Diverse Imaging Appearances and Locations of Meningioma.
Poster No.:
C-1616
Congress:
ECR 2013
Type:
Educational Exhibit
Authors:
L. Fatahi Bandpey , P. J. Sanchez Santos , D. yago , F. O.
1
1
1
1
1
2
Lenghel , E. Santa Eulalia Mainegra , I. Fernandez Bedoya , G.
1 1
2
Martinez Sanz ; TERUEL/ES, Buenos Aires/AR
Keywords:
Neoplasia, Diagnostic procedure, MR, CT, Neuroradiology spine,
Neuroradiology brain
DOI:
10.1594/ecr2013/C-1616
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Learning objectives
To describe typical and atypical findings of meningiomas in CT and MRI.
To assess frequent and infrequent localizations in 41 cases of our archive.
To establish possible differential diagnosis when atypical characteristics or unusual
localizations are found.
Background
Meningiomas are the most common primary nonglial extraaxial tumor and account for
15% of all intracranial neoplasms.They can be found in any place where meninges exist
and are benign in most of the cases.
There are 15 different histological types of meningiomas, classified in the WHO (World
Health Organization) grading system in three grades. In the WHO Grade I (classically
defined as benign and accounting for 80% of all meningiomas), the most common
subtypes are the transitional, fibroblastic, and meningothelial ones. The WHO Grade II
meningiomas are atypical and the WHO Grade III meningiomas are malignant.
Meningiomas are usually recognised on imaging studies by their typical localizations and
characteristic features; however, some of them have atypical appearances and occur in
atypical locations that can mimic other intracranial pathologies, leading to misdiagnosis.
Imaging findings OR Procedure details
Meningiomas are typically well-circumscribed, broad-based extra-axial lesions closely
abutting the duramadre.
On unenhanced CT they are usually hyperdense, with frequent calcifications, that can be
nodular, punctate or dense and confluent (Figure 1).
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Adjacent bone may show hyperostosis and bone erosion (Figure 2).
Meningiomas generally show homogeneous enhancement on contrast enhanced CT
(Figure 3).
The homogeneous enhancement, the presence of calcifications and the adjacent bone
sclerosis on CT are signs suggestive of benignity.
On MRI meningiomas are classically iso- or slightly hypointense on T1W images, with
variable signal intensity on T2W images (iso-hyperintense), and intense homogeneous
gadolinium enhancement (Figure 4).
They can also present a heterogeneous appearance, mainly on T2W images, due to the
existence of vascularization and the presence of calcifications and cystic foci (Figure 5).
MRI is less sensitive and specific than the CT for calcifications' characterization; its signal
intensity may vary (generally low both on T1W and T2W images) (Figure 6).
According to some recent studies, the histological type of meningiomas might
be suggested depending on its aspect on T2W MRI; fibroblastic and transitional
meningiomas would be hypointense, and the angyoblastic ones would be hyperintense.
The typical radiological signs of extra-axial lesion are better identified on MRI;
although not specific, they can be observed more frequently in meningiomas than in other
extra-axial lesions. These signs are the following: "cortical buckling" of the underlying
brain, "dural-tail" sign, "cerebrospinal fluid cleft" sign and "pial vascular structures"
interposed between the tumor and the brain surface (Figure 7).
These are some less frequent or atypical radiological appearances of the
meningiomas (among others):
•
Large amount of edema. In patients with meningiomas, the amount of
edema is better quantified on FLAIR sequences and it is not related tothe
tumor size (Figure 8). It has been suggested that the degree of perilesional
edema may be dued to the meningiomas' location (in our experience,
associated mainly with the six olfactory groove or frontobasal meningioma
cases included in our series), histological type and tumor blood supply.
The true nature of this phenomenon is still unclear, but tumors with a
disproportionate degree of edema could orientate to more aggressive
histological types, with a greater malignant potential.
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•
Heterogeneous internal structure and heterogeneous enhancement (Figure
9).
