2021, 3(1):18-22 e-ISSN: 2674-7103

DOI: 10.37085/jmmv3.n1.2021.pp.18-22

Jornal Memorial

Medicina

Review

Surgical Medicine

Hemorrhagic angiomatous meningioma: what we know. Case report and review

of the literature

Marcelo Palmares Oliveira e Silva Vitor Palmares Oliveira e Silva Allan Victor Tavares da Silva

Giovani Crestana Nogueira Lima Matheus Augusto Pinto Kitamura

Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil

Abstract

Meningiomas are the most common benign intracranial tumors and rarely present with sponta-

neous bleeding. We report on a case of hemorrhagic angiomatous meningioma that was treated

surgically (the rst case described in Brazil) and present a review of the literature. The patient was

a 38-year-old female with progressive headache and vomiting. She also had a previous history of

chronic headaches and refractory depression. Imaging studies showed a large left frontal extra-axial

tumor, with intense contrast enhancement and hyperperfusion/hypervascularization. There was an

extensive intratumoral and pericapsular hemorrhagic region, with dilation of the middle meningeal

arteries and falx cerebri vessels. The lesion was compatible with hemorrhagic meningioma. The

patient underwent bifrontal craniotomy and tumor devascularization, followed by total resection.

Histopathological and immunohistochemical analyses led us to conclude that this was a case of

angiomatous meningioma. Subsequently, the patient’s headaches and depression improved. No

residual or recurrent neoplastic lesion was observed during the follow-up.

Marcelo Palmares Oliveira e Silva

palmaresm12@hotmail.com

Edited by

Marcelo Moraes Valença

Keywords:

Angiomatous meningioma

Spontaneous hemorrhage

Neurosurgery

Intracranial tumor

Received: June 29, 2021

Accepted: June 30, 2021

ASAA

Oliveira e Silva MP

Hemorrhagic angiomatous meningioma: what we know. Case report and review of the literature

Introduction

eningiomas are the commonest benign intracranial

tumors

. Although these are richly vascularized lesions,

spontaneous bleeding is rare

and such cases may become

challenging. Few reports of angiomatous meningiomas with

spontaneous hemorrhage have yet been published.

Here, we report on a case of angiomatous meningioma with

an uncommon initial hemorrhagic presentation that was

treated through surgical resection, and we present a specic

review of the literature. So far, this is the rst case of its type

to be reported in Brazil.

Case report

The patient was a 38-year-old woman who was admitted to

the emergency service with an incapacitating frontal pulsatile

headache that she had for one day. This was accompanied

by nausea and vomiting. Her neurological examination was

normal. She had antecedents of chronic headache of the

same pattern but of lower intensity, and history of hypothy-

roidism and treatment-resistant depression. She did not have

any history of trauma or coagulopathy.

Magnetic resonance imaging (MRI) demonstrated the pres-

ence of a voluminous left frontal extra-axial solid tumor measur-

ing 7.1 x 5.4 x 6.0 cm, with its base in contact with the frontal

dura mater and falx cerebri, and with a signicant mass

effect and subcortical edema. This lesion presented intense

contrast enhancement, hyperperfusion-hypervascularization

and an extensive intratumoral and pericapsular hemorrhagic

component. There was also increased vascularization of the

left frontal bone plate. The ndings were compatible with

hemorrhagic meningioma (Figures 1A, 1B, and 1C).

Intracranial magnetic resonance angiography (MRA) demon-

strated dilation of the middle meningeal arteries, which was

greater on the left side. These participated in nutrition for the

tumor, as did the falx cerebri vessels. The tumor was in contact

Figure 1: Left frontal tumor, isointense in T1 and T2-weighted MRI, with intense contrast enhancement, hyperperfusion, dural

tail, peritumoral edema, and hemorrhage. 1A: MRI T1 sequence with contrast, in sagittal view. 1B: MRI T1 sequence with

contrast, in axial view. 1C: MRI T2 sequence, in axial view.

ASAA

Oliveira e Silva MP

Hemorrhagic angiomatous meningioma: what we know. Case report and review of the literature

with the superior sagittal sinus, without invasion (Figures 2A

and 2B).

The patent was admitted to the intensive care unit (ICU) and

corticoid treatment was started. She underwent bifrontal

craniotomy, with exposure of the superior sagittal sinus. The

hematoma was drained and the tumor was devascularized.

This was followed by complete resection of the tumor, curet

tage, and coagulation of adjacent structures. There was no

gross evidence of any remaining tumor or active bleeding. The

postoperative period was free from complications. A cranial

Figure 2: Intracranial magnetic resonance angiography (MRA) showing dilation of the middle meningeal artery and falx cerebri vessels.

2A: sagittal view. 2B: coronal view.

