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Intra paranchymal menangioma without dural
attachment is a rare condition we present a 63 years old man with intra
paranchymal cystic lesion which pathological diagnosis is meningioma.
Keywords:
Intracranial tumor, Menangioma, Cyst lesion
INTRODUCTION
Menangioma most common extra axial brain
tumor [1], intraparanchymal with cystic part without dural attachment type is
very rare and can mimic the gilioma or metastasis or other intra axial tumors,
we present a patient with intra paranchymal cystic lesion with mural nodule a
pathological diagnosis is atypical meningioma.
CASE PRESENTATION
An 65 years old man representing with head ache and periodic vomiting
and paralysis of left upper and lower extremity from 10 days ago and
dysarthria, he was treated with oral agent to control essential hypertension
and history for cranial irradiation is negative, in the first step he evaluated
by non-contrast brain CT, hypo dense lesion in right frontal lobe in MRI
evaluation T1 sequences hypo and in T2 sequences hyper signal intraparanchymal
lesion 3*4 cm with perilesional edema in right frontal with mass effect which
have ring enhancement and cystic characteristic with peripheral hyper signal
foci (mural nodule) in T1 with gadolinium (Figure
1), patient go under edema therapy with dexametason (32 mg/day) and manitol
20% (0.5 g/kg) for 48 h patient paralysis improvement not significantly but
dysartia was improve, primary diagnosis based on Imaging metastatic or high
grade glioma, patient evaluated for suspected extra cranial tumor but we can’t
find origin for metastasis, patient go under standard microsurgery tumor
resection, intraoprative finding include intra paranchymal well defined solid
(mural nodule) with cystic part lesion in frontal lobe and have clear margin
without invading to brain parenchyma, bone abnormality and Dural attachment was
not detected. Under the microscope small cell with high ratio of
nucleus/cytoplasm, Large and prominent nucleoli Pattern less or sheet-like
growth (loss of lobular architecture) Foci of “spontaneous” or geographic
necrosis conformity with atypical menangioma (Figure 2).
DISCUSSION
Meningioma is commonly a
solid-form tumor and extra axial with dural attachment [1], intra parenchymal
and cystic menangioma is very rare and in English literature 29 cases reported
[2]. Brain tumor associated with the cyst part frequently seen in gliomas and
metastatic tumors. The incidences of meningiomas that are associated with
cystic lesions are rare 1.6-11.7% [1-3]; several hypotheses mentioned how
cystic part developed. According to the degenerative phenomenon hypothesis, the
development of the cavity is due to intracellular regressive processes that
cause macrocavitation [5-7], such as vacuolar, myxomatous, mucoid and fatty
degeneration, oasis phenomenon also introduced by certain researchrers based on
this hypothesis arterial hyalinization in necrotic part of tumor developed
cavitation, many author s argued that intra tumoral hemmorrgy in angioblastic
menangioma can be developed cystic part, extension of CSF to subarachinoid
space around tumor which was compressed may be source of cavitation and cystic
feature of menangioma, if degenerative process main cause of cyst formation
longer duration of disease most probably associated with cystic part but
menangioma in skull base and posterior fossa rapidly deterioration the patient
condition because of raised intracranial pressure or hydrocephalus in
radiological evaluation we can’t see cystic part based on article cystic
menangioma classified in four class and type 1 is more frequent than other
[1,8] (Table 1). Intra parachymal
menangioma may be developed from ectopic menagoepithelial cell or piamater
which encased in sulcul region and developed intra paranchymal menangioma
another theory emphasis on cranial nerve sheath cells to developed intra
paranchymal menangioma, because of cystic type and intraparanchymal location
and pritumoral edema radiologically diagnosis some time lead neurosurgeon to
glioma or metastasis and sometimes hemangioblastoma [9], but in microscopic
evaluation menangioma feature is typically was seen in these cases because of
older age and MRI finding metastasis and glioma was first diagnosis but
pathological finding reveal us to meningioma [10].
CONCLUSION
Menangioma should be in mind in cases was
radiological finding not typically for glioma and metastasis; we present a
patient with an intraparenchymal cystic lesion which was pathologically
menangioma.
1. Ostrom
QT, Gittleman H, Fulop J, Liu M, Blanda R, et al. (2015) CBTRUS statistical
report: Primary brain and central nervous system tumors diagnosed in the United
States in 2008-2012. Neuro Oncol 17: iv1-iv62.
2. Goldbrunner
R, Minniti G, Preusser M, Jenkinson MD, Sallabanda K, et al. (2016) EANO
guidelines for the diagnosis and treatment of meningiomas. Lancet Oncol 17:
e383-e391.
3. Sahm
F, Schrimpf D, Olar A, Koelsche C, Reuss D, et al. (2016) TERT promoter
mutations and risk of recurrence in meningioma. J Natl Cancer Inst 108: djv377.
4. Louis
DN, Perry A, Reifenberger G, von Deimling A, Figarella-Branger D, et al. (2016)
The 2016 World Health Organization classification of tumors of the central
nervous system: A summary. Acta Neuropathol 131: 803-820.
5. Hanft
S, Canoll P, Bruce JN (2010) A review of malignant meningiomas: Diagnosis,
characteristics and treatment. J Neurooncol 99: 433-443.
6. Kaley
T, Barani I, Chamberlain M, McDermott M, Panageas K, et al. (2014) Historical
benchmarks for medical therapy trials in surgery and radiation-refractory
meningioma: A RANO review. Neuro Oncol 16: 829-840.
7. Abedalthagafi
M, Bi WL, Merrill PH, Gibson WJ, Rose MF, et al. (2015) ARID1A and TERT
promoter mutations in dedifferentiated meningioma. Cancer Genet 208: 345-350.
8. Shiroishi
MS, Castellazzi G, Boxerman JL, D'Amore F, Essig M, et al. (2015) Principles of
T2*-weighted dynamic susceptibility contrast MRI techniques in brain tumor
imaging. J Magn Reson Imaging 41: 296-313.
9. Shiroishi
MS, Habibi M, Rajderkar D, Yurko C, Go JL, et al. (2011) Perfusion and
permeability MR imaging of gliomas. Technol Cancer Res Treat 10: 59-71.
10. Essig
M, Shiroishi MS, Nguyen TB, Saake M, Provenzale JM, et al. (2013) Perfusion
MRI: The five most frequently asked technical questions. AJR Am J Roentgenol
200: 24-34.
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