Malignant meningioma with repeated multiple recurrence. A case report.

A case of malignant meningioma with repeated multiple recurrence was reported. A 22 year-old male first underwent the total removal of left parieto-occipital convexity meningioma in 1965. Although he had lived an uneventful life after the operation, he recognized motor weakness of the left lower limb in April 1985 when he was 41 years old and CT revealed a large tumor in the parieto-occipital parasagittal region. He underwent the total removal of the tumor and cranioplasty on May 23, 1985. After the second operation, repeated recurrence of multiple tumors was seen, which were in the frontal, parietal and occipital convexities, parasagittal regions and falx. He underwent further operations on January 23, 1986, December 11, 1986, March 30, 1987 and July 20, 1987 in addition to the first and second ones. Histological study on every operation indicated malignant meningioma with mitosis, hypercellularity and necrosis. Though radiotherapy (56 Gy whole brain irradiation) was conducted after the sixth operation, multiple tumors recurred and clinical symptoms and signs deteriorated gradually and he finally died September 9, 1989. In malignant meningioma such as our case, early aggressive radiotherapy and chemotherapy should be considered besides radical operations.     

Meningioma associated with Werner syndrome--case report--

A 53-year-old man presented with a rare meningioma associated with Werner syndrome. Screening brain magnetic resonance (MR) imaging with gadolinium had detected multiple homogeneously enhanced tumors in the right convexity and in the anterior and posterior thirds of the falx cerebri after surgery for osteosarcoma in his right leg at age 52 years. Ten months later, the right convexity tumor was removed because follow-up MR imaging detected tumor growth. The histological diagnosis was transitional meningioma. The postoperative clinical course was good and the patient remains healthy. Review of the literature found meningiomas associated with Werner syndrome occur about two times more frequently in men than in women, and typically in the fourth decade. Most meningiomas associated with Werner syndrome are benign, but are sometimes complicated with extracranial tumors such as sarcoma, thyroid carcinoma, and others. Patients with meningioma associated with Werner syndrome should be carefully followed up to detect the occurrence of other extracranial tumors such as sarcoma by brain MR imaging, echography, or body computed tomography.     

Cystic falx meningioma: report of a case with difficulty in radiologic diagnosis]

A case of cystic falx meningioma in the frontal region in which preoperative neuroradiologic diagnosis was difficult is reported. This 33-year-old man had suffered from epileptic seizures three times in one month. Physical and neurological examinations on admission were normal. A cystic mass with a small nodule was found on CT in the frontal region. Thin wall was enhanced smoothly and the nodule attached to the falx was enhanced heterogeneously. The mass was considered to be an extra-axial lesion on MRI. The right anterior falcine artery seemed to feed the mass. Bifrontal craniotomy was performed. Cyst was evacuated, and a soft reddish mass was subtotally removed. Cyst fluid was yellowish and protein content was 3.5 g/dl. Histopathological diagnosis was a meningotheliomatous meningioma and tumor cells were present also in the thin cyst wall. At the second operation the mass was completely removed, cyst wall inclusive. When we encounter a cystic mass in the sites of predilection of meningiomas, we have to consider the possibility of a cystic meningioma. If the mass has meningeal vascularization, a correct diagnosis is not difficult. Taking the location of the mass into consideration, an accurate interpretation of CT and MRI findings indicating extra-axial nature of the mass is indispensable.     

Multiple meningiomas of the spinal canal and posterior fossa--case report

The majority of multiple meningiomas are associated with von Recklinghausen's disease, and those that are not, i.e., true multiple meningiomas, particularly with simultaneous development in the posterior fossa and spinal canal, are very rare. We recently encountered a case of true multiple meningiomas in which the lesions were found simultaneously in the left posterior fossa and the upper thoracic spinal canal. The spinal meningioma consisted mainly of meningotheliomatous components, and that in the posterior fossa of fibroblastic components. Both tumors were surgically removed. The cause of the multiplicity in cases of true multiple meningiomas is unknown. Incidental multiplicity is a consideration when the number of tumors is relatively small. Spinal meningiomas are often undetected in the absence of neurological symptoms. However, even if von Recklinghausen's disease is not present, and particularly when more than two meningiomas have been discovered, the patient must be carefully examined for other tumors.     

