A case of 39 years old male is described who presented with headache, right-sided focal fits and decreased power in the right hand. CT scan brain showed a left fronto-parietal cystic lesion with centrolateral intramural nodule with homogenous enhancement. At surgery, the extra-axial lesion with cyst containing xanthochromic fluid had a well-defined capsule that could easily be separated from the peri-lesional cortical surface. The dural-based nodule with its cyst wall was resected in toto. The histopathology of mural nodule was reported as meningioma while the cyst wall histology revealed meningothelial cells

Asharaf, Junaid

Shah, Ahmed Ali

Siddiqui, Arshad A

English

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eCommons@AKUSection of Neurosurgery Department of SurgeryAugust 2003Peritumoral cystic meningiomaArshad A. SiddiquiJunaid AsharafAhmed Ali ShahFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_neurosurgPart of the Surgery CommonsRecommended CitationSiddiqui, A. A., Asharaf, J., Shah, A. A. (2003). Peritumoral cystic meningioma. Journal of the College of Physicians and SurgeonsPakistan, 13(8), 461-462.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_neurosurg/138CASE REPCRTArshad A. Siddiqui, Junaid Ashraf. and Ahmed Ali Shah.AssrmserA case of 39 years old male is described who presented with headache, right-sided focal fiis and decreased power inthe right hand. CT scan brain showed a left fronto-parietal cystic lesion wiih centrolaieral intramurai nodule withhomogenous enhancement. Ai surgery, the extra-axial lesron with cyst containing xanthochromic fluid had a well-deflned capsule that could easily be separated from ihe peri-lesional cortical surface. The dural-based nodule with itscyst wall was resected in toto. The'histopathology of mural nodule was reported as meningioma while the cyst wallhistology revealed meningothelial cells.KEY WORDS: Cystic meningioma. CT scan. extra-axial. Cystic tumors. Peiltumord cysltrl'.JT'r.t(tr ': tr,-'l'i, i,.lThe cystic meningiornas are uncoilImon tumors with air inci-dence of 1.6-7'/". They lnay be associated with either intratu-moral or peli-tr-unoral cyst folmation.l,2,3 Tilese are easily con-fnsecl r,r'iih metastatic tumors, g1ia1 inrnors rvith cystic or'necrotic change, a haer-narrgioblastoma or a nenroblastorna.lControversy exists regarding the pathogenesis of the cyst,whether extlinsic to tlrmol mass (peritr-rmoral cyst) ol part ofthe ureningioma itself (intratr-unoral cysis).2-o We are describ-ing a case of a perilr-unoral c1rs1i6 rneningioma rvith its Llnllstl-al CT scan appearance corlelating rvith opei"ative andhistopathological findings.Ca:;t i{ irP{-,ii'i'A 39 years old r.na1e was admitted rarith complaints ofheadache, r'ight-sided focal fits and weakness of the right handfcr ihe last 6 rnonths. On examination, he only had lt'eaknessof the light hand grip with no papiiloedema or othel net'lro-logical features. CT scan brain showed a 5cm x Scm left fron-io-parietai cystic lesion with a 2 cm centlolateral irrtratr-rmoralnodr-rle that was i-ryperderlse on plain CT scan (Figr"rre 1). Theintramural nodr-rle showed marked enhancement on contrastadministration (Figr-rre 2). A diagnosis of pilocytic astrocy-toma was rnade. At slirgery, the lesion was found to be extra-axial. The cyst cor-rtained xanthochromic fluid and was linedby a distinct, weil-defined capsule, which could easily be sep-arated from the peri-lesional pial surface of the cerebral cortex.The intramural nodr-rle was grayish in color and attached tothe dura. En bioc resection of the cyst wa1l with durai-basednodule was performed. Separate histopaihological examina-tion of the nodr,rle and the cyst wal1 was done. The histologyof the nodule was consistent with rneningioma. The exarnina-tion of ihe cyst wa11 revealed neoplastic meningotl-relial ce1ls inthe wall as well. Postoperatively, there was a complete recov-ery of weakness in the right hand grip and the fits were conDepanment of Neurosurgery The Aga Khan University Hospital, Karachi.-Department of Neurosurgery Dow Medical College and Civil Hospital, Karachi.Correspondence: Or. RrsnaO n SidOiqur, Chref Resrdent Neurosurgery,Department of Surgery, The Aga Khan University Hospital, Karachi. PakistanE-mail: doc4brains@yahoo.comFeceived May 31. 2003 : accepted: Juy 25 2003trolled on anti-epileptic medication. A contrast enhanced Cf'scan (Figure 3), performed after the operation, showed com-plele resection of the lesion .i .,i rt;r : r ;iri,;it, l'..,Per-rfieldT was the first to describe cyst formation in a menin-gioma secondary to central degeneration. Cr-rshingt describedprimary formation of a cyst and de novo appearance of nod-ule within tire cyst. The most frequent iocation of cysticmeningiomas is on the cerebral convexity u'ith parasagittallocalionT the next commonesL sifs.2,3,5,8 The clinical presenta-JCPSP 2003; Vol. 13 (B): 461-462 4()"1Arshad A. Siddiqui. Junaid Ashraf and Ahmed Ali Shahtion and radiologicai appearance of the lesion are difficult tobe distingr-rished flom pilocytic astrocytomas, cystic rnetas_tases. slrpratentorial haernangioblastomas and ner_rroblas_iorna"2 Ab against sorrle of these lesions like cystic metastasesand pilocytic astrocyiomas where a subtotal resection mav becomplemented by adjr-rvant ther.apy a compiete surgical Jxci-sion is the opti'ral method of tr.eatir-rg me'ingiomas-Hence, iiis in.rportant to l-rave an accurate pre-ope.uiirre diagnosis inorder to pla^ co*rplete resectio^. Unfort'rrately, desplte r.ecentadvances _ in imaging, the differential dlagnostic dilemmabeLweer-r the cystic rne^i'giorna a.cr otrrer int.-racra'iar tr-r'rorshas not been resolved.e Althor-rgh 56% diagnostic accr-rracy ofCT scan is reported,e the introduction of ilRI has made ore_opelative diagnosis simpler. In this case too, in retrospect, tireCT scan findings wer.e also sr-rggestive of a meningioma. Forrnstance, plain CT scan showed a slightly hyperdenie nodr,rlarlesior-r (Hounsfield valr_re is +62) witli sLrirouncling.hypodensi-ty (Hor-rnsfield va1'e is +31). O'co^trast sL'dy, the .lirial_basedrlod'le e*ha^ced brlghtly with rnir-ri'rai e.liancerne.t of theg/st wall. The typical iocatio^, broad sr-ilface contact with dr-rr.aand l-righ attenuation or-r prair-r CT scar-r with co.tr.ast e'rrance-ment wele all sr_rggestive of this lesion being a rneningiorna.Two molphoiogical types of tumor.cysts are clescribed intr.atu_rnolal and peritr-''ora1. It is said that the extra-tr'noral cystrvalls consist of brain pare.crrymal witr-r grial cerl proliferationonly and is irot par-t of rnass lesion itseif.z The cyst consists ofeither localiy entrapped CSF or xanthochromic iiuid acting asan interface between the nodr_rle and the adjacent brain, imily_ing that the cyst is extri^sic to the tr-rmor mass.10 I' onl case theperoperative findings incl,rded the well-defined encapsr-rlatedcyst and its wal1 was merging with the c{ural_basecl nodule.Tl-re separate }ristopatirology of the circunferential cyst r,vallshowed neoplastic rneningotheliai celis, emphasizingihat thecyst wall also had the same rristorogy as thaI of trre iritrai''uralnodr,rle and it was a part of the turnor.l*Ut";i i l_r!jit.ri..iThe r-rn's'a} appearance of cystic me.irrgi.*a shorrld be keptin mir-rd while considering the differential diagnosis of cysiicbrain lesions, as en bioc sr_ugical resection o] tirese tr.rmorsalong with its neoplastic cyst wall is essential in order to avoidrecLtrrellces.j-. f i-L-'1rr i\{_l!:,1. Cushing H, Eisenhardt L. Meningiomas, ln: Cushing H, EisenhardtL, (edi). Classification, regional behavtour, life history and surgicaiend results" New york: Cbarles C Tlsornas 1g3B:26_27.2. Weber J, Gassel AM, Hoch A, Kilisek L, Sprung A. lntraoperativemanagement of cystic meningiomas. Netn.ostu.g Reu 2OO3; 26: 62-66"3. Russel EJ, George AE, Kricheff ll, Budzilovich G. Atypical com-puted tomograph features of inlracranial meninglomai: radiologi-cal-pathologicar correration in a series of r3i consecutrve cases.Radiology 1980; j35: 673-82.4. Pinna G, Beltramello A, Buffatti p, Signosini G, Columbari R, Bri_colo A, et a1. Cystic meningiomas: an update. Surg Neurctl 1986;26. 441-452.5. Goyat /\, Singh AK, Gupta V, Singh D, Tatke M, Kumar S.Suprasellar cystic meningioma: unusual presentation and reviewof the iiterature.J Clirt Neurosci ZOO2;9.702-4.6. Qasho R, Epimenio RO. Cystic meningioma: neuroradiological(MRl, Cf) and macroscopic intraoperative appearance: a caserepofi., NeurosurgReu 1998; 21: 155_7.7. Penfield W. Tumors of the sheaths of the nervous system. ln: pen_field W, (edi). Cytology and cellular pathology of the nervous sys_tem. New Yark, pcrul B. Hoeber 1932..953_90.B. Jimenez O, Nagore N. Cystic lesions associated with intracranialmeningiomas: repofi of three cases. BrJ Neuroun.g20OO; .,l4: 595-6.L Umansky F, pappo l, pizov G, Shalit M. Cystic changes inintracranial meningiomas: a review. Acta Atet.tochir (Wien): lgBB,95: 13-8.I0. Ashkan K, Rose p, Walter p Cystic meningioma: challenges in thediagnosis. Br J Netn.osurg 2002; 16: 72_3..... l\.....462JCPSP 2003; Vol. i3 (B): 461-462

Peritumoral cystic meningioma

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Peritumoral cystic meningioma

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