Parasagittal meningioma

Parasagittal meningioma

Harvey Williams Cushing and Louise Eisenhardt defined parasagittal meningioma as one that fills the parasagittal angle with no brain tissue between the tumor and superior sagittal sinus. Sometimes, it invade partially or completely the superior sagittal sinus 1).

Classification

History

During excavation in 1931 by Riek in the cave of Vogelherd close to Stetten in the Lone Valley in southwestern Germany there was found an anatomically modern human skull (called: “Stetten 2”) dated 32500 years before present. The skull was excavated without postcranial skeleton in the cave and showed no signs of burial. Paleopathological examinations of the calvarium reveals skeletal abnormalities that indicate parasagittal meningioma next to the bregma. Paracentral Meningiomas cause seizures and focal weakness, followed by headache. These observations are discussed in the context of modern medical knowledge. Our theory integrated archaeological, anthropological and paleopathological knowledge and helped to create the understanding of Paleolithic and earliest modern man knew regarding the “brain” and illness 2).

Meningiomas frequently invade cerebral venus sinuses, especially parasagittal meningioma to superior sagittal sinus. A frontal parasagittal meningioma could invade directly the internal jugular vein 3).

Epidemiology

85-90% of the meningiomas are supratentorial. 45% parasagittal, convexities.

Clinical features

Diagnosis

Differential diagnosis

Intracerebral schwannoma 4) 5) 6) 7).

Extra-axial ependymoma 8) 9).

Fibrous histiocytoma 10).

Rosai Dorfman disease 11).

Separate tumors

A 70-year-old woman with an asymptomatic parasagittal meningioma had been under observation with follow-up imaging for 2 years. She gradually developed motor weakness in the left hand. Magnetic resonance (MR) imaging disclosed a newly developed well-enhanced area in the cerebral parenchyma adjacent to the stable original meningioma. The new lesion was enhanced more intensely and less well demarcated. We suspected that the meningioma had enlarged into the brain parenchyma, although MR imaging suggested a border between the extra-axial and intra-axial portions. Craniotomy was performed. Two separate tumors were identified with quite different histological features. The extra-axial tumor was identified as benign transitional meningioma and the intra-axial tumor as diffuse large cell type malignant lymphoma. Immunostaining revealed the lymphoma had B cell origin. After surgical resection, stereotactic radiosurgery was performed for the residual lymphoma. The original site of the lymphoma remained free from relapse, but another lesion developed in the right frontal lobe 3 months later and chemotherapy was performed. The main concern for follow-up imaging of asymptomatic meningioma without surgical resection is growth of the meningioma. However, development of new different tumors is possible, although thought to be rare 12)

Simultaneous detection of an intracranial meningioma with a pituitary tumour prior to radiotherapy is an extremely uncommon occurrence. Mathuriya et al., have managed an elderly acromegalic lady with an acidophilic pituitary adenoma, who also harboured an asymptomatic anterior third parasagittal meningioma. There were no features of neurofibromatosis. Both tumours were concurrently excised 13).

Treatment

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Complications

The radical resection of parasagittal meningiomas without complications and recurrences is the goal of the neurosurgeon.


Skudas and Tamasauskas retrospectively reviewed 132 patients with parasagittal meningiomas operated in the Department of Neurosurgery during the period of 1995-2000. Forty-four (33.3%) meningiomas invaded the superior sigittal sinus (SSS) and partially or totally obturated it. One hundred-five (79.5%) meningiomas were removed totally and post-surgery results of 111 (84.1%) patients were good. On discharge 17 (12.9%) were in poor condition, and 4 (3%) patients died. Postoperative complications occurred in 46 (34.8%) patients 14).