A case of convexity meningioma associated with chronic subdural hematoma

There are 5 reported cases of meningioma complicated by chronic subdural hematoma so far as we reviewed. Considering frequency of occurrence, association of meningioma and chronic subdural hematoma is very rare. Recently, we experienced with a case of convexity menigioma complicated by chronic subdural hematoma. The patient was a 61-year-old woman who complained of headache and numbness of the left hand. She received hysteromyomectomy 28 years before but had no past history of trauma of the head. She suffered from frequent profound pain in both orbits for one year, and she consulted a neighboring practitioner due to occurrence of numbness of the left hand and malaise. Then, CT scan revealed abnormalities, so that she was referred to our center. On admission, neurological oxamination revealed no abnormalities but plain X-ray film of the skull showed a round destruction in the right parieral bone. CT scan showed a round high density area of 3 cm in diameter in the right parietal region, this is markedly enhanced with contrast media. There is a crescent-shaped low density area extending forward from the high density area. The body of the right lateral ventricle is totally collapsed. Selective arteriography of the right external carotid revealed tumor stain in the parietal region. Therefore, under the diagnosis of association of chronic subdural hematoma and convexity meningioma, craniotomy of the right frontal, parietal and temporal regions was carried out and a meningioma of 10 g, and a subdural hematoma with its capsule touching the maningioma were entirely extirpated.(ABSTRACT TRUNCATED AT 250 WORDS)     

A case of brain metastasis of rhabdomyosarcoma in a child

We report here a specific case of metastatic brain tumor orienting from rhabdomyosarcoma. An 11-year-old boy came to our hospital with complaints including headache, exophthalmos and tumors in the right frontal and left occipital region. 6 months previously subtotal removal of rhabdomyosarcoma in his right foot had been performed. CT scan demonstrated tumors in the right orbit, right frontal region and left occipital region. The tumors existed bilaterally in the skull and markedly enhanced by contrast medium. But the changes of the cranium were mild, only the dipole was slightly dilated. MRI showed that the tumors were extraaxial masses. Right external carotid angiogram revealed numerous tumor vessels fed by the meningeal artery. On April 3rd, biopsy was performed at the right frontal region. The tumor had spread in the epidural space but the cortical surface seemed to be intact. Histologically, the tumor consisted of small round cells and revealed multinuclear giant cells. It involved the skull bone, dura mater and subdural tissues. Accordingly the tumor was diagnosed as rhabdomyosarcoma. Although tumor increased rapidly, the intracranial region did not change remarkably. It was an interesting phenomenon. Eventually, rhabdomyosarcoma metastasized to the lung, and the patient died due to respiratory distress.     

Two cases of von Recklinghausen's disease with multiple brain and spinal tumors]

The authors reported two cases of von Recklinghausen's disease with multiple brain tumors and multiple spinal tumors. The first case, a 21-year-old man who had a past history of optic gliomas was admitted because of gait disturbance. Computed tomography (CT) and magnetic resonance imaging (MRI) showed calcification of the basal ganglia, bilateral C-P angle tumors, cystic cerebellar tumor and arachnoid cyst in the quadrigeminal cistern. Myelography and MRI revealed multiple spinal tumors. Surgical management was performed and cerebellar tumor was histologically confirmed to be a pilocytic astrocytoma. Spinal tumors were also astrocytomas. The second patient, a 56-year-old woman suffered from right iliac pain, right hemiparesis and motor aphasia. CT revealed two round tumors in the left cerebral hemisphere and bilateral C-P angle tumors. Myelography and MRI demonstrated multiple intradural-extramedullary spinal tumors. Histologically, supratentorial tumors were transitional meningiomas and spinal tumors were neurinomas. It is well known that von Recklinghausen's disease is often associated with brain or spinal tumors. But, in the literature, only 22 cases of von Recklinghausen's disease combined with multiple brain tumors with different histological types and multiple spinal tumors have been reviewed. With our two cases, the average age of these 24 cases was 28.6 years old, nine cases were male and 15 cases were female. All patients had C-P angle tumors and 23 cases were combined with intracranial meningiomas. In this paper, the clinical features and diagnostic aspects were discussed.     

Osteoblastic skull metastasis of lung cancer

A case of osteoblastic skull metastasis of lung cancer is reported. A 56-year-old female patient was admitted to our hospital with complaints of headache and tumor of the right parietal bone. A plain skull X-ray showed hyperostotic feature of the right parietal bone. CT scan displayed that right parietal bone became thick and osteoblastic. Soft tissue was shown in the hyperostotic bone under MRI. An external carotid angiogram showed that the skull tumor was fed by the middle meningeal artery. The skull tumor and 2 solid intracerebral tumors were extirpated. Histological examination revealed adenocarcinoma in the skull and intracerebral lesions. The present case indicates that osteoblastic stimulating factor may be secreted by lung cancer.     

