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388 Agrawal et al Intracranial-extracranial meningioma
Intracranial-extracranial meningioma mimicking an aggressive
skull bone tumor
Amit Agrawal1, K.V. Murali Mohan2, Vissa Shanthi3,
Umamaheshwar Reddy4
Narayana Medical College Hospital, Chinthareddypalem, Nellore, Andhra Pradesh, India
1Professor of Neurosurgery, Department of Neurosurgery
2Professor of Pathology, Department of Pathology
3Associate Professor of Pathology, Department of Pathology
4Assistant Professor of Radiology, Department of Radiology
Abstract
Intracranial meningiomas with
extracranial extension are rare lesions with
only few reported cases in literature. In
present article we report a case of 62 year
male patient presented with progressive
swelling over right side frontal region of 2
year duration. In our case the tumor was in
close proximity to right fronto-parietal
suture and there was a possibility that
suture line could have paved the way for its
extracranial spread and also there was
evidence of transdiploic extension on
histopatholgical examination.
Key words: Meningioma, head injury,
extracranial meningioma, intracranial-
extracranial.
Introduction
Meningioma account for 24-30% of
primary intracranial tumors and typically
arises in proximity to the meninges (1, 2, 3).
Intracranial meningiomas with extracranial
extension are rare lesions with only few
reported cases in literature (3-8). In present
article we report a case of intracranial and
extra-cranial menigioma.
Case report
A 62 year male patient presented with
progressive swelling over right side frontal
region of 2 year duration. Weakness of left
upper and lower limbs of one month
duration. There was history of headache
and vomiting for last 3-4 days. Local
examination revealed a non-tender, hard
swelling over right fronto-parietal region,
non-pulsatile, with bruit. Skin over the
swelling was healthy and there were no
prominent vessels. There was history of
trauma at the same site about 15 year back.
His general and systemic examination was
unremarkable. There was mild upper
motor neuron type of weakness of left facial
nerve. Other cranial nerves including
fundus were normal. He was conscious,
alert and oriented to time, place and person.
There was grade 4/5 weakness of left upper
and lower limbs. Deep tendon reflexes were
exaggerated on left side and were normal on
right side. Planter was extensor on left side
and was flexor on right side. CT scan brain
plain with bone window revealed a large
tumor consisting of intracranial and
extracranial parts with erosion of the
calvaria involving right frontal and parietal
and crossing the coronal suture on right
Romanian Neurosurgery (2013) XX 4: 388 - 392 389
side (Figure 1 A-F). The tumor was
invading the parenchyma and there was
significant peri-lesional edema. Based on
the imaging findings a high grade malignant
lesion was considered. The patient
underwent right fronto-parietal craniotomy
and total excision of the tumor including
excision of the involved bone. The tumor
was attached to the dural and infiltrating the
bone. It could be easily separated from the
underlying brain parenchyma.
Histopathological examination of the tumor
confirmed the diagnosis of meningioma
(Figure 2 and 3). The patient recovered
well and the postoperative course was
uneventful.
Discussion
The reported incidence of intracranial
meningiomas with extracranial extension is
up to 20% of cases (9, 10).
There is strong evidence there is an
elevated risk brain tumor after head trauma
particularly for meningiomas in males (1,
11-16). Many explanations have been put
forward to explain extracranial spread of
tumor and the extracranial extension in
meningiomas may occur by direct
extension of an intracranial meningioma
through a natural, traumatic, or iatrogenic
skull defect (17, 18). This may occur
through skull foramina, through the
supraorbital fissure (into the orbit), through
the cribriform plate (into the nasal cavities
and nasopharynx), through floor of middle
cranial fossa (into paranasal sinuses and
pterygoid region) and extracranial extension
through the suture line of the skull (4, 9,
10, 19-23). In a case report the transdiploic
extension was suggested as the underlying
mechanism for the extracranial spread of
the meningioma (8).
