meningioma rubel.pptx

Meningioma

1. Case presentation Dr. Rubel Chakma MD resident , Phase-B ,3rd year Department of Radiology and Imaging BSMMU

2. Patient particulars 40 years old female patient,hailing from Manikgonj came with the complains of progressive impairment of vision on both sides (more on right side) for 6 months . She also complains occasional headache but gives no history of vomiting , convulsion and focal neurological deficit. She had no history of DM , hypertention ,TB , any primary malignacncy or hematological disorder. With this complains she went to see doctor at eye outdoor department, BSMMU and respective doctor adviced to do MRI scan of brain in our radiology department

3. Radiological findings Multiplaner sagital ,coronal and axial images show a well defined ,midline, broad dural based, lobulated T1WI iso , T2WI iso to slightly hyper and FlAIR hyperintense mass noted in suprasellar area having extension forwards along the planum sphenoidale and backwards along the dorsum sellae . After IV contrast avidly homogenous enhancement of the lesion and adjacent linear dural enhancement over the clivus and planum sphenoidale representing dural tail are noted. The lesion causing compression over the optic chiasma , pituitary gland and floor of 3 rd ventricle, and encasing the supraclinoid ICA, ACA and MCA of both sides. The mass effect is evidenced by obliteration of Suprasellar & interpeduncular cysterns and symmetrical indentation of underlying cerebral cortex. No perilsional edema is noted However lateral , 3 rd and 4rth ventricles appear normal Complementary CT cut was taken and showing iso to slightly hyperdense lesion. No calcification is noted. Bone CT shows bony hyperostosis at planum sphenoidale . S ellar size is within normal limit

4. Radiological diagnosis Suprasellar meningioma with planum sphenonale and dorsum sallar extension

5. Intracranial Meningioma Defintion A tumour originating from arachnoid cell rest(which are related to arachnoid mater granulations)

6. Demographics Age Middle decades. A peak prevalence during 5 th and 6 th decades Gender Female : Male= 2:1 Epidemiology The commonest non-glial intracranial neoplasm 20% of all primary intracranial tumours

7. Grading according to WHO WHO grade-I: The majority (90%) and representing a typical benign tumour . WHO grade-II: Demonstrating atypical features( increased mitotic activity and necrosis).10% of all meningioma(frequency rising) WHO grade-III: An anaplastic (malignant) tumour.1-3% of all meningioma(rare)

8. Pathology Etiology Arise from arachnoid meningothelial (“cap”) cells Loss of chromosome 22(40-60% of sporadic meningiomas ) NF2 meningioma genomic instability more likely to be atypical Non NF2 meningioma nearly always benign chromosomal stability

9. Associated abnormalities Neurofibromatosis type2(NF2) Multiple inherited schwannomas , meningiomas and ependymomas . 50-75% of patients with NF2 develop meningioma 10% of patients with multiple meningiomas have NF2

10. Location Supratentorial (90%) Parasagital region( falx ) and cerebral convexities( 45%) Sphenoid ridge(15-20%) Olfactory grove(5-10%) Parasellar (5-10%) Other(5%): intraventricular , optic nerve sheath, pineal region Infratentorial (8-10%) Cerebellopontine angle, clivus Multiple meningioma in1-9% cases

11. Morphology Two basic morphologies Globose =globular , well demarcated neoplasm with wide dural attachement 60% of tumors demonstrates local invasion into dural tail En plaque=sheet like extension covering dura without parenchymal invagination

12. Clinical presentation The majority are asymptomatic <10% of all meningiomas are symptomatic Symtomps depend on tumor site

13. Imaging NECT Sharply cercumscribed , smooth mass abutting the dura Hyperdense (70-75%), isodense (25%) Hypodense (1-5%), fat density(rare lipoblastic subtype) Calcified(20-25%) Can be diffuse, focal ,sand lie(“ psammomatous ”), sunburst, globular rim patterns Necrosis, cysts, hemorrhage(8-23%) Trapped CSF pools, cysts in adjacent brain common Peritumoral hypodense vasogenic oedema (60%)

14. Bone CT Hyperostosis, irregular cortex( Particularly common when the skull base or anterior cranial fossa is involved) CECT >90% enhance homogenously and strongly

15. MRI T1WI Typically iso -to slightly hypointense with cortex Necrosis, cyst, hemorrhage(8-23%) Look for gray matter buckling T2WI Frequently isointense Best sequence for visualizing CSF/vascular cleft between tumour and brain identifying vascular flow void(80%)