A case of vacuolated meningioma

A rare case of falx meningioma with extensive vacuolization was reported. A 57-year-old woman was admitted to Okayama University Hospital because of numbness in her left lower limb. A plain CT scan showed a hypodense mass in the right frontal region with marked enhancement after contrast medium injection. MRI on T1 weighted images showed low intense mass with the so-called "peritumoral band" of low intensity at the periphery of the mass. Angiogram showed a mass effect and a tumor stain fed by the right pericallosal artery and left middle meningeal artery. The mass was excised en bloc. Microscopic examination demonstrated tumor cells with varied sized vacuoles, which were mostly fat-negative, except for small islands with typical meningothelial cells in the periphery of the tumor. Ultrastructurally, there were two kinds of vacuole in the tumor cells. The smaller, round vacuoles were in the cytoplasm, while the larger ones were in the extracellular space. The cell processes had developed junctional complex, and numerous cytoplasmic filaments were evident. With these findings, this mass was diagnosed as vacuolated meningioma. It is important especially in frozen section not to misdiagnose the tumor as liposarcoma, chordoma, metastatic brain tumor and so on.     

A case of convexity meningioma en plaque

We present a case of convexity meningioma en plaque (MEP). A 51-year-old male occasionally suffering from right parietalgia and numbness of left upper limb. An intracranial abnormal mass was pointed out incidentally by the brain check up. Computed tomographic (CT) scans demonstrated a hyperostosis and an enhanced abnormal mass at the right front-parietal region. Magnetic resonant images (MRI) revealed a carpet like tumor extended along the dura mater. Cerebral angiography disclosed feedings from parietal branches of right middle meningeal artery and superficial temporal artery. The tumor was removed subtotally with adjacent dura mater, leaving the portion of close adhesion to the brain parenchyma. Histologic diagnosis was transitional meningioma. Immunohistological stainings showed a high staining index (6.9%) of MIB-1 (Ki-69 antigen) and high expression of metalloproteinase-9 (MMP-9), especially along the dura mater. Convexity MEP is so rare that we review previous reported cases of convexity MEP, and discuss the clinicopathologic features on that.     

Recurrent meningioma with malignant changes and extracranial multiple metastases

A case of recurrent meningioma with malignant change and extracranial multiple metastases is reported. A 51-year-old female was operated on and left parasagittal meningioma was extirpated by Simpson grade II. Histological diagnosis was fibroblastic and transitional meningioma with slight atypism. Six years later, however, the tumor (transitional meningioma with slight mitosis) recurred in the same portion and was removed again by Simpson grade II. Further more, four years after the second operation, bilateral parasagittal meningioma (atypical meningioma; transitional type) was extirpated by Simpson grade I including superior sagittal sinus and falx. Only eight months after the last operation, a few tumors with central necrosis were demonstrated in the bilateral parasagittal area on a computerized tomography scan and she received radiation therapy. But the tumor had metastasized to the extracranial multiple organs including lungs, liver, pancreas, adrenal gland, muscles, multiple bones and lymph nodes. Post mortem diagnosis was malignant meningioma. We reviewed and discussed the characteristics of metastasizing meningioma, the effectiveness of radiation therapy on the prevention of recurrence of meningioma and the curative effect of radiation therapy for recurrent or metastasized meningioma.     

Three cases of acute interhemispheric subdural hematoma

Traumatic acute subdural hematomas over the convexity of the cerebral hemispheres are often encountered, but acute interhemispheric subdural hematomas are rare. Fourty-eight cases of acute subdural hematomas was admitted to our hospital between 1977 and 1986, and three cases of them (6%) were located in the interhemispheric subdural space. In this paper, these three cases are reported with 20 documented cases. Case 1: an 81-year-old female was admitted to our hospital because of headache, nausea and vomiting. She hit her occiput a week ago. CT scan demonstrated contusion in the right frontal lobe and a high density in the interhemispheric space of the right frontal region. Her complaints disappeared gradually by conservative therapy and she returned to her social life. Case 2: a 50-year-old male fell downstairs and hit his vertex. As he lost consciousness, he was admitted to our hospital. He was stuporous and had left-hemiparesis. Skull X-ray film showed fracture line extending from the right temporal bone to the left parietal bone across the midline. CT scan revealed intracerebral hematoma in both frontal lobe and right parietal lobe and subarachnoid hemorrhage in the basal cistern and Sylvian fissure of the right side. And interhemispheric subdural hematoma in the right parietal region was visualized. Angiography demonstrated a lateral displacement of the right callosomarginal artery and an avascular area between the falx and the callosomarginal artery. After admission his consciousness recovered and convulsion was controlled by drug. Left-hemiparesis was improved by conservative therapy and he was discharged on foot.(ABSTRACT TRUNCATED AT 250 WORDS)     