•
Multilobular or irregular borders (Figure 10).
•
Peripheral rim enhancement, low-grade astrocytoma alike.
•
En plaque meningiomas, which tend to infiltrate the duramadre and
frequently invade the adjacent bones. This type of meningioma is much
more commonly associated with subjacent bone hyperostosis, which is
disproportionately greater in size compared with the (intracranial) tumor
(Figure 11).
•
Cystic meningiomas. They are uncommon and its most frequent location is
overlying the cerebral convexity (particularly in the frontoparietal regions) or
parasagittal. Cystsassociated with meningiomas may be intra- or peritumoral
(Figure 12).
•
Necrosis, fat transformation and bleeding (Figure 13).
•
Target appearance (central enhancement), that may mimic an aneurysm
(Figure 14).
Typical localizations of meningioma include the convexity, parasagittal, the sphenoid
wing, the olfactory groove and the parasellar region. Meningiomas' most frequent
locations are variable, depending on different series.
The cases we present do not estimate the real prevalence of meningiomas' localizations
in our environment, because they have been collected from our Radiology Department
teaching image files, and therefore do not represent all the patients diagnosed with
meningiomas in our hospital.
We present the most illustrative images of different locations of meningiomas according
to our experience (41 cases) during the last 8 years (2004- 2012).
27 cases of supratentorial meningiomas
•
•
•
•
13 cases of convexity / parasagittal meningiomas (Figure 15).
6 cases of sphenoid meningiomas (Figure 16).
6 cases of olfactory groove meningiomas (Figure 17).
2 cases of parasellar meningiomas (Figure 18).
The sphenoid wing meningiomas are the most common of the skull base and its
location is very typical, but its extension varies widely. Some of them are very invasive
and its extension should be specified facing the neurosurgical approach (Figure 19).
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3 cases of tentorial meningiomas (Figure 20).
6 cases of subtentorial meningiomas
•
•
3 cases of cerebellopontine angle meningiomas (Figure 21).
3 cases of clival and clivo-sphenoidal meningiomas (Figure 22).
It is sometimes difficult to make the differential diagnosis between cerebellopontine angle
meningioma (the second most common tumor in the posterior cranial fossa) and acoustic
neurinoma (the most common in this location); diagnosis is suspected based on the
frequency of the following radiological features.
Dural- tail sign and adjacent bone reaction are uncommon in acoustic neurinomas. Cysts
and calcifications may be seen in 10% of the cases. Inhomogeneous enhancement may
be present in up to 32% of the cases. Internal auditory canal (IAC) extension is frequent
(80% of the cases) (Figure 23).
Dural-tail sign and adjacent bone reaction are more frequent in meningiomas. There
are usually no cysts and calcifications may be seen only in 20% of cases. The contrast
enhancement is homogeneous, and the extension to IAC is possible but uncommon.
3 cases of multiple meningiomas (meningiomatosis) (Figure 24).
•
•
•
One operated patient, with recurrence in the convexity and other locations
such as the optic nerves' sheets and the cerebellopontine angle.
One patient with parasellar and temporal locations.
One patient with multiple lesions: falx-convexity, intraventricular (operated)
and cerebellar tentorium.
Meningiomatosis is more frequently seen in women. In young patients, type 2
neurofibromatosis is the most common cause.
The differential diagnosis for meningiomatosis includes multiple metastases (Figure 25).
2 cases of spinal meningiomas (one in cervical and another in dorsal spine) (Figure
26).
Spinal meningiomas are the second most common intradural extramedullary
malignancies after metastases. They are more commonly located in the dorsal spine and
its differential diagnosis must be basically made with schwannoma, neurofibroma and
paraganglioma (Figure 27).
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Images for this section:
Fig. 1: Different patients with calcified meningiomas on Axial brain CT.
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Fig. 2: Calcified sphenoid wing meningioma (A, B) with reactive subjacent bone sclerosis
(arrows) at plain brain CT with bone window settings (C, D).
