An Uncommon Coexistence of Dural and Intraventricular Meningiomas

Abstract

Meningiomas, originating from the meninges encasing the brain and spinal cord, are the most prevalent primary intracranial tumors, constituting around 40% of all such tumors. These tumors primarily manifest within the dura mater, the outermost meningeal layer, and occasionally in locations such as the ventricular system. However, the concurrent presence of dural and intraventricular meningiomas is exceedingly rare. It could be challenging to tell them apart from metastases. We present a case of a middle-aged female with chronic headaches, where magnetic resonance imaging (MRI) revealed two distinct supratentorial lesions, one dural and the other intraventricular. Surgical excision was successfully performed, and histopathological analysis confirmed the presence of meningiomas in both locations, and subsequent referral was made for comprehensive management, encompassing radiotherapy and chemotherapy. This case underscores the significance of advanced imaging modalities, particularly MRI, in diagnosing and assessing intricate brain tumors.

Keywords: alanine; headache; magnetic resonance imaging; meningioma; neurofibromatoses.

Figure 1. Axial T1 weighted MRI shows coexisting dural meningioma (white arrow) and intraventricular meningioma (yellow arrow)

Figure 2. Axial T2 weighted MRIs (A,B) show internal heterogeneous signal changes and signs of mass effect in both lesions with perilesional edema seen in the dural-based lesion (white arrow)

Figure 3. FLAIR magnetic resonance axial (A) and sagittal (B) images show internal heterogeneous signal changes and signs of mass effect in both lesions (white arrows) with perilesional edema seen in the dural-based lesion (red arrow)

FLAIR: fluid-attenuated inversion recovery

Figure 4. Axial SWI image shows no obvious evidence of internal blooming artifacts

SWI: susceptibility weighted imaging

Figure 5. Magnetic resonance angiogram time-of-flight (TOF) images (A,B) show displacement of both the anterior cerebral arteries to the left (yellow arrow) and small blood vessels seen traversing the intraventricular lesion (blue arrow)

Figure 6. Axial ADC (A) and DWI (B) MRIs show high signal intensity (red arrow) with no obvious ADC hypointensity (yellow arrow) in the intraventricular lesion

ADC: apparent diffusion coefficient; DWI: diffusion-weighted imaging

Figure 7. Postcontrast T1W axial (A) and sagittal (B) MRIs show intense homogenous enhancement with internal necrotic areas in both dural and intraventricular lesions

Figure 8. Gross specimen of the dural-based meningioma

Figure 9. Photomicrographs of H&E-stained sections showing (a) neoplasm composed of cells arranged in sheets and whorls (black arrow) (40x); (b) meningothelial cells with moderate eosinophilic cytoplasm, indistinct cytoplasmic borders and uniform round to slightly oval nuclei (black arrow) (100x); (c) blood vessels of varying sizes intervening the cells (black arrow) (100x); (d) cells with mild to moderate nuclear pleomorphism (black arrow) (400x)