Lymphoplasmacyte-rich meningioma: a report of three cases and a review of the literature]

We report three patients (a 36-year-old man, a 41-year-old woman, and a 22-year-old man) with lymphoplasmacyte-rich meningioma who manifested characteristics on radiological and blood examinations. Two were hospitalized with gradual deterioration of hemiparesis and one with general convulsive seizure. Radiological examination revealed typical meningiomas of convexity in two and that of falx in one. Two of the patients showed large perifocal edema. Anemia was found in one patient and an elevated level in the zinc sulfate turbidity test was noted in all cases. Abnormal findings in laboratory examination improved quickly, whereas perifocal edema remained for six months after tumor removal. The tumors were histologically confirmed to be meningioma with massive infiltrates of plasma cells and lymphocytes. Seventeen cases of lymphoplasmacyte-rich meningioma that have been reported to date including our three cases were reviewed.     

Multiple brain tumours with von Recklinghausen's disease

Summary Over the past 10 years we have experienced 33 cases of von Recklinghausen's disease, among whom 5 were cases of multiple (3 or more) brain tumours. In the past we have extirpated multiple tumours in a one-stage operation, but the results were poor. Recently, we have done multi-stage operation in two cases thought to require surgical treatment and have obtained satisfactory results.We have discussed the autopsy results of our own case of multiple neurinomas and meningiomas and have reviewed the 44 reported cases of von Recklinghausen's disease in whom the presence of three or more brain tumours had been confirmed at surgery or autopsy.     

Meningeal hemangiopericytoma manifesting as massive intracranial hemorrhage--two case reports

Meningeal hemangiopericytoma is rare, and only seven cases have manifested as intracranial hemorrhage. We treated two patients with meningeal hemangiopericytoma manifesting as life-threatening massive intracerebral hemorrhage. Case 1: A 66-year-old woman presented with consciousness disturbance and left hemiparesis. Computed tomography showed a mass lesion in the right frontal parasagittal region and massive hematoma in the brain tissue at the medial border of the lesion. Immediate evacuation of the hematoma was performed. Postoperative magnetic resonance imaging revealed a well-enhanced mass lesion with small intratumoral hemorrhage. The tumor was removed totally through a bilateral frontal craniotomy. The postoperative course was uneventful. The histological diagnosis was meningeal hemangiopericytoma. Radiotherapy was not performed. Case 2: A 59-year-old man presented with consciousness disturbance. Computed tomography showed a mass lesion in the right frontotemporal convexity region and massive hematoma in the brain tissue at the medial border of the lesion. His neurological condition was refractory to any treatment and the clinical diagnosis of brain death was confirmed. Autopsy was performed and the histological diagnosis was meningeal hemangiopericytoma. Meningeal hemangiopericytoma manifesting as intracranial hemorrhage is quite rare, but carries the risk of life-threatening massive bleeding from the tumor.     

Thoracic intramedullary neurinoma with multiple intracranial meningiomas; case report]

A 42-year-old man suffered from numbness in his right leg in May, 1989, and was admitted to another hospital for examination. Computed tomography and magnetic resonance imaging revealed thoracic intramedullary tumor and multiple intracranial tumors in the right frontal convexity, the right lower surface of the tentorium and the right parietal parasagittal region. In December, he underwent craniotomy and the right frontal tumor was totally removed. It was diagnosed histologically as meningioma. Because of continuing numbness in his right leg, he visited a neurologist at our university and was referred to us for removal of the spinal tumor on April 25, 1990. Neurological examination on admission revealed mild weakness of his right leg and exaggerated right knee jerk. Though he complained of numbness in his right leg, no sensory disturbance was demonstrated objectively. His bladder-bowel function was normal. There were no café au lait spots or subcutaneous neurofibromas. He and his mother were positive for anti-HTLV-1 (human T-lymphotrophic virus type 1) antibody. On May 1, laminectomy was performed at Th-7 to Th-9, and a yellowish brown tumor was found occupying the right posterolateral portion of the cord and extending to the surface. The dorsal root of Th-9, which was involved in the tumor, was cut and the tumor was subtotally removed. Histological examination showed interlacing bundles of spindle cells and loose areolar region. Immunohistochemically, the tumor was positive for S-100 protein and negative for GFAP. From these findings, the tumor was diagnosed as neurinoma. The postoperative course was uneventful, numbness disappeared, and the patient was discharged without neurological deficits.     

