Meningioma Presenting With Intratumoral Hemorrhage on Active Surveillance

Abstract

Meningiomas are relatively common primary adult brain tumors. They are slow-growing, highly vascular, and graded according to histology, phenotypic and genotypic features. We present a case of a 66-year-old male with a history of tongue squamous cell carcinoma, which presented multiple risk factors for cardiovascular and thromboembolic events. A brain lesion was initially detected on a computed tomography (CT) scan and later characterized by magnetic resonance imaging (MRI). The multidisciplinary team decided to maintain surveillance due to the lack of associated symptoms. Upon expansion in size and acute intralesional hemorrhage seen on follow-up imaging, the patient was submitted to surgical excision. The histopathological testing determined it to be an atypical meningioma. Two months later, the patient received stereotactic radiotherapy, and a post-surgical MRI showed no evidence of tumor recurrence. This case report describes a rare occurrence of intratumoral hemorrhage in a meningioma during surveillance, highlighting the importance of vigilant monitoring and consideration of potential risk factors for hemorrhagic events.

Keywords: fractionated stereotactic radiotherapy; hemorrhagic meningioma; intracranial meningioma; intracranial radiosurgery; intratumoral hemorrhage; meningioma; neuroradiology; radiology report; radiotherapy (rt).

Figure 1. Magnetic resonance imaging showed an extra-axial tumor suggestive of meningioma.

(a) Axial T1-weighted images showed a left fronto-opercular, extra-axial lesion with well-defined borders, and isointense to white matter. (b) The lesion showed strong enhancement on post-contrast axial T1-weighted imaging and a dural tail sign. (c) Axial T2-weighted MR images showed that the lesion was slightly hyperintense to white matter; this sequence demonstrated no vasogenic edema in the parenchyma surrounding the lesion.

Figure 2. Magnetic resonance imaging at six months of follow-up showed signals of acute intratumoral hemorrhage.

(a) Axial T1-weighted images showed areas of hyperintense signal inside the tumoral. (b) Axial T2-weighted MR images showed that the lesion had a heterogeneous signal. The lesion showed a marked loss of signal intensity on T2 gradient-echo images (c) and heterogeneous signal on axial T1-weighted after contrast (d).

Figure 3. Histopathologic examination.

a) Meningeal neoplasia showing high cellularity with indistinct cytoplasmatic borders, nuclei slightly pleomorphic; b) EMA +; c) Ki67 >4%; d) PR +.