Intracranial Meningiomas Revealed by Non-Traumatic Subdural Haematomas: A Series of four Cases

Summary. Summary. Objective: A review of the literature shows 33 cases of ipsilateral subdural haematomas (SDH) associated with meningiomas. We suggest that physiopathological mechanisms could be primary haemorrhages from abnormal vessels in the tumours and the opening of the intratumoral haematomas into the subdural space. Our working hypothesis relies on a series of 300 meningiomas operated upon in our department since 1990; of these, 4 were revealed by SDH. Clinical Presentation: The four patients surgically treated in our department had developed a progressive impairment of consciousness. There was no history of trauma, blood dyscrasia or anticoagulant therapy. After diagnosis, the SDH was drained, and the meningeal tumour was totally resected once it had been discovered. In one case, the presence of a tumour was demonstrated by magnetic resonance imaging (MRI) performed only after the evacuation of a recurrent SDH. Intervention: In each case, an acute SDH showing signs of recent bleeding was evacuated. The meningeal tumour discovered proved to be the source of the haemorrhage because of the numerous fresh blood clots both around and inside it. Histology: In the four cases histology showed fresh intratumoral haemorrhages (ITH), large blood vessels with thin endothelial linings and haemosiderin deposits. In this review, SDH is associated with other haemorrhage sites in 24 of 37 cases (33+our 4 cases). ITH was present in 14 cases (40%). Conclusion: The treatment should consist of the extirpation of the meningioma at the same time as the evacuation of the haematoma. If primary ITH from abnormal vessels is the source of SDH, complete meningioma resection should prevent the recurrence of SDH. Subdural membranes and haematomas should therefore be inspected for their intrinsic pathology, especially when there is no history of trauma.     

Initial presentation of a giant gastrointestinal stromal tumour of the stomach with recurrent spontaneous intra-peritoneal haemorrhage

IntroductionGastrointestinal stromal tumours are a rare group of tumours of the digestive tract. In the majority of cases, at the time of the diagnosis, tumours are usually small and patients are asymptomatic or have non-specific symptoms. The occurrence of digestive haemorrhage is relatively common; however, the manifestation with a spontaneous hemoperitoneum is extremely rare, specially if chronic and non-emergent.Case reportWe report an unusual case of a 65-year-old man with a history of alcohol abuse, presenting with abdominal distension due to ascites and a constitutional syndrome. He was found to have a gastrointestinal stromal tumour (GIST) of the stomach associated with a chronic hemoperitoneum, due to recurrent spontaneous haemorrhage. In an elective setting, the lesion was resected completely without rupturing the tumour pseudo-capsule and the patient had an uneventful postoperative course. The tumour was classified as a moderate-risk lesion for aggressive biological behaviour, and imatinib mesylate was initiated as an adjuvant to treatment. No evidence of disease recurrence after one year was noted.Discussion and conclusionGISTs are uncommon and rarely present with spontaneous intra-peritoneal haemorrhage, which may be life threatening. In our understanding, this is the first reported case of the reviewed literature presenting with a chronic hemoperitoneum, due to recurrent brisk episodes of tumour haemorrhage. Tumour rupture and large tumour size are two poor independent prognostic tumour factors for recurrence. Despite this, the patient remains free of disease after surgery and instituted adjuvant imatinib mesylate.     

Intracranial haemorrhage from meningiomas: a report of five cases

Intracranial haemorrhage from meningiomas is rare and carries a mortality of over 40%. The authors present five cases presenting with intratumoral, intracerebral, subarachnoid or subdural haemorrhage. The relevant literature is reviewed and the pathology and possible mechanisms of haemorrhage in these tumours are discussed.     

Intracranial meningioma of an infant: a case report

An 11-month-old male infant with intracranial meningioma is presented. Intracranial meningiomas in infancy under the age of 1 year are extremely rare, and only 22 cases have been reported previously. The authors reviewed the clinical and pathological findings of these meningiomas including our case. The patient feel ill with convulsive attacks followed by unconsciousness at 11 months of age without any other neurological deficit. Computed tomographic scannings revealed a high density lesion in the frontal region. The tumor was located entirely in the frontal lobe 2 cm anterior to the Sylvian vein and was removed en bloc. It was 3 X 3 X 3 cm in diameter and 10 g in weight. Histological diagnosis was of fibroblastic meningioma. He was discharged two weeks after the operation without any neurological deficits. Several characteristic features of meningiomas in infant under 1 year old were drawn from the review of literature in comparison with those of meningiomas in adult. 1) Predominant sex was male (16/23). 2) All meningiomas developed in the supra-tentorium. 3) Eight of 18 tumors being described did not have the dural attachment. 4) Nine of 16 tumors showed cyst formation. 5) The most cases were histologically diagnosed benign (17 of 22), and 15 cases was fibroblastic meningioma.     

