De Belder, F

Eyselbergs, M

Gielen, J

Lammens, M

Parizel, PM

Salgado, R

Somville, J

Van Dyck, P

Vanhoenacker, Filip

English

Ghent University Academic Bibliography

Case 11770 Meningioma (ECR 2014 Case of the Day)M. Eyselbergs , P. Van Dyck , F. De Belder , F.M. Vanhoenacker , R. Salgado , M. Lammens ,1 1 1 1, 4 1 2J. Somville , J. Gielen , P.M. Parizel  3 1 1University Hospital Antwerp  Neuroradiology Section: 2014, Apr. 23 Published: 47 year(s), femalePatient:Authors' InstitutionDepartment of Radiology, Antwerp University Hospital; Antwerp/BE 1Department of Surgical Pathology, Antwerp University Hospital; Antwerp/BE2Department of Orthopedic Surgery, Antwerp University Hospital; Antwerp/BE3Faculty of Medicine and Health Sciences, Ghent University; Ghent/BE4Clinical HistoryA 47-year-old female patient was referred to the radiology department by her general practitionerbecause of chronic pancranial headache that exacerbated acutely. Neurological and systemicexamination were otherwise unremarkable.Imaging FindingsComputed tomography (CT) with bone window settings shows multiple broad-based hyperostoticlesions in the left frontal region, the left parietooccipital region, the right temporal region and highparietal region extending bilaterally. The lesions show marked thickening of the tabula externa,sclerosis of the diploe and an irregular delineation of the tabula interna (Fig 1 a, b). The lesion onthe right temporal side shows, besides irregular delineation of the tabula interna and sclerosis of thediploë, an aggressive periostal reaction with hair-on-end pattern adjacent at the tabula externa (Fig.1 a). Additional Magnetic Resonance Imaging (MRI) demonstrates multiple broad-based duralmasses that are hyperintense to brain parenchyma on FLAIR-weighted images (WI) (Fig. 2). T1-WIafter gadolinium contrast administration revealed marked enhancement of the dural masses adjacentto the skull masses and confirmed the sclerosis of the diploë and hyperostosis (Fig. 3).DiscussionMeningioma is the most frequently observed intracranial non-glial tumour in the adult populationwith a female predominance and arises more frequently in African-Americans. About 10% of themenigiomas are clinically silent. In 1-9% meningiomas are multiple on imaging. The presence ofmultiple meningiomas is also referred to as meningiomatosis. In neurofibromatosis type 2 (NF-2),the combination of multiple inherited vestibulocochlear schwannomas, meningiomas andependymomas are pathognomonic [1]. However, multiple meningiomas can also occur in theabsence of NF-2, as in our case.The tumours are slow-growing, sharply demarcated and surrounded by a capsule. The two maintypical morphological configurations are a spherical lobulated dural-based mass and a moresheet-like 'en plaque' configuration. Although highly variable in expression, hyperostosis is awell-known imaging feature of most meningiomas and is more frequently seen with the 'en plaque'configuration [2].CT and MRI are complementary imaging techniques for the diagnosis of meningiomas. CT withbone window settings can easily identify adjacent bony involvement such as erosions, sclerosis andhyperostosis. The degree of hyperostosis is usually disproportionate to the underlying size of thelesion. Tumoural invasion of the overlying bone seems to represent the most appropriate hypothesisof the hyperostosis. Histologically, the affected bone frequently contains tumour cells in the diploëand Haversian canals [3]. Sometimes a subdural plaque of ossification can be seen that is separatedfrom the sclerotic or hyperostotic bone by a translucent line corresponding to dura mater on skullradiographs [4]. On MRI the lesions are iso- to hypo-intense on T1-WI and have a variableappearance on T2-WI. The presence of a cerebrospinal fluid cleft on T2-WI confirms the extra-axiallocalization