Figure 3: Postoperative images: 3A: Postoperative CT scan, in transversal view, showing total resection, wide surgical cavity

and left frontal pneumocephalus, without hemorrhage. 3B: Control MRI, T1 sequence with contrast, in axial view, showing

wide surgical cavity, with absence of residual or recurrent lesion.

ASAA

Oliveira e Silva MP

Hemorrhagic angiomatous meningioma: what we know. Case report and review of the literature

CT scan showed that the postoperative appearance was satis-

factory. Left frontal pneumocephalus was present (Figure 3A).

The histopathological examination showed that this was a

case of angiomatous meningioma, of WHO grade I. The

sample was positive for epithelial membrane antigen, proges-

terone receptors and Ki-67 cell proliferation antigen.

During the patient’s outpatient follow-up, her headache and

depression improved. Through MRI done later on within the

follow-up period, presence of residual or recurrent neoplastic

lesion in the left frontal region could be ruled out (Figure 3B).

Discussion

Meningioma is the commonest primary tumor of the nervous

system and accounts for 13% to 33.8% of all intracranial

neoplasms.

The risk of developing this neoplasm increases

with age and becomes signicantly greater beyond the age

of 65 years. It is twice as common in women and may be

associated with progesterone receptors.

Its incidence is 4.4

cases per 100,000 people

, and autopsy studies have shown

prevalences of 2-3%.

Meningiomas are derived from capillary cells of the arachnoid

and adhere to the dural surface. They are typically extra-axial

lesions and can be separated from the adjacent cerebral

tissue. The middle meningeal artery tends to be dilated as

the artery that feeds the tumor.

The symptoms caused depend on the site and size of the

meningioma. In most cases, meningiomas give rise to symp-

toms such as headache, dizziness, convulsions, or gradual

progression of neurological decits.

It should be highlighted

that 50-78% of cerebral tumors are accompanied by mental

disorders and that 21% of patients with meningioma of the

frontal lobe in the fourth decade of life only present psychiatric

symptoms.

Spontaneous bleeding is a rare complication of meningiomas,

even though these are extremely vascularized tumors. The

incidence of hemorrhagic meningiomas ranges from 0.5 to

2% in the literature.

The etiology that leads to the low rate

of bleeding in meningiomas is uncertain. It is thought that

this might occur through rupture of undifferentiated tumor and

dural vessels because of rapid neoplastic growth, release of

vasoactive substances, and necrosis.

The site of bleeding de-

pends on the location of the tumor: subarachnoid hemorrhage

occurs most commonly, followed by subdural hemorrhage.

Angiomatous meningioma is a rare histological subtype of

meningioma, according to the WHO classication. It gen-

erally presents a good prognosis and low recurrence rates.

It accounts for 2.1% of all meningiomas and is dened by

predominance (greater than 50%) of the vascular compo-

nent

. It is of notably benign nature and is placed in WHO

grade 1, given its low cell multiplication rates, low Ki-67

levels and positivity for progesterone receptors. Despite its

rich vascular structure, its bleeding rates are similar to those

of other subtypes.

The denitive diagnosis of angiomatous meningioma is made

through histopathological evaluation. The location where it

is most commonly found is the cerebral convexity (68.8%),

followed by the falx cerebri (7.53%).

Typically, CT scans show

mild hyperdensity. In MRI, the patterns most often reported

are hypointensity in T1 and hyperintensity in T2.

Other com-

mon ndings in cases of angiomatous meningioma include

a ringlike signal (30.1%), peritumoral edema (87.1%), cystic

formations (51.6%), and vascular voids (49.5%).

After hemorrhagic meningioma has been diagnosed, a radi-

cal approach becomes necessary.

This consists of drainage

of the hematoma and complete excision of the tumor. It is not

always possible to achieve this nal objective: the hemorrhage

may worsen during the operation (seen in 63.8% of the cases),

with the need for blood transfusion (14%).

Conclusion

Spontaneous bleeding as the initial presentation of meningi-

oma is rare, including in the angiomatous subtype. Careful

analysis of radiological examinations may help in making

differential diagnoses. Antecedents such as refractory de-

pression, with or without accompanying chronic headaches,

in patients may also raise suspicions of neoplasms of the

frontal lobe.

Emptying of the hematoma, accompanied by total resection,

is the treatment of choice for hemorrhagic meningiomas.

Marcelo Palmares Oliveira e Silva

https://orcid.org/0000-0002-5538-3753

Vítor Palmares Oliveira e Silva

https://orcid.org/0000-0003-4803-1255

Allan Victor Tavares da Silva.

https://orcid.org/0000-0002-0534-4406

Giovani Crestana Nogueira Lima:

https://orcid.org/0000-0001-9152-4827

Matheus Augusto Pinto Kitamura

https://orcid.org/0000-0003-2745-9068

ASAA

Oliveira e Silva MP

Hemorrhagic angiomatous meningioma: what we know. Case report and review of the literature

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