Intraspinal cyst communicating with the intervertebral disc in the lumbar spine: discal cyst.

STUDY DESIGN: A retrospective case study of patients with intraspinal cyst having a distinct connection with the corresponding intervertebral disc. OBJECTIVES: To propose a new clinical entity, "discal cyst," by clarifying the clinical, radiographic, and histologic aspects of the disease. SUMMARY OF BACKGROUND DATA: Several types of intraspinal cysts with different pathogenesis, causing symptoms indistinguishable from those of lumbar disc herniation, have been reported, such as perineural cysts, synovial cysts, and ganglion cysts. However, to the authors' knowledge, no detailed analysis has been made of cysts that have a distinct connection with the corresponding intervertebral disc. METHODS: Clinical pictures, radiographic findings, and surgical and histologic findings in eight surgically treated patients with intraspinal cyst having a distinct connection with the intervertebral disc were reviewed. Possible pathogenesis and a proposal for nomenclature were also discussed. RESULTS: This disease can be characterized by (1) clinical symptoms indistinguishable from those of typical disc herniation, manifesting as a unilateral single nerve root lesion; (2) incidence at slightly younger age and at upper intervertebral levels than with typical disc herniation; (3) T1 low signal and T2 high signal intensity, round to oval mass lesion on magnetic resonance imaging, compatible with a liquid-containing cyst; (4) minimal degeneration of the involved disc, either on discography/computed tomographic discography or magnetic resonance imaging; (5) a connection between the cyst and the corresponding intervertebral discs on discograms with severe radiating pain in the affected leg at the time of injection; (6) immediate relief of symptoms after simple removal of the cyst; (7) cyst wall consisting of dense fibrous connective tissue containing bloody to clear serous discharge; and (8) absence of disc materials and a specific lining cell layer on histologic examination. Although the exact cause is unknown, underlying minor disc injury may serve as a basis for cyst formation. CONCLUSION: Eight cases of intraspinal cysts communicating with the intervertebral disc presenting symptoms identical to those of disc herniation are presented. Because all cysts were connected to the corresponding disc and the development of the cyst was assumed to be related to underlying disc injury, it is proposed to name this clinical entity discal cyst.     

Revisited: spinal angiolipoma--three additional cases.

Angiolipomas are benign tumours which usually arise from subcutaneous tissue, particularly in the forearm, but they do occur rarely in the spinal canal. To the best of our knowledge 60 cases of histologically confirmed spinal angiolipoma have been reported in the medical literature. They show a female predominance (1.6:1), and the mean age at presentation is 43 years. They usually arise in the thoracic spine, most cases presenting with slowly progressive signs and symptoms of cord compression. Rarely, massive acute haemorrhage into the tumour may herald its presence. Surgical resection or decompression are the most satisfactory methods of treatment in most patients. We describe three further cases of spinal angiolipoma, and discuss their aetiology, pathogenesis, clinico-pathological features and surgical management.     

Intracerebral meningiomas

Opinion statement Meningiomas are extra-axial brain tumors of middle to late adult life, and they have a female predominance. Overall, 90% of meningiomas are benign, 6% are atypical, and 2% are malignant. Most patients diagnosed with a meningioma decide to have it removed surgically and are advised to do so based on their neurologic symptoms. Complete surgical resection is usually curative. For incompletely resected or recurrent tumors not previously irradiated, radiotherapy is administered. Radiotherapy may be administered as conventional external beam irradiation or stereotactically. Stereotactic radiotherapy, as linear accelerator or gamma-knife radiosurgery is increasingly used. Advocates of stereotactic radiotherapy have suggested this therapy in lieu of surgery particularly for poor surgical risk patients, patients with meningiomas in eloquent or surgically inaccessible locations, and patients of advanced age. When the meningioma is unresectable or all other treatments (surgery, radiotherapy) have failed, immunochemotherapy may be considered. Hydroxyurea, interferon-alpha, tamoxifen, and mifepristone have been modestly successful in patients with recurrent meningiomas, whereas cyclophosphamide, adriamycin, and vincristine, ifosfamide/mesna, or adriamycin/dacarbazine have been administered to patients with aggressive or malignant meningiomas.     