of the tumour(s). After contrast administration, more than 95 % of the lesions enhancevividly both on CT and MRI. A dural tail is a typical imaging finding, but not pathognomic formeningioma [5]. The differential diagnosis comprises benign and malignant lesions. In the case of dural-basedgranulomas, abnormal chest X-rays and laboratory values are the key to the diagnosis such as anincreased erythrocyte sedimentation rate (ESR) and serum angiotensin converting enzyme (ACE)(neurosarcoidosis) or infectious parameters (tuberculosis). In fibrous dysplasia, the surface of thehyperostosis is smooth. Extramedullary haematopoiesis, dural and osteoblastic metastases should beconsidered in the case of a known malignancy. In osteosarcomatosis, multiple hyperostotic lesionswith an aggressive periostal reaction can be seen.Final DiagnosisMeningioma with reactive hyperostosis without signs of malignancy (Fig. 4).Differential Diagnosis ListDural/osteoblastic metastases, Extramedullary haematopoiesis, Osteosarcomatosis, Multiplemeningiomas, Granulomas (neurosarcoidosis - tuberculosis), Fibrous dysplasiaFiguresFigure 1 Axial CT with bone window settingThickening of the tabula externa (arrowheads), sclerosis of the diploe (asterisk) and irregulardelineation of the tabula interna (arrows). Periostal reaction (hair-on-end pattern) adjacent atthe tabula externa (double arrow in A). © Department of Radiology, Antwerp University Hospital; Antwerp/BE Area of Interest: Neuroradiology brain;  Imaging Technique: CT;  Procedure: eLearning;  Special Focus: Neoplasia; Figure 2 Axial FLAIR-WIMultiple broad based dural masses that are hyperintense to brain parenchyma (arrows in Aand B). © Department of Radiology, Antwerp University Hospital; Antwerp/BE Area of Interest: Neuroradiology brain;  Imaging Technique: MR;  Procedure: eLearning;  Special Focus: Neoplasia; Figure 3 T1-WI without (A) and after gadolinium contrast administration (B)Marked enhancement of the dural masses (arrows in B) adjacent to the skull masses.Sclerosis of the diploe (asterisk) and hyperostosis (arrowheads). © Department of Radiology, Antwerp University Hospital; Antwerp/BE Area of Interest: Neuroradiology brain;  Imaging Technique: MR;  Procedure: eLearning;  Special Focus: Neoplasia; Figure 4 Photomicrograph (overview (A) and detailed view (B), HE stain)Intertrabecular space with tumoral invasion. Immunohistochemistry confirmed the presenceof meningotheliomatous meningioma WHO grade 1 (epithelial membrane antigen positive). © Department of Radiology, Antwerp University Hospital; Antwerp/BE Area of Interest: Neuroradiology brain;  Imaging Technique: Experimental;  Procedure: Biopsy;  Special Focus: Neoplasia; References[1] Evans DG (2009) Neurofibromatosis type 2 (NF2): a clinical and molecular review Orphanet JRare Dis 4:16[2] Eyselbergs M, Vanhoenacker FM, Kools D (2011) Hyperostotic meningioma mimicking skullosteoma JBR-BTR 94:222[3] Kim KS, Rogers LF, Goldblatt D (1987) CT features of hyperostosing meningioma en plaqueAJR Am J Roentgenol 149:1017-23[4] Kim KS, Rogers LF, Lee C (1983) The dural lucent line: characteristic sign of hyperostosingmeningioma en plaque AJR Am J Roentgenol 141:1217-21[5] Takeguchi T, Miki H, Shimizu T, Kikuchi K, Mochizuki T, Ohue S, et al. (2004) The dural tailof intracranial meningiomas on fluid-attenuated inversion-recovery images Neuroradiology46:130-5CitationM. Eyselbergs , P. Van Dyck , F. De Belder , F.M. Vanhoenacker , R. Salgado , M. Lammens ,1 1 1 1, 4 1 2J. Somville , J. Gielen , P.M. Parizel  (2014, Apr. 23) 3 1 1 Meningioma (ECR 2014 Case of the Day) {Online}URL: http://www.eurorad.org/case.php?id=11770

Meningioma (ECR 2014 Case of the Day)

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Meningioma (ECR 2014 Case of the Day)

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