Figure 1
(A-F) CT scan brain showing extensive osteolytic lesion in right fronto-parietal region with intra-extracranial
components and adjacent hyperostosis of frontal and parietal bones
390 Agrawal et al Intracranial-extracranial meningioma
Figure 2
(A) Spindle shaped tumor cells forming whorling pattern (H&E,X100)., (B) spindle shaped tumor cells with
areas of hyalinization (H&E,X100), (C) tumor cells infiltrating the skeletal muscle bundles and congested blood
vessels (H&E,X100) and (D) spindle shaped tumor cells with psammoma body (H&E,X100)
Figure 3
Showing the bony trabeculae with interstitial tissue
showing infiltrating tumor cells and psammoma
bodies (H&E,X100)
In our case the tumor was in close
proximity to right fronto-parietal suture
and there was also a possibility that suture
line could have paved the way for its extra-
cranial spread and also there was evidence
of transdiploic extension on
histopatholgical examination. Clinical
symptoms are usually non-specific and can
be according to the site of involvement
(20). If the extracranial component is large
enough and there is extensive hyperostosis
the lesion can be palpable through the scalp
(18). Both MRI and CT will help to suggest
the extent of the lesion and this can be
Romanian Neurosurgery (2013) XX 4: 388 - 392 391
confirmed by FNAC prior to surgical
intervention (4, 7, 24). Whenever possible
the complete excision of the tumor is the
treatment of choice as this has been shown
to be associated with best long-term
outcome compared with subtotal excision
(19, 23, 25, 26 27 28, 29). The recurrence
rate ranges from 7% to 84% (30, 31) and the
recurrences usually develop at the primary
site of lesion and probably represent the
residual disease rather than true recurrence
(27, 30, 31).
Address for correspondence:
Dr. Amit Agrawal
Professor of Neurosurgery, Department of
Neurosurgery, Narayana Medical College
Hospital, Chinthareddypalem
Nellore-524003
Andhra Pradesh (India)
Email: dramitagrawal@gmail.com
dramit_in@yahoo.com
Mobile: +91-8096410032
References
1.Longstreth WT, Dennis LK, McGuire VM,
Drangsholt MT, Koepsell TD. Epidemiology of
intracranial meningioma. Cancer 1993;72:639-648.
2.Louis D, Ohgaki H, Wiestler O, Cavenee W, Fuller C.
World Health Organization classification of tumours of
the central nervous system. JOURNAL OF
NEUROPATHOLOGY AND EXPERIMENTAL
NEUROLOGY 2008;67:260.
3.Russell D, Rubinstein L. Pathology of tumors of the
central nervous system. London: Butleeer & Tanner
1989:421-428.
4.Neeff M, Baysal E, Homer J, Gillespie J, Ramsden R.
Intracranial/Extracranial meningioma arising in the
hypoglossal canal: case report. Skull base : official
journal of North American Skull Base Society [et al]
2007;17:325-330.
5.Cech DA, Leavens ME, Larson DL. Giant intracranial
and extracranial meningioma: case report and review of
the literature. Neurosurgery 1982;11:694-697.
6.Djindjian M, Raulo Y. [Giant intra-extracranial
meningioma of the calvaria]. Neuro-Chirurgie
1984;30:341-345.
7.Nakagawa H, Lusins JO. Biplane computed
tomography of intracranial meningiomas with
extracranial extension. Journal of computer assisted
tomography 1980;4:478-483.
8.Akif M. Intra-Extracranial Meningioma. Turkish
Neurosurgery 1993;4:170-172.
9.Farr HW, Gray GF, Vrana M, Panio M. Extracranial
meningioma. Journal of surgical oncology 1973;5:411-
420.
10.Friedman CD, Costantino PD, Teitelbaum B,
Berktold RE, Sisson GA. Primary extracranial
meningiomas of the head and neck. The Laryngoscope
1990;100:41-48.
11.Preston-Martin S, Pogoda JM, Schlehofer B, et al.
An international case-control study of adult glioma and
meningioma: the role of head trauma. International
journal of epidemiology 1998;27:579-586.
12.Barnett GH, Chou SM, Bay JW. Posttraumatic
intracranial meningioma: a case report and review of the
literature. Neurosurgery 1986;18:75-78.
13.Carpenter AV, Flanders WD, Frome EL, Cole P, Fry
SA. Brain cancer and nonoccupational risk factors: a
case-control study among workers at two nuclear
facilities. American journal of public health
1987;77:1180-1182.
14.Inskip PD, Mellemkjaer L, Gridley G, Olsen JH.
Incidence of intracranial tumors following
hospitalization for head injuries (Denmark). Cancer
causes & control : CCC 1998;9:109-116.
15.Claus EB, Bondy ML, Schildkraut JM, Wiemels JL,
Wrensch M, Black PM. Epidemiology of intracranial
meningioma. Neurosurgery 2005;57:1088-1095;
discussion 1088.
16.Wiemels J, Wrensch M, Claus EB. Epidemiology and
etiology of meningioma. Journal of neuro-oncology
2010;99:307-314.
17.Teague SD, Conces DJ. Metastatic meningioma to
the lungs. Journal of thoracic imaging 2005;20:58-60.
18.Younis G, Sawaya R. Intracranial osteolytic
malignant meningiomas appearing as extracranial soft-
tissue masses. Neurosurgery 1992;30:932-935.