Spinal cord herniation into an extensive extradural meningeal cyst: postoperative analysis of intracystic flow by phase-contrast cine MRI

We report a patient with idiopathic spinal cord herniation who underwent postoperative myelography and phase-contrast cine magnetic resonance imaging (MRI) to clarify the condition of the ventral cystic lesion into which the spinal cord had been herniated. This 58-year-old man showed symptoms and signs compatible with Brown-Séquard syndrome. A myelogram and MRI showed that the spinal cord was incarcerated in a small space, and this finding led to the diagnosis of spinal cord herniation. In the operation, the herniated spinal cord was returned to the initial intradural space, and the dural defect was enlarged to prevent recurrence of the herniation. After the operation, leg muscle strength improved and bladder and bowel dysfunction resolved, but analgesia was unchanged. Postoperative myelography revealed a very large extradural cystic lesion, which extended from C2 to L1 vertebral level. A cerebrospinal fluid (CSF) flow study of the intradural space disclosed a near-normal pattern, but the intracystic CSF dynamics were abnormal. In the intracystic space at just the upper level of the lesion, cranial flow (reverse directional flow in comparison with the intradural flow) was seen in the systolic cycle after momentary fast caudal flow, and these CSF dynamics may have been related to the spinal cord herniation. Received for publication on Jan. 21, 1999; accepted on May 28, 1999     

Multiple complications from an intracranial epidermoid cyst: case report and literature review

Intracranial epidermoid and dermoid tumors are unusual benign lesions that are potentially curable. Subtotal removal carries a high incidence of recurrence, plus the rare possibility of carcinomatous degeneration of the remnants. Aseptic meningitis from spillage of cyst contents into the subarachnoid space is frequent after operation and has been reported to occur spontaneously. A case of a patient with a posterior fossa epidermoid cyst presenting with multiple bouts of aseptic meningitis in which squamous cell carcinoma arose in recurrent tumor 5 years after subtotal removal of the benign lesion is described.     

Spinal cystic meningioma presenting as a ring enhancing lesion on MRI

Spinal meningiomas are much more common in women. The peak age incidence of presentation occurs in the sixth decade. Cystic meningiomas are rare and seem to have a predilection for children. We report a case of cystic spinal meningioma in a young man presenting as a ring enhancing lesion on Magnetic Resonance Imaging (MRI). This case is unusual because of the atypical features of the tumour, the relatively young age and sex of the patient.     

Intracranial and intratemporal meningiomas with primary otologic symptoms

Intratemporal extensions of cerebellopontine angle (CPA) meningiomas are unusual and primary intratympanic meningiomas are extremely rare. The initial symptoms of both types are otologic. The presenting symptoms of even large meningiomas of the cerebellopontine angle can also be otologic. In this article we report the clinical features, diagnosis, and management of five CPA meningiomas, three combined intratemporal and CPA meningiomas, and one primary intratympanic meningioma.     

Spinal arteriovenous malformations and subarachnoid haemorrhage.

Seventy patients with spinal arteriovenous malformations (AVMs) referred to the author over a 25-year period (1958-82), were equally divided between congenital, intradural and acquired, dural lesions. Amongst the intradural AVMs, were 22 with subarachnoid haemorrhage (SAH), a presenting feature in 18. The clinical findings in these 22 patients are tabulated, the radiological and operative findings indicated, and an account given of the overall outcome. Early operation is recommended, with a good prognosis and prevention of further haemorrhage in most cases. An extended follow-up has been maintained. The influence of menstruation, pregnancy and the puerperium on AVM symptoms is described.     

Case report of Brunner’s gland hyperplasia: A rare “mimic” of malignant pathology

IntroductionBrunner’s gland hyperplasia is a rare, benign lesion of the duodenum. The symptomology can range from asymptomatic (as an incidental finding on endoscopy) to gastrointestinal obstruction or haemorrhage.Case presentationWe report a case of a 60-year-old man presenting with post-prandial vomiting and weight loss. Inpatient evaluation led to the likely diagnosis of a duodenal malignancy for which the patient underwent a laparotomy and proximal duodenectomy.Clinical discussionBrunner’s gland hyperplasia is a rare, benign condition that can be overtreated due to the difficulty in obtaining an accurate pre-operative diagnosis. The literature has been reviewed to discuss the approach to diagnosis.ConclusionThis case highlights the potential for Brunner’s gland hyperplasia mimicking a malignancy.     

Ultrasound of the Breast

Breast ultrasound (US) has developed into an essential imaging modality for evaluation and management of the patient with breast symptoms or mammographic abnormalities. US is usually an adjunct to mammography and the clinical examination but in the young patient presenting with symptoms sonography may be the initial or sole imaging procedure. A screening role has not been established, but there may be a subset of high-risk patients for whom US will prove useful as a screening adjunct. Proper selection of equipment, careful attention to the technical aspects of scanning, and awareness of artifacts are necessary to avoid misinterpretation and to demonstrate subtle changes in breast architecture which indicate a malignancy. Thorough knowledge of the range of normal appearances of the breast and the alterations produced by breast disease are essential requisites for accurate evaluation and lesion characterization. Two of the most important clinical advances in breast US have been the development of criteria that allow improved benign/malignant differentiation of solid breast lesions and the use of US to guide interventional procedures. Other developments such as Doppler and contrast agents remain investigational.     

