Papillary Meningioma With Vital Abnormal Vessels

Abstract

Papillary meningioma is an uncommon meningioma subtype of World Health Organization grade III. It could show some radiologic profiles pointing to malignant behavior, such as a cystic change, a heterogeneous enhancement, and an ill- defined border. However, to date, the radiologic profile described in this article has not been reported in previous literatures, and it is just the characteristic being considered as the major cause for patients’ death. A 16-year-old adolescent boy with a 6-month history of headache was admitted to our department on June 28, 2012. Magnetic resonance imaging showed a giant well-defined mass in the left temporal region, with a severe flow void on T2-weighted image and an abundant stripelike enhancement on T1-weighted contrast-enhanced scan. In view of its middle cranial fossa location (one predilection site for meningioma), meningioma was suspected preoperatively. A regular left frontotemporal craniotomy was performed. Unexpectedly, extreme hemorrhage happened intraoperatively, and it was difficult to stop the bleeding. After identification of no hemorrhage in the operative cavity through intraoperative magnetic resonance imaging, the operation was finished, with an overall blood loss of 15,000 mL. The patient died of brain stem dysfunction the second day after the operation.

Papillary meningioma with prominent flow voids

“…One previously reported case resulted in severe intra-operative bleeding and death of the patient on the second day after surgery. 3 In the presented case, the feeding vessels were identified at the time of the MRI and secured intraoperatively, resulting in no significant bleeding and a favourable surgical outcome. Pre-operative embolisation of the feeding vessels may also be considered in such cases.…”

“…Papillary meningioma is a rare malignant meningioma subtype with a predilection for young male patients, similar to this case. 3 Papillary meningiomas present with variable clinical symptoms including seizures, headache, blurred vision, dizziness, tinnitus, vomiting and hemiparesis depending on the location of the tumour and surrounding oedema. 4 In this case, the mass was located along left parietotemporal convexity and headache was the only presenting symptom.…”

“…Vascular neoplasms (like hemangioblastoma, hemangiopericytoma), high-flow vascular lesions (like arteriovenous malformation and aneurysms), benign neoplasms (like Schwannoma and pituitary adenoma) and malignant neoplasms (like glioblastoma) can also demonstrate flow voids. 3 Of these, the closest differential for PM is haemangiopericytoma, an extra-axial, multilobulated heterogeneously enhancing lesion. Unlike meningiomas, these tumours may show signal voids, bone erosion and a narrow-based attachment.…”

“…Flow voids in PM represent fast blood flow through either dilated veins or dilated arteries. 3 Papillary http://www.sajr.org.za Open Access meningiomas can secrete many proangiogenic factors, such as vascular endothelial growth factor (VEGF) leading to more vessel proliferation. 3 High vascularity of PM may lead to significant haemorrhage during surgery.…”

“…Presently, only two reports were found in the literature about PM associated with flow voids. 3 , 4 The different MRI characteristics of PMs have also been discussed because MRI studies on PMs are very limited due to the relative rarity of the lesion.…”