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Fig. 3: Typical parasagittal meningioma on plain (A) and contrast-enhanced (B) brain
CT. Homogeneous enhancement.
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Fig. 4: Typical parasagittal meningioma on Axial SE T1 (A), Axial (B) and Coronal (D)
FSE T2 and Sagittal SE T1W + Gd (C) brain MRI.
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Fig. 5: Calcified olfactory groove meningioma with heterogeneous signal intensity and
vasogenic perilesional edema at Axial (A, B) and Coronal (C, D) FSE T2W brain MRI.
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Fig. 6: Calcified meningioma with perilesional edema. Hypointense central calcification
on Sagittal plain (A) and Gadolinium-enhanced (B) SE T1W and Axial FSE T2W (C) brain
MRI.
Fig. 7: Typical radiological signs of extra-axial lesion in different patients with
meningiomas. A - Pial vascular structures (short arrows) and cerebrospinal fluid cleft sign
(large arrow) on Sagittal SE T1W brain MRI. B - Cerebrospinal fluid cleft sign (arrow) and
perilesional edema (asterisk) on Axial FSE T2W brain MRI. C - Dural-tail sign (arrows)
on Sagittal SE T1W brain MRI.
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Fig. 8: Great perilesional edema (asterisks) in two different patients with meningiomas.
1 - Axial FLAIR brain MRI (A). 2 - Calcified meningioma of the olfactory groove on axial
non-enhanced brain CT (B).
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Fig. 9: Parietal meningioma of the convexity with heterogeneous structure on plain (A)
and contrast-enhanced (B) brain CT.
Fig. 10: Meningiomas with lobulated borders in two different patients. 1 - Axial contrastenhanced brain CT (A and B). 2 - Sagittal SE T1W Gadolinium-enhanced brain MRI (C).
Fig. 11: Right spheno-orbital en plaque meningioma in plain brain CT with soft-tissue
window (A) and MIP bone window (B).
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Fig. 12: Intratumoral cyst (asterisks) in left parasagittal meningioma. Axial (A) and
contrast-enhanced (B) brain CT.
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Fig. 13: Patient with multiple meningiomas on axial plain brain CT. Intraventricular
meningioma of the right trigone with small laminar hemorrhage (short arrows) and
perilesional edema (asterisks). Tentorial meningioma with central calcification (large
arrow).
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Fig. 14: "Inverse target appearance" due to central and lineal peripheric calcification
en tentorial meningioma with supratentorial extension. Axial plain (A, B) and contrastenhanced (C, D) brain CT. Coronal T2W (D) and Sagittal plain (E) and Gadoliniumenhanced (F)T1W brain MRI.
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Fig. 15: Parasagittal meningiomas. Different patients. 1 -Coronal (A) Gadoliniumenhanced T1W brain MRI. 2 - Sagittal (B) and Axial (C) Gadolinium-enhanced T1W brain
MRI. 3 - Contrast-enhanced axial brain CT (D). Axial Plain (E) and Gadolinium-enhanced
(F) T1W brain MRI.
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Fig. 16: Sphenoid meningiomas (different patients). Axial plain brain CT (A, B). Sagittal
Plain (C) and Gadolinium-enhanced (D), Axial Plain (E) and Gadolinium-enhanced (F)
T1W brain MRI.
Fig. 17: Olfactory groove meningioma in two different patients. 1 - Contrast-enhanced
brain CT (A). 2 - Plain (B) and Gadolinium-enhanced (C) Axial T1W MRI and plain (D)
and Gadolinium-enhanced (E) Sagittal T1W brain MRI.
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Fig. 18: Left parasellar meningioma with suprasellar extension. Coronal FSE T2W (A),
Axial (B) Gadolinium-enhanced and plain (C) and Gadolinium-enhanced (D) Sagittal T1W
brain MRI.
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Fig. 19: Invasive sphenoid wing meningioma with homogeneous contrast-enhancement
on Axial (A, B, C, D), Sagittal (E) and Coronal (F) Gadolinium-enhanced T1W brain MRI.
