New York Association of Neuropathologists
Presented by: Dr. Jianying Zeng (from Dr. Rao and Dr. Zeng - SUNY Downstate Medical Center)
A 48-year-old woman came to the Emergency Room with dizziness and left arm weakness for one hour. There was a past history of HIV, and coagulation studies were normal. A stroke code was called. Physical examination showed she had high blood pressure (188/90 mm Hg), left facial droop, slurred speech, and left sided weakness. Head CT scan revealed a large right parietal intraparenchymal heterogenous lesion, measuring 4.7 x 3.6 cm, with density compatible with hemorrhage, causing shift. Emergency craniotomy was performed to evacuate the intracranial hematoma.
The slide showed a hemorrhagic tumor mass. The cellular tumor had a loose texture, microcystic areas, hyalinized blood vessels, and a clear border with the brain. Some cells were vacuolated but others were spindly with palisading around microcystic spaces. There were elongated nuclei with fine processes; other areas had compact to oval cells with fibrillary background and bland nuclei. Occasional mitoses were present. The differential diagnosis included ependymoma, Grade II, clear cell ependymoma, meningioma, EBV-associated smooth muscle tumor, glioma, schwannoma and solitary fibrous tumor.
The tumor expressed S100 (weak), EMA (diffuse), and progesterone receptors. MIB1/Ki-67 was focally expressed. The tumor did not express GFA or CD34. The diagnosis was Meningioma with a microcystic pattern, and hemorrhage.
Discussion centered on tumor-related intracranial hemorrhage, most of which is intraparenchymal. Tumor-related subdural hemorrhage is rare, and usually occurs in metastatic lesions; subdural hemorrhage is rare with meningiomas. There is an incidence of 1.5-5.4% intracranial hemorrhage in primary brain tumors, most of which are GBM; meningioma only rarely presents this way. Of 25 meningiomas with intracranial hemorrhage, 15 were meningothelial, 3 “angioblastic”, 3 transitional, 3 fibrous and 1 atypical.
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