A case of multiple myeloma presenting with a subcutaneous mass: significance of "dural tail sign" in the differential diagnosis of the meningeal tumors

A 65-year-old female was admitted to our hospital with a 6-month history of a gradually enlarging subcutaneous mass in the frontal region. Neurological examination on admission showed no significant abnormality. Skull X-P showed an osteolytic lesion of the frontal bone. External carotid angiogram demonstrated a tumor stain fed by the middle meningeal artery. Computed tomography (CT) showed a slightly high density mass with a marked homogeneous enhancement. MRI revealed an iso-intensity mass on both T1- and T2-weighted images. Gd-DTPA-enhanced T1-weighted images showed a mass with a marked homogeneous enhancement with the "dural tail sign" in the dura adjacent to the tumor. The tumor was totally removed; this mass was diagnosed as a multiple myeloma. No tumor cells were seen in the dura adjacent to the tumor and the mechanism of dural enhancement around the tumor was not clear. However, it is possible that the "dural tail" is due to increased vascular permeability of the dural vessels. Although the "dural tail" sign has been considered as a highly specific feature of meningioma, multiple myeloma can show the same findings on MRI. Therefore, it is important to consider the possibility of multiple myeloma in the differential diagnosis of meningeal tumors.     

A case of convexity cavernous hemangioma associated with meningioma

A case of convexity cavernous hemangioma associated with sellar meningioma with parasellar extension is presented. A 61-year-old female who had complained of left blepharoptosis and diplopia was admitted to our hospital. On admission she showed left oculomotor nerve palsy. Plain CT revealed an isodense mass in the sellar and parasellar region. Computed angiotomography demonstrated that this mass was enhanced heterogeneously and filled the sellar turcica and extended superiorly. And homogeneously enhanced mass in the convexity without mass effect was observed. Angiogram revealed no tumor stain in any phase. With these findings, this case was diagnosed as the multiple meningiomas preoperatively. Left frontotemporal craniotomy was carried out, and subtotal removal of sellar and parasellar tumor and total removal of convexity tumor were performed. Pathologically the sellar and parasellar tumor was diagnosed as meningioma, convexity tumor as cavernous hemangioma derived from dura mater. Convexity cavernous hemangioma derived from dura mater is very rare, only one case was reported previously. Only 2 cases of cavernous hemangioma associated with meningioma have been reported in the literature. Correlation between cavernous hemangioma and meningioma is discussed. It is possible to owe this complication to the developmental abnormality concerning with inner factor like genetic factor and so on, because both tumors are mesodermal origin. However it is proper to regard that this complication occurred by chance.     

Unusual clinical presentation of a presumed pineal germinoma with two disseminated lesions

We report a case of a presumed pineal germinoma in a 28-year-old man. Although the pineal body, the presumed primary lesion, was small, there were two disseminated tumors, one in the posterior fossa and the other in the left parietal region. The initial symptom was cerebellar ataxia. These two disseminated tumors had attachments to the inferior surface of the cerebellar tentorium and the dura mater of the parietal convexity, respectively, and they were fed by external carotid artery branches, like meningiomas. Neither angiography nor magnetic resonance imaging could provide the differential diagnosis between germinoma and meningioma. Computed tomographic scanning revealed slight enlargement of the pineal body suggestive of a germinoma.     

Intracranial localized Castleman's disease. Case report

A 68-year-old woman presented with generalized clonic seizure following a 2-month history of initiative loss, incoherent speech, headache, and left hemiparesis. No systemic signs or symptoms were seen and laboratory studies were within normal range. Computed tomography and magnetic resonance imaging demonstrated a well-delineated small mass with homogeneous enhancement in the right parietal convexity, associated with unusually extensive perifocal edema compared to the size of the mass. Cerebral angiography showed a faint stain fed by the middle meningeal artery. These imaging features were very similar to those of meningioma. Full recovery from the symptoms was achieved by total removal of the lesion and no recurrence was found after 3 years. Histological examination identified the hyaline-vascular type of angiofollicular lymph node hyperplasia (Castleman's disease). Castleman's disease involving the central nervous system is rare, with only 12 previous cases, but should be considered in the diagnosis of intracranial meningeal tumors. The treatment of choice for localized Castleman's disease is complete surgical resection, which is curative in most of the cases.