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Fig. 20: Small tentorial meningioma, almost unnoticed (despite presenting the
"cerebrospinal fluid cleft sign") on brain MRI (isointense on T2W (A) and plain Axial (B)
and Sagittal (D)T1W images), but for the intense Gadolinium-enhancement (Axial (C)
and Sagittal (E) T1W+ Gd images.
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Fig. 21: Cerebellopontine angle meningiomas in two different patients. 1 - Plain (A) and
Gadolinium-enhanced (B) Axial T1W brain MRI. 2 - Axial (C) and Coronal (D) Gadolinium
-enhanced T1W brain MRI.
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Fig. 22: Clival meningioma with right growth that occupies the prepontine cistern.
Axial plain (A) and contrast-enhanced (B) brain CT. Sagittal plain (C) and Gadoliniumenhanced (D) T1W brain MRI.
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Fig. 23: Left acoustic neurinoma on Coronal T2W (A), Coronal Gadolinium-enhanced
T1W (B) and Axial 3D FIESTA (C) brain MRI. Enlargement and erosion of internal auditory
canal (arrow) on brain CT with bone window setting (D).
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Fig. 24: Multiple meningiomas (meningiomatosis) in two different patients. 1 Right optic nerve (large arrows) and right cerebellopontine angle (short arrows)
meningiomas on plain (A) and contrast-enhanced (B) brain CT. 2 - Patient with operated
right intraventricular meningioma. Tentorial meningioma (with central hipointensity on
Gadolinium-enhanced images) that hang down towards the supravermian cistern, and
multiple falcines meningiomas. Axial (C) and Sagittal (D) T1W brain MRI.
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Fig. 25: Dural metastases from prostate carcinoma. Meningeal involvement
characterized by a diffuse smooth thickening, nodular appearance (short arrows), with
peritumoral cyst (large arrow). Axial plain (A, B) and contrast-enhanced (C, D) brain CT.
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Fig. 26: Spinal meningiomas in two different patients. 1 - C7 -D1 meningioma on Plain
(A) and Gadolinium-enhanced Sagittal (B) and Axial (C) T1W cervical spine MRI. 2 Dorsal meningioma on Plain (D) and Gadolinium-enhanced Sagittal (E) and Axial (F)
T1W dorsal spine MRI.
Fig. 27: Spinal Paraganglioma. Intradural extramedullary lesión (medullary cone,
L1-L2 level), with small internal cystic element (high-signal in T2W image) and
homogeneous enhancement, meniningioma-alike. Plain Sagittal T1W (A), Gadoliniumenhanced Sagittal (B) and Axial (C) T1W, Sagittal (D) and Axial (E) T2W lumbar spine
MRI.
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Conclusion
Meningiomas are common central nervous system tumors.
Radiologists must be aware of their less frequent locations and uncharacteristic imaging
features in order to suggest the correct diagnosis in atypical cases.
References
1- Buetow MP, Buetow PC, Smirniotopoulos JG. Typical, atypical, and misleading
features in meningioma. Radiographics. 1991 Nov; 11(6):1087-106.
2- Smirniotopoulos G, Yue NC, Rushin EJ: Cerebellopontine angle masses: radiologicpathologic correlation. Radiographics: September 1993 13: 1131-1147.
3- Koeller K, Sandberg GD. Cerebral Intraventricular Neoplasms: Radiologic-Pathologic
Correlation. RadioGraphics 2002; 22:1473-1505.
4- Shaman MA, Zak IT, Kupsky WJ. Best Cases from the AFIP: Involuted Sclerotic
Meningioma. Radiographics 2003; 23:785-789.
5- Guermazi A, Lafitte F, Miaux Y, Adem C, Bonneville JF, Chiras J. The dural tail sign-beyond meningioma. Clin Radiol. 2005 Feb; 60(2):171-88.