Venous Infarction

see Venous infarction

Venous air embolism (VAE) during an elective craniotomy for parasagittal meningioma resection. The surgery was done in the supine position with slightly elevated head position. VAE was provisionally diagnosed by sudden decreased in the end tidal carbon dioxide pressure from 34 to 18 mmHg, followed by marked hypotension and atrial fibrillation. Prompt central venous blood aspiration, aggressive resuscitation and inotropic support managed to stabilize the patient. Post operatively, he was admitted in neuro intensive care unit and made a good recovery without serious complications 15).

Intraoperative fatal pulmonary embolism 16).

Paraparesis can occur as a primary presentation of brain pathology at the motor strip along the parasagittal region. It could also occur as a neurological complication especially following resection of parasagittal meningioma with infiltration of the superior sagittal sinus (SSS). We report a case of a complete paraparesis immediately following resection of bilateral parasagittal meningioma with infiltration of the middle third of the SSS. A gradual improvement in neurological recovery and functional outcome was observed over a period of one year after undergoing an intensive neurorehabilitation program beginning from the acute inpatient phase post surgery 17).

Hemostatic agents, routinely used in neurosurgery to achieve intraoperative hemostasis may cause foreign body reaction. These may produce clinically symptomatic and radiologically apparent mass lesions. It should be kept in mind that retained cotton or rayon materials may mimic the appearance of a tumor or an abscess on MRI scan, especially at sides of previous craniotomies. Here we report a case of intracranial foreign body granuloma which occurred due to remained cottonoid after removal of a parasagittal meningioma. This entity was also documented by MR imaging technics included diffusion weighted, flair and ADC mapping 18).

Recurrence

Recurrent aggressive falcine meningiomas are uncommon tumors that recur despite receiving extensive surgery and radiation therapy (RT).

Abou Al-Shaar et al have utilized brachytherapy as a salvage treatment in two such patients with a unique implantation technique. Both patients had recurrence of WHO Grade II falcine meningiomas despite multiple prior surgical and RT treatments. Radioactive I-125 seeds were made into strands and sutured into a mesh implant, with 1 cm spacing, in a size appropriate to cover the cavity and region of susceptible falcine dura. Following resection the vicryl mesh was implanted and fixed to the margins of the falx. Implantation in this interhemispheric space provides good dose conformality with targeting of at-risk tissue and minimal radiation exposure to normal neural tissues. The patients are recurrence free 31 and 10 months after brachytherapy treatment. Brachytherapy was an effective salvage treatment for the recurrent aggressive falcine meningiomas in our two patients 19).

Case series

Case reports

Unclassified

References

1)

Cushing H, Eisenhardt L. Their Classification, Regional Behavior, Life History, and Surgical End Results: The chiasmal syndrome, in Meningiomas. Suprasellar Meningiomas. 1938:224–49.
2)

Weber J, Spring A, Czarnetzki A. [Parasagittal meningioma in a skull dated 32500 years before present from southwestern Germany]. Dtsch Med Wochenschr. 2002 Dec 20;127(51-52):2757-60. German. PubMed PMID: 12491193.
3)

Seo EK, Cho YJ, Koo H, Lim SM. Unusual Intracranial Parasagittal Meningioma Extending into the Internal Jugular Vein through the Sinuses. J Korean Neurosurg Soc. 2008 May;43(5):250-2. doi: 10.3340/jkns.2008.43.5.250. Epub 2008 May 20. PubMed PMID: 19096607; PubMed Central PMCID: PMC2588220.
4)

Li M, Mei J, Li Y, Tao X, Hong T. Intracerebral schwannoma mimicking meningioma: case report. Can J Neurol Sci. 2013 Nov;40(6):881-4. PubMed PMID: 24257236.
5)

Ma L, Yang SX, Wang YR. Intracerebral schwannoma mimicking parasagittal meningioma. J Craniofac Surg. 2013 Nov;24(6):e541-3. doi: 10.1097/SCS.0b013e31828601bf. PubMed PMID: 24220461.
6)

