Meningiomas associated with hemorrhage: A report of two cases with a review of the literature

Abstract

Two cases of extensive spontaneous hemorrhage related to intracranial angioblastic meningiomas are reported. One of these also had glandular and papillary formations with mucin production. A review of 115 meningiomas with significant hemorrhage including the two current instances disclosed that they occurred in the first to ninth decades of life but were most common in the fourth to eighth decades (85%), with a peak occurrence in the fifth decade (24%). The average age of 51 years was 9 years more than in those patients with non‐bleeding meningiomas. The female‐ to‐male ratio was 6:5 for the entire series. Bleeding meningiomas arose most often on the cerebral convexity followed by the parasagittal region, the lateral ventricle, and the sphenoid ridge. Bleeding most frequently involved multiple sites, and was followed in decreasing frequency by hemorrhage into the subarachnoid space, subdural space, intracerebral tissue including the peritumoral region, and intratumoral substance. Meningocytic menin‐gioma was the most common type of bleeding meningioma, followed in decreasing frequency by the angioblastic, fibroblastic, transitional and malignant types. The mech‐anism of bleeding was uncertain in many cases, and multiple factors are probably involved. Patients with bleeding meningiomas had worse prognoses than those with non‐bleeding meningiomas.

Radiological classification of meningiomas with hemorrhagic onset and its clinical significance

“…There is no difference in the therapeutic method for the different bleeding patterns; however, this bleeding classification system could offer some implications for the treatment strategy. According to the review of prior cases reported in the literature ( 4 – 8 , 11 , 17 – 21 , 25 , 26 ) and the cases in the present study, the symptoms in most patients with the first bleeding type were usually mild and their clinical statuses were generally stable, and early or selective surgery could be performed following adequate preoperative evaluations. The symptoms in patients with the second bleeding type were at times mild and in other cases moderate to severe, so emergency or early surgery should be chosen according to the clinical status of the patient and their corresponding radiological results.…”

“…As this condition is rare, the determination of causative factors for the hemorrhage is difficult, and it is not as easy to understand the mechanisms of spontaneous hemorrhage (11,15,16). Cases of spontaneous hemorrhage in meningioma have been sporadically reported, however, and a number of clinical features of the condition have been characterized (4)(5)(6)(7)10,11,(16)(17)(18).…”

“…The exact mechanism of the hemorrhage from meningiomas is not fully understood; however, several pathological mechanisms have been considered in the explanation of this rare condition. The proposed mechanisms include weakened blood vessel rupture, endothelial proliferation and resultant vascular occlusion, direct tumor cell invasion of the vasculature, bioactive substance accumulation in the tumor, concomitant vascular malformation or aneurysm, stretching and rupture of subdural bridging veins, venous compression induced by tumor growth and associated with peritumoral edema, and infarction due to rapid tumor growth (2)(3)(4)(5)(6)(8)(9)(10)(11)(16)(17)(18). In addition, two specific types of blood vessels, differentiated and undifferentiated vessels, were found in our prior study; undifferentiated blood vessels contribute to a fragile tumor vasculature, which a precipitating event may disrupt, thus resulting in a spontaneous hemorrhage (11).…”

Meningiomas with Hemorrhagic Onset: A New Bleeding Classification and its Clinical Significance

“…These patients could gain good outcomes when they are managed appropriately with early diagnosis and correct treatment 2,4 . The majority of these cases require surgical intervention because observation and other treatments do not alleviate mass effect and risk of repeated hemorrhage 2,11 . Previous reports had provided some information on the signal intensity on MRI and indicated hyperintensity on T2-weighted MRI as a risk factor of meningioma bleeding 10,12 ; however, this nding was just found more frequently in the patients with type I and type III bleeding in this study.…”