DOI: 10.33962/roneuro-2020-018 Fast growing recurrent grade I meningioma. A rare case report Prashank Goel, Daljit Singh Romanian Neurosurgery (2020) XXXIV (1): pp. 127-132 DOI: 10.33962/roneuro-2020-018 www.journals.lapub.co.uk/index.php/roneurosurgery Fast growing recurrent grade I meningioma. A rare case report Prashank Goel1, Daljit Singh2 1 Senior resident, Department of Neurosurgery, G. B Pant Institute of Post Graduate Medical Education and Research, New Delhi, INDIA 2 Director, Professor and Head of Department, Department of Neurosurgery, G. B PantInstitute of Post Graduate Medical Education and Research, New Delhi, INDIA ABSTRACT Meningiomas are mostly regarded as benign tumours, accounting for 13% to 26% of all primary intracranial tumors1. According to 2016 World Health Organization (WHO) classification, meningiomas are classified into grade I (benign), II (atypical), and III (anaplastic).2 Meningioma are neoplasms derived from arachnoidal (meningothelial) cells. These lesions can occur in people of any age but commonly present in middle age. Women are more likely to develop a meningioma, with a female/male ratio of approximately 2:1 intracranially and 10:1 in the spine.3 Even after complete removal, meningiomas have been estimated to recur in 10 to 32% of the cases within 10 years. However, recurrences in grade 1 meningiomas are rare and occur after long duration.4 We herein report a case of grade 1 meningioma that recurs very fast, within the duration of 1 yr and the recurrent size of the tumor was approx three times the size of the primary one. To our knowledge, very few cases in the literature have been reported with such a fast-growing grade 1 meningioma. CASE REPORT A 45 years female, case of right cavernous sinus meningioma (figure 1,2) operated 1 year back, was admitted to o ur department of neurosurgery with altered sensorium for last 20 days. Simpson grade III excision of the tumor was done 1 year back. The histopathology report of first surgery was transitional meningioma grade 1 with MIB index 10-12%. After the first surgery post-operative scan (figure 3) reveals gross total excision of tumor and patient went back with no deficits. Now after 1 year patient present to us in altered sensorium, right lower motor neuron paresis of facial nerve and paresis of lower cranial nerves over the right side. MRI Brain plain with contrast was done which reveals a large recurrent mass lesion extending from right Keywords grade I meningioma, recurrence, fast-growing Corresponding author: Prashank Goel G. B Pant Institute of Post Graduate Medical Education and Research, New Delhi, India prashankgoel1@gmail.com Copyright and usage. This is an Open Access article, distributed under the terms of the Creative Commons Attribution Non–Commercial No Derivatives License (https://creativecommons .org/licenses/by-nc-nd/4.0/) which permits non- commercial re-use, distribution, and reproduction in any medium, provided the original work is unaltered and is properly cited. The written permission of the Romanian Society of Neurosurgery must be obtained for commercial re-use or in order to create a derivative work. ISSN online 2344-4959 © Romanian Society of Neurosurgery First published March 2020 by London Academic Publishing www.lapub.co.uk http://www.lapub.co.uk/ 128 Prashank Goel, Daljit Singh cavernous sinus to ipsilateral cerebellopontine angle attaching to the petrous bone with gross hydrocephalus (figure 4,5). As the patient presented in altered sensorium, patient was intubated, put on ventilator and emergency ventriculoperitoneal shunt was done. Subsequently right retromastoid suboccipital craniotomy and tumor decompression was done and a part of tumor inside the cavernous sinus was left behind (figure 6). Histopatholgy report again came out to be transitional meningioma. Post operatively patient continued on ventilator, tracheostomised and after few days gradually weaned from tracheostomy. At the time of discharge, patient was conscious, oriented, following commands and walking with support. Figure 1. Contrast CT scan (coronal and saggital images) of patient done preoperatively 1 yr back, showing homogenously contrast enhancing lesion in right cavernous sinus. 129 Fast growing recurrent grade I meningioma Figure 2. MRI Brain (axial, coronal and saggital images) of patient done preoperatively 1 yr back, showing homogenously contrast enhancing lesion in right cavernous sinus. 130 Prashank Goel, Daljit Singh Figure 3. Contrast CT (axial and coronal) post-operative images of the patient done 1 year back, showing gross total resection of meningioma. Figure 4. Contrast CT axial images showing brilliantly homogenous contrast enhancing lesion in cavernous sinus with extension to the right cerebellopontine angle. Figure 5. MRI Brain contrast images showing brilliantly homogenous contrast enhancing lesion in cavernous sinus with extension to the right cerebellopontine angle. 131 Fast growing recurrent grade I meningioma Figure 6. CT brain palin and contrast post-operative images showing total removal of meningioma in C P angle with residual tumor in cavernous sinus with vp shunt in situ. DISCUSSION Recurrences in grade 1 meningioma are rare and occur after long duration. In our case patient had recurrent grade I meningioma and that too in just 1 year and now tumor has grown to such a big size that it had extended to right cerebelloopontine angle displacing the midbrain causing mass effect and hydrocephalus. To date very few cases has been reported in literature where the grade 1 meningioma recurs in such a short interval and of such a big size. Recurrences in grade 2 and grade 3 are common. In the study by Gallagher5, the median time to recurrence /progression was 60 months (range 6 to 134 months) and another study done by Ildan4, the mean time to recurrence was 60.5 ±  27.9 months (range, 28 to 114 months) for benign meningiomas and 39 ± 14.5 months (range, 28 to 68 mos) for malignant meningiomas. Despite complete total resection, 7-20% of benign (Grade I), 29-40% of atypical (Grade II), 50-78% of anaplastic (Grade III) meningiomas recur.6 The factors involved in tumor recurrence, other than tumor grading are extent of surgery, age, gender, location and brain invasion. Meningiomas in males and children tend to be aggressive and recur more than in females7,8. However, Ildan et al4, and 132 Prashank Goel, Daljit Singh Adegbite et al9 reported that age and gender has no influence on proliferative activity. Location was one of the factors implicated in recurrence. Meningiomas of the skull base and tumors close to major sinuses were reported to have a high proliferative index and were associated with recurrence4,8,12. Bitzer et al10 and Ide et al11 reported that large tumors were more prone for recurrence than smaller tumors, as large sized tumors were associated with a higher incidence of tumor infiltration and adherence to arachnoid membrane and the adjacent brain tissue. Nakasu et al12 found that lobulated tumors recurred more often than round tumors. Gallagher et al reported that 5-year recurrence / progression free survival (RPFS) for Simpson grade 1 was 96.8%, 2: 100%, 4: 82.4% and 5: 0%. Simpson grade and gross total/subtotal resection were significant predictors of recurrence with most of the recurrences occurring in the subtotal resection group and only a few occurring in patients who underwent total removal. The overall mortality among recurrent meningiomas was 9.7%, and recurrence-related mortality constituted 75% of all meningioma related mortalities in the series by Guarnaschelli et al2. CONCLUSION Recurrence in grade 1 meningioma is rare. Recurrence is common with subtotal resection of meningiomas. The predicting factors for recurrence in this case were subtotal resection, primay tumor location (cavernous sinus) with high MIB index. 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