16. FLAIR Hyperintense peritumoral vasogenic oedema Vasogenic oedema does not correlate with tumour size T1WI C+(best imaging tool) >95% enhance homogenously ,intensely Dural tail sign(35-80% of cases) non specific A linear contrast –enhancing “ dural tail” extending from the tumour along the dura matter En plaque: sessile thickened enhancing dura MRS Alanine peak( chareterstic ) but seen in 50%

17. DWI DWI, ADC maps for TM variable in appearance Lower ADC in MM and AM compared to TM T2* GRE C a ++ common, Hemorrhage MRV: Evaluate sinus involvement Perfusion MRI High rCVB in peritumoral edema of anaplastic meningioma

18. Angiographic findings “ sunburst”or radial appearance dural vessels supply lesion core Pial vessels supply pheriphery Prolonged vascular stain Venous phase vital to evaluate sinus involvement

19. Falx meningioma

20. Cerebral convexity meningioma

21. Sphenoid wing meningioma

22. Olfactory groove meningioma

23. CPA meningioma

24. Intraventricular meningioma

25. Multiple meningioma with NF2

26. Atypical and Malignant Meningioma General features Dural based , locally invasive lesion with areas of necrosis ,marked brain edema Location may occur anywhere in neuraxis (brain>> spine) AM frequent in CPA, along tentorium MM frequent in parasagittal (44%),cerebral convexities(16%)

27. Pathology AM: High mitotic activity MM: AM features+ findings of frank malignancy

28. Imaging Difficult to predict meningioma tumor grade on imaging Imaging findings of typical meningioma do not exclude atypical, malignant variant NECT CT triad of MM: extracranial mass, osteolysis , intracranial tumour Marked perifocal edema CECT Enhancing tumour mass Prominent tumour pannus extending away from mass=mushrooming

29. MRI T1WI Indistinct tumour margin Infiltrating tumour interdigitates with brain T1WI+C Enhacing tumour mass May extend into brain, skull scalp FAIR marked peritumoral edema DWI markedly hyperintense on DWI , hypointense in ADC map

30. Differential diagnosis Papillary Craniopharyngeoma Chaismatic -hypothalamic glioma

31. Differtiating points Suprasellar meninigioma Papillary Craniophayngioma Chaismatic Hypothalamic glioma Definition A tumour originating from arachnoid cell rest(which are related to dura mater arachnoid granulations) A benign mostly solid suprasellar tumor arising from squamous epithelial remnants of rathke’s pouch An astrocytic tumor Age Middle decades Middle decades Usually 4rth to 6 th decade Childhood Location and extention Tebercular , dorsal or diapgragm sellae Often shows forward extension along dura mater of anterior cranial fossa Commonly located within the suprasellar region A purely intrasellar location is uncommon optic chiasm and optic tract. Chaismal tumor tumors may into hypothalamus

32. Differentiatig points Suprasellar meningioma Papiilary Craniopharyngioma Chiasmatic Hypothamic glioma NECT Usullally broad dural based, hyperdense lesion Calcification is seen 20% cases Usuully solid suprasellar tumour Small cysts but not a significant feature calcification is absent Often large and lobulated when at chiasm and can extend into hypothalamus No calcification CECT/MRC+ Avidly homogenous enhancement Soild component-intense contrast inhencement Variable inhancement T2WI Frequently isointense to cortex High signal intesity High signal intensity Bony hyperostosis Usually present Absent Absent Dural tail sign Usually present Absent Absent

33. Papillary craniopharyngeoma

34. Chaismatic -hypothalamic gioma

35. Treatment Preoperative embolization Surgical goals Resection of tumor and involved dura / dural tail(with tumor free margin) Resection of involved or hyperostotic bone Radiotherapy : frequently used for AM, MM

36. Prognosis Typical benign meningioma –only 9% recurrence AM recurrence 28% 5 years survival :86% MM recurrence 75% 5 years survival :35%

37. Take home massage A tumour originating from arachnoid cell rests The majority (90%) are typical benign tumour Common age 4th to 6 th decades and slight female predominance Two common morphological types: a spherical well circumscribed mass or a flat ,infiltrating (en plaque)lesion 90% are supratentorial location Best imaging protocol T1WI+c showing avid homogenous enhancement of the lesion with dural tail sign(supportive sign) Bone C T to see hyperostosis and calcification(supportive sign)