Cathepsins B and L are markers for clinically invasive types of meningiomas

OBJECTIVE: Meningiomas are benign neoplasms that derive from coverings of the brain. Approximately 10% of benign tumors progress into atypical, malignant tumors, thus constituting a subset of histopathologically benign tumors that are clinically invasive. The aim of this study was to evaluate cathepsins B and L and their inhibitors as new prognostic factors that could distinguish malignant from benign forms of meningiomas. METHODS: Using immunohistochemical analysis and specific monoclonal antibodies, we evaluated the levels of cathepsins B and L and the levels of the endogenous cysteine proteinase inhibitors stefin A and cystatin C in 88 meningiomas. Immunohistochemical scores were determined as the sum of the frequency (0-3) and intensity (0-3) of immunolabeling of the tumor cells. RESULTS: Of the 88 tumors studied, 67 were benign meningiomas and 21 were atypical meningiomas. Among the benign group, nine tumors had certain features of malignancy. These tumors were classified as border benign meningiomas, and the rest were classified as clear benign meningiomas. A high immunohistochemical score (4-6) for cathepsin B was more frequent in atypical tumors than in clear benign tumors (P < 0.001). Compared with clear benign tumors, higher cathepsin B immunohistochemical scores were found in atypical tumors (P < 0.001) and border benign tumors (P < 0.03). No statistical difference in immunohistochemical staining of cathepsin B was found between atypical meningiomas and border benign meningiomas. Higher expression of cathepsin L was found in atypical tumors as compared with clear benign tumors (P < 0.03), but it was not observed in border benign as compared with clear benign meningiomas. No immunostaining for stefin A and cystatin C was detected in any of the tumors. CONCLUSION: We show that the levels of cathepsin B and cathepsin L antigens are significantly higher in invasive types of benign meningioma. Specifically, cathepsin B may be used as a diagnostic marker to distinguish histomorphologically benign but invasive meningiomas from histomorphologically clear benign tumors.     

Thoracic disc herniation. Improved diagnosis with computed tomographic scanning and a review of the literature

Thoracic disc herniation is uncommon. One of the main problems in the treatment of thoracic disc herniation has been the lack of accuracy of diagnostic tests. Now, with the use of computed tomographic scanning with and without metrizamide in the subarachnoid space, this accuracy has greatly improved. Computed tomography scanning can demonstrate the type and level of the lesion even when the myelographic study is negative. We have reviewed 280 cases; a peak incidence was noted in the fourth decade with 75% of the protruded discs occurring below T-8. Back pain was the most common presenting symptom followed by sensory disturbances. By the time of diagnosis, 70% of the patients had signs of spinal cord compression. A small group of patients could be identified that invariably had a good prognosis. They had a history of trauma, symptoms lasting less than a month, and soft disc herniation. Regarding the results of surgical treatment, there was a success rate ranging from 57% for decompressive laminectomy to over 80% for the posterolateral, lateral, and transthoracic approaches.     

Torsed reactive nodular fibrous pseudotumor in an adolescent: case report and review of the literature

We describe a case of a 13-year-old girl presenting with acute abdominal pain and imaging suggesting acute appendicitis. Upon laparoscopy, she was found to have a mass attached to the jejunum that had torsed upon its blood supply. On histopathologic studies, the mass was determined to be a reactive nodular fibrous pseudotumor. This lesion is a benign neoplasm that may arise from the gastrointestinal tract and has only been recently described in the literature. Our case is unique because it is the first report of reactive nodular fibrous pseudotumor presenting as a torsed polypoid lesion and the first arising in an adolescent.     

Inflammatory myofibroblastic tumor (inflammatory pseudotumor) of the neck infiltrating the trachea

Inflammatory myofibroblastic tumor (IMT), popularly known as inflammatory pseudotumor, is a slow growing quasi-neoplastic lesion with a distinct histologic appearance and benign clinical course. A case of a neck IMT with infiltration into the trachea causing asthmalike symptoms in a 12-year-old girl is described. Both tracheal and neck IMT have been described, but no other case has displayed this infiltration. A review of the pertinent literature and the etiology, diagnosis, treatment, and outcomes of this tumor are discussed. It is important to consider IMT in a differential diagnosis because it can be easily misdiagnosed as a malignancy. A surgeon must not perform radical surgery, radiation, or chemotherapy until a final pathologic diagnosis is made because of the nature of this lesion.