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Meningioma, atypical: case 1

CLINICAL HISTORY:
This 61-year old man presents with rapidly progressive dementia, manifesting as memory disturbances, disorientation, changes in personality and troubles with word finding.

NEUROLOGICAL EXAMINATION confirms higher cortical functional disturbances.

CT:
a) NON-CONTRAST SCAN (IMAGE 1): There is midline shift to the right with a multicystic space-occupying lesion in the left temporal region. At the posterior border the cysts have a definite thick wall (arrowheads).

b) CONTRAST-ENHANCED SCAN (IMAGE 2): There is very inhomogeneous enhancement of the tumor with non-enhancing cystic parts alternating with more enhancing solid parts, while the walls of the cysts sometimes appear thickened.

MRI:
a) TRANSAXIAL T2-WEIGHTED (2500/90/1) SPIN-ECHO SEQUENCE (IMAGES 3 AND 4): Confirmation of the markedly inhomogeneous character of the tumor, with a multilobular predominantly cystic appearance. In one of the cysts a fluid level can be seen (arrowheads). Diffuse hypointense strands within the lesion point to septations within the tumor.

b) TRANSAXIAL T1-WEIGHTED (600/15/1) SPIN-ECHO SEQUENCE (IMAGES 5 AND 6): Again note the multicystic nature of the lesion, with some increased signal within the cystic components.

c) TRANSAXIAL (IMAGES 7 AND 8), CORONAL (IMAGE 9) AND SAGITTAL (IMAGE 10) GADOLINIUM-ENHANCED SPIN-ECHO SEQUENCES: There is inhomogeneous enhancement of the tumor. At the level of the cysts thick walled enhancement can be seen. Furthermore several parts of the tumor show nodular intense enhancement. Only a small part of the tumor is adjacent to the petrous bone.

RADIOLOGICAL DIAGNOSIS is glioblastoma based on the inhomogeneous appearance of the lesion and the surrounding edema.

SURGICAL FINDINGS: At surgery the overlying dura mater was somewhat adherent to the tumor. The tumor appears to be well delineated from the surrounding white matter. Macroscopically the tumor was intra-axial in location. Cystic and solid components could be discerned.

PATHOLOGICAL DIAGNOSIS was endotheliomatous meningioma.

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Fig. 1

Meningioma, atypical: case 1, Fig. 1
Meningioma, atypical: case 1, Fig. 2
Meningioma, atypical: case 1, Fig. 3
Meningioma, atypical: case 1, Fig. 4
Meningioma, atypical: case 1, Fig. 5
Meningioma, atypical: case 1, Fig. 6
Meningioma, atypical: case 1, Fig. 7
Meningioma, atypical: case 1, Fig. 8
Meningioma, atypical: case 1, Fig. 9
Meningioma, atypical: case 1, Fig. 10