Clinical analysis for an unusual large cystic meningioma: Case report and review of the literature

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作者：Xu Zhao ; Jin Long Sun ; Zhi Gang Wang ; Ting Guo Zhang ; Cheng Wei Wang ; Yong Ji
关键词：Cystic meningioma ; Intratumoral cyst ; Anaplastic meningioma ; Computerized tomography ; Magnetic resonance imaging
刊名：Clinical Neurology and Neurosurgery
出版年：2008
期刊代码：60_03038467
类别：med
出版时间：June 2008
卷：110
期：6
页码：605-608
文件大小：504 K

摘要

Methods: We report 3 cases of “true cystic” meningiomas and discuss the preoperative evaluation, etiology and surgical treatment of these cystic lesions with reference to the literature.

Results: Magnetic resonance imaging (MRI) and computed tomographic (CT) studies usually display a cystic lesion close to the dura with or without enhancement of the cyst wall. Multiplanar MRI scans are very useful to show the presence of a solid tumour or some dura enhancement. However, some cases of “true cystic” meningiomas are still erroneously preoperatively diagnosed. Complete surgical removal of the tumours and of the entire cyst wall was performed in our cases. Despite the absence of a typical ring enhancement of the cystic lesion in two cases, histopathological studies displayed the presence of tumours cells on the cyst wall of both cases.

Discussion/Conclusions: Cystic meningiomas are rare tumors. There is a clear prevalence in infants, accounting or 10-19%of all intracranial meningiomas in this age group, compared with only 2-4%in adults. Etiology of these cystic tumors shows that degenerative alterations, ischemic events and intratumoral bleeding might be operative in the intratumoral cyst formation. Every effort should be made to remove not only the nodule but also the cyst wall in order to prevent recurrence of the tumor or recurrent space-occupying cyst formation. Tumours cells can be present on the cyst wall and therefore may be one of the causes of tumour recurrence if not totally removed. Accurate preoperative radiological diagnosis (multiplanar MR images) and intraoperative histopathological studies are fundamental in that it will definitely influence the surgical strategy and outcome.

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BACKGROUND

Meningiomas are generally solid tumors and are easily diagnosed by CT scans and MRI scans. Rarely are these tumors associated with cysts that can cause a confusion in the pre- and intraoperative diagnosis. Cysts associated with meningiomas may be intratumoral or peritumoral.

METHODS

The authors conducted a retrospective study of the seventeen meningiomas, out of a total number of 232, which were associated with cysts. The cysts were classified based on their relationship to the tumor. The patients' sex, age group, location of the tumor, and pathological type of tumor were also analyzed.

RESULTS

The 17 cases of cystic meningioma formed 7.3%of the meningiomas seen between 1984 and 1993. Eleven of these were intratumoral and 6 peritumoral. One case had both intra- and peritumoral cysts. The tumors were found mostly in the fourth and fifth decades of life. Histologically, all the peritumoral cysts except one were associated with meningotheliomatous meningiomas. Tumors with peritumoral cysts were more common in males. Intratumoral cysts, more common in females, were angioblastic or meningotheliomatous on histopathology. Only one case was an anaplastic meningioma.

CONCLUSION

Cysts associated with meningiomas, although uncommon, are certainly not rare. The peritumoral and the intratumoral cysts form distinct subtypes needing separate consideration. Cystic meningiomas are only rarely malignant.

To study the clinical characteristics of cystic meningiomas, we analyzed retrospectively 21 patients with cystic meningiomas and reviewed the literature with regard to clinical presentation, imaging features, preoperative diagnosis, surgical findings, and histopathological results. The cysts were classified into intratumoral and peritumoral cysts based on their relationship to the tumor, and also according to the classification method described by Nauta. For the 21 patients in our group, there were seven peritumoral cysts and 14 intratumoral cysts. Various pathophysiological mechanisms contribute to the formation of cystic meningiomas. The diagnosis of cystic meningiomas based on CT scan can be problematic, and differentiation from glioma or metastasis may be difficult. MRI scans show low signal intensity areas within the mass on T₁-weighted images and high signal intensity areas on T₂-weighted images, and the solid parts of tumors are contrast-enhanced after gadolinium administration. MRI with gadolinium enhancement dramatically increases the diagnostic accuracy for cystic meningiomas and provides critical information for their surgical care. Total surgical resection of cystic meningioma is ideal, but special attention should be paid to the cyst walls.

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