6- Gelabert-González M, Leira-Muiño R, Fernández-Villa JM, Iglesias-Pais M. Multiple
intracranial meningiomas. Rev Neurol. 2003 Oct 16-31; 37(8):717-22.
7- Katzman GL. Atypical and Malignant Meningioma. In: Diagnostic imaging: brain. Salt
Lake City, Utah: Amirsys, 2004; II-4-60.
8- Bonneville F, Cattin F, Marsot-Dupuch K et al. T1 signal hyperintensity in the sellar
region: spectrum of findings. Radiographics. 2006 Jan-Feb; 26(1):93-113. Review.
9- Razek AA, Castillo M. Imaging lesions of the cavernous sinus. AJNR Am J Neuroradiol.
2009 Mar; 30(3):444-52.
10- O'Leary S, Adams WM, Parrish RW, Mukonoweshuro W. Atypical imaging
appearances of intracranial meningiomas. Clin Radiol. 2007 Jan; 62(1):10-7.
11- Majós C, Cucurella G, Aguilera C, Coll S, Pons LC. Intraventricular meningiomas:
MR imaging and MR spectroscopic findings in two cases. AJNR Am J Neuroradiol. 1999
May; 20(5):882-5.
Page 30 of 32
12- Bonneville F, Cattin F, Marsot-Dupuch K, Dormont D, Bonneville JF, Chiras J. T1
Signal Hyperintensity in the Sellar Region: Spectrum of Findings. Radiographics
January-February 2006 26:1 93-113.
13- Bonneville F, Sarrazin JL, Marsot-Dupuch K, Iffenecker C, Cordoliani YS, Doyon D et
al. Unusual lesions of the cerebellopontine angle: a segmental approach. Radiographics.
2001, 21:419-438.
14- Silk PS, Lane JI, Driscoll CL. Surgical Approaches to vestibular schwannomas: what
the radiologist needs to know. Radiographics. 2009, 29: 1955-1970.
15- Osborn AG, Blaser SI, Salzman KL, Katzman GL, Provenzale J, Castillo M et al.
Diagnostic Imaging: Brain. 1st ed. Salt Lake City, Utah: Amirsys; 2004.
16- Rockhill J, Mrugala M, Chamberlain MC. Intracranial meningiomas: an overview of
diagnosis and treatment. Neurosurg Focus. 2007; 23(4):E1.Review.
17- Bosnjak R, Derham C, Popovic M, Ravnik J. Spontaneous intracranial meningioma
bleeding: clinicopathological features and outcome. J Neurosurg 2005; 103:473-484.
18- Kawahara Y, Nakada M, Hayashi Y et al. Prediction of high-grade meningioma by
preoperative MRI assessment. J Neurooncol 2012; 108:147-152.
19- Sotoudeh H, Yazdi HR. A review on dural tail sign. World J Radiol 2010; 2:188-192.
20- Yue Q, Isobe T, Shibata Y, Anno I, Kawamura H, Yamamoto Y, Takano S, Matsumura
A. New observations concerning the interpretation of magnetic resonance spectroscopy
of meningioma. Eur Radiol. 2008 Dec;18(12):2901-11.
21- Majós Torró y Àngels Camins Simons: Tumores del sistema nervioso central.
Radiología Esencial. Editorial médica panamericana. 2009.
22- Johnson MD, Powell SZ, Boyer PJ, Weil RJ, Moots PL. Dural lesions mimicking
meningiomas. Hum Pathol. 2002 December; 33(12): 1211-1226.
23- Bonnal J, Thibaut A, Brotchi J, Bom J. Invading meningiomas of the sphenoid ridge.
J. Neurosurg. 1980; 53:587-99.
24- Saraf S, McCarthy BJ, Lee Villano J. Update on Meningiomas. The Oncologist 2011;
16:1604-1613.
25- Schubeus P, Schörner W, Rottacker C, Sander B. Intracranial meningiomas: How
frequent are indicative findings in CT and MRI? Neuroradiology (1990) 32:467-473.
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