Bristol RE, Coons SW, Rekate HL, Spetzler RF. Invasive intracerebral schwannoma mimicking meningioma in a child. Childs Nerv Syst. 2006 Nov;22(11):1483-6. Epub 2006 Sep 22. PubMed PMID: 17021734.
7)

Takei H, Schmiege L, Buckleair L, Goodman JC, Powell SZ. Intracerebral schwannoma clinically and radiologically mimicking meningioma. Pathol Int. 2005 Aug;55(8):514-9. PubMed PMID: 15998381.
8)

Singh V, Turel MK, Chacko G, Joseph V, Rajshekhar V. Supratentorial extra-axial anaplastic ependymoma mimicking a meningioma. Neurol India. 2012 Jan-Feb;60(1):111-3. PubMed PMID: 22406799.
9)

Salunke P, Kovai P, Sura S, Gupta K. Extra-axial ependymoma mimicking a parasagittal meningioma. J Clin Neurosci. 2011 Mar;18(3):418-20. doi: 10.1016/j.jocn.2010.04.042. Epub 2011 Jan 13. PubMed PMID: 21236682.
10)

Tsutsumi M, Kawano T, Kawaguchi T, Kaneko Y, Ooigawa H, Yoshida T. Intracranial meningeal malignant fibrous histiocytoma mimicking parasagittal meningioma–case report. Neurol Med Chir (Tokyo). 2001 Feb;41(2):90-3. PubMed PMID: 11255634.
11)

Kattner KA, Stroink AR, Roth TC, Lee JM. Rosai-Dorfman disease mimicking parasagittal meningioma: case presentation and review of literature. Surg Neurol. 2000 May;53(5):452-7; discussion 457. Review. PubMed PMID: 10874144.
12)

Mori Y, Kondo T, Iwakoshi T, Kida Y, Kobayashi T, Yoshimoto M, Hasegawa T. Malignant lymphoma arising in the cerebral parenchyma adjacent to a parasagittal meningioma. Neurol Med Chir (Tokyo). 2006 Aug;46(8):398-400. PubMed PMID: 16936461.
13)

Mathuriya SN, Vasishta RK, Dash RJ, Kak VK. Pituitary adenoma and parasagittal meningioma: an unusual association. Neurol India. 2000 Mar;48(1):72-4. PubMed PMID: 10751818.
14)

Skudas G, Tamasauskas A. [Prognosis of the surgical treatment of parasagittal meningioma]. Medicina (Kaunas). 2002;38(11):1089-96. Lithuanian. PubMed PMID: 12532723.
15)

Mohd Nazaruddin WH, Asmah Z, Saedah A. Venous Air Embolism during Elective Craniotomy for Parasagittal Meningioma. Med J Malaysia. 2013;68(1):69-70. PubMed PMID: 23466772.
16)

Gaoyu C, Hua F, Kaizhi L, Yanli G, Yi H. Intraoperative fatal pulmonary embolism during resection of a parasagittal meningioma. Anaesth Intensive Care. 2008 Sep;36(5):753. PubMed PMID: 18853607.
17)

Mazlan M, Fauzi AA. Complete paraparesis following resection of parasagittal meningioma: recovering function with an early intensive neurorehabilitation program. Med J Malaysia. 2011 Oct;66(4):371-3. PubMed PMID: 22299564.
18)

Bilginer B, Yavuz K, Agayev K, Akbay A, Ziyal IM. Existence of cotton granuloma after removal of a parasagittal meningioma: clinical and radiological evaluation -a case report-. Kobe J Med Sci. 2007;53(1-2):43-7. PubMed PMID: 17582203.
19)

Abou Al-Shaar H, Almefty KK, Abolfotoh M, Arvold ND, Devlin PM, Reardon DA, Loeffler JS, Al-Mefty O. Brachytherapy in the treatment of recurrent aggressive falcine meningiomas. J Neurooncol. 2015 Sep;124(3):515-22. doi: 10.1007/s11060-015-1873-3. Epub 2015 Aug 8. PubMed PMID: 26253325.
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