Lumbar angiomatous meningioma: how to manage this rare entity? A case report

Abstract

Introduction: Spinal meningiomas (SM) are rare intradural extramedullary tumors arising from arachnoid cells of the leptomeninges. They are most commonly found in the thoracic region, with angiomatous subtypes being even rarer and carrying a high hemorrhagic risk. Diagnosis and treatment are guided by clinical presentation and imaging, with surgery being the primary therapeutic approach. Recurrence is uncommon, occurring in 1.3 % to 6.4 % of cases, and decisions between surgery and adjuvant treatments like radiotherapy depend on factors such as tumor location, histological subtype, and the surgeon's expertise. This case aims to explore the radiological features and treatment strategies for SM.

Case presentation: A 58-year-old man with a history of disc herniation surgery presented with lower back pain, bilateral sciatica, cruralgia, and sphincter dysfunction. Spinal MRI revealed an intra-dural, extra-medullary tumor, which was surgically removed and the patient had an uneventful postoperative recovery. Histopathological examination confirmed an angiomatous meningioma (WHO Grade 1).

Clinical discussion: SM are rare tumors, often causing pain and neurological issues. Imaging is crucial in assessing tumor extent and vascularization, helping in treatment decisions. Although recurrences aren't common, they are usually treated surgically, with adjuvant therapies like radiotherapy being considered for high-grade or inoperable tumors. Further research is needed to refine the understanding and management of spinal meningiomas.

Conclusion: SM are exceptional, mostly benign, slow-growing tumors, with surgical resection remaining the primary treatment and offering low recurrence rates. Adjuvant therapies, including radiotherapy and molecular-targeted treatments, remain largely investigational, with no established clinical application.

Keywords: Simpson grading; Spinal meningiomas; Spinal tumor.

Fig. 1

Pre-operative spinal MRI findings in sagittal T2-W (A), Sagittal T1-W (B), Sagittal T1-weighted after contrast administration (C), Coronal T2W FS (D), Axial T2W (E), DWI (F), and post-contrast axial images (G) revealing: An intradural extramedullary tumor extending from D12 to L3 (blue star), appearing hypointense on T1W images, hyperintense on T2W and DWI images, with strong enhancement after contrast administration. The tumor extends through the foramina, exerts a mass effect leading to ectasia of the venous spinal network, and displaces the conus medullaris and the cauda equina nerve roots (red arrow). Additionally, it is associated with scalloping of the adjacent vertebral bodies (yellow arrow). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 2

Histopathological examination revealing: A: Low-power view showing a meningothelial-like tumor proliferation, interspersed with variably sized vessels with hyalinized endothelial walls in places (H&E, x100). B: Clusters of cells with ill-defined borders, characterized by eosinophilic cytoplasm and round to oval nuclei, associated with numerous vascular vessels (H&E, x200).