancement measuring30xl5 mm.

Fig.l-b.; Non-enhanced CT scan after deterioration showsenlargement of the same mass with a lobulation atits medial aspect which corresponds to intraparen­chymal hemorrhage (Time interval between la and1b is 10 days).

She was immediately taken to theatre anda right retroauricular retromastoid craniotomywas performed. The mass was first debulked in­tracapsularly. There was widespread hemor­rhage within the tumor. The periphery of thetumor was giving cleavage because of the hemor­rhage around it. The pia of the cerebellarhemisphere was found to be tom with only 2-3ml of hematoma over the cerebellar cortex.

Overall. a gross total removal of the infratentorial

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portion was accomplished. The tumor bed onthe underside of the tentorium was againcoagulated. The patient made an unexpectedlygood recovery and was ~p on her feet on the 3rdday. Histopathology this time was a diffuselyangioblastic meningioma (Fig. 2). A week laterthe previous craniotomy was reexplored and thesupratentorial portion and the tumor betweenthe sheets of the tentorium was totally exdsed.The patient was discharged happy andsymptom-free on the 10th postoperative day.

Fig.2 ; Photomicrograph of the angioblastic meningioma. Notehypercellularity and abundance of the blood vessels(Hematoxylin and eosin; x llO).

DISCUSSION

Brain tumors may occasionally present acute­ly. Such a presentation is mainly because ofbleeding into or around the tumor (5,6.8,11).In­tracerebral bleeding has been found particular­ly in malignant melanomas and metastatic braintumors (5).Gliomas like anaplastic astrocytomasand less commonly oligodendrogliomas. choroidplexus papillomas and cardnomas and thepituitary tumors may present in an apoplectiformmanner (5.8). Intracerebral hemorrhage frombenign intracranial tumors is rare (6). The oc­curence of hemorrhagic onset of a meningiomahas been documented in the neurosurgicalliterature mostly in form of single reports.Martinez-Lage et al (8) have made a literaturereview only recently and found 57 cases in­cluding theirs out of which 55 were intracranialmeningiomas. Wakai et al (12) reported an in­ddence of 1.3 % for the hemorrhagic manifesta­tions of meningiomas and for Martinez-Lage etal this figure was up to 2.4% (8).

There appears few points that deserve men­tioning. Meningiomas with hemorrhage manifestthemselves during the fifth decade when the in­dden<;:eof cerebral stroke is already high whichmakes the initial diagnosis quite difficult onclinical grounds (8).No preponderance related tosex has been noted (6).The clinical presentationis almost always that of sudden deterioration ofsensorium accompanied by severe headacheand/or hemiparesis. The occurence of seizuresand the finding of papilledema are rarely en­countered.

The value of CT as the emergency imagingmethod can not be overemphasized. Non­enhanced and enhanced CT scans are necessaryto visualize both the tumor and the hemorrhage(6).

Of the 55 cases reported to date (6.8). pureintratumoral bleed occurred in 2 (3.5%)and pureintracerebral in 6 (11%) cases. Intracerebral andintratumoral bleed with extension to

subarachnoid and/or subdural space accountedfor 17 (34%).Subdural space was involved alonein 4 (7%)while pure subarachnoid hemorrhageoccurred in 15 (28%). The rest were subject tocombinations of different locations as to hemor­

rhage. Major reviews on the subject (6,8),noteda correlation between the location of the men­

ingioma and the likelihood of hemorrhage. Con­vexity (38%), parasagittal (16%) andintraventricular location in the decreasing orderof frequency resulted in hemorrhagic onset in 55cases upto date. To our knowledge, our case ap­pears as the first tentorial meningioma case tobleed.

Though angioblastic type would be the mostlogical histological type to bleed, meningothelia!meningiomas dominated the related literature(39%)(6).Only 9 (15%)cases of angioblastic men­ingioma cases with hemorrhage were reported(8).

The mechanism for production of hemor­rhage is unknown. Goran etal (4) and Lazaro etal(7) stated that even nonangioblastic men­ingiomas may have more than one tissue pat­tern. As Goran etal (4),Modest eta! (9) an Nakaeta! (10) pointed out. the meningiomas assodatedwith hemorrhage showed an unusual vasculari-

ty near the site of hemorrhage and the-ruptureof these angiomatous vessels probably accountedfor the hemorrhage in nonangioblastic subtypes.A transformation to angioblastic subtype afterradiotherapy for sarcomatous meningioma mighthave been the case for our patient. but why thetumor bled infratentorially supports the view ofGoran eta! and Lazaro etal (4,7).

Anticoagulation (3). trauma (1,13) andhypertension (5)have all been implicated as con­tributory factors. Hamer (5)also speculated thathemorrhagic infarction due to compression of thebrain and of cortical veins leading to erosionmight be another cause (5).

The success rate of treatment depends onlyon prompt diagnosis. A high index of clinicalsuspidon is necessary. The overall mortality ofthe reported cases in the literature in up to 50%(8). in spite of easy availability of CT worldwide.The mortality figures for the angioblastic type hasbeen even higher. The fact that our patient wasa diagnosed meningioma patient contributedpositively to the outcome since she was takento theatre in few hours.

In conclusion, we have reported the case ofa female patient with a bleeding meningioma.We stress the fact that clinical suspidon isnecessary for prompt and accurate diagnosis ofsuch patients and that the preoperativeneurological state correlate well with theoutcome.

Correspondence: Ismail H. Tekkok, M.D.Hacettepe UniversitesiTIp Fakilltesi HastanesiNoro~iriirji Ana Bilim DahSIhhiye. Ankara 06100 - TURKiYEphone: 90-4-3108495Fax: 90-4-311 1131

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