1/8/2012 Case 1: Meningioma with microcystic pattern and hemorrhage

Presented by: Dr. Jianying Zeng (from Dr. Rao and Dr. Zeng - SUNY Downstate Medical Center)

Clinical History:

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.

Diagnostic Notes:

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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