A Rare Case of Life-Threatening Multicompartmental Spontaneous Intracranial Hemorrhage From a Grade 1 Convexity Meningioma

Abstract

Meningiomas are slowly growing benign tumors. The incidence of hemorrhage associated with intracranial meningiomas is in the 0.5%-2.4% range. However, intracranial meningiomas with hemorrhagic presentation are associated with higher rates of overall major morbidity (36%) and mortality (21.1%). We report a case of a convexity meningioma presenting with intraparenchymal hematoma and bilateral acute subdural hematomas (SDH) in a comatose patient (Glasgow Coma Scale (GCS) score: 7) who had a history of recurrent episodes of headaches over the past few months. Hemorrhagic presentation of a meningioma is a rare but potentially devastating event. Early recognition of the potential underlying meningioma as a cause of bleeding followed by rapid appropriate additional imaging is crucial to direct treatment plans to achieve the best outcome.

Keywords: bleeding inside meningioma; grade 1 meningioma; hemorrhagic meningioma; intracerebral hematoma; subdural hematoma.

Figure 1. Multiplanar non-contrast head CT in a sexagenarian male presenting with progressive confusion and loss of consciousness.

CT demonstrating a large, dural-based hemorrhage at the right temporal convexity with bilateral tentorial and hemispheric subdural hematomas and parafalcine subdural hematoma. Regional mass effect with right to left subfalcine shift is also evident.

Figure 2. Initial pre- and post-contrast MRI (left to right: T1 pre- and post-contrast axial sequences, FLAIR sequence, and T2-weighted sequence).

MRI demonstrating an extra-axial, dural-based mass at the right temporal convexity with nodular, dural-based enhancement (red arrow) with internal hemorrhagic cysts with variable age blood products. Multiple internal hemorrhagic cysts with fluid-fluid levels are present in addition to a well-defined and thickened T2WI hypointense capsule (red block arrow). The absence of a surrounding CSF cleft with prominent, perilesional vasogenic edema, mass effect, and right uncal herniation is also noted.

Figure 3. Pre- and post-contrast MRI status post-tumor resection (left to right: T1 pre- and post-contrast axial sequences, FLAIR sequence, and T2-weighted sequence).

MRI demonstrating no evidence of residual enhancing tumor at the operative site with involution of the thickened, tumoral capsule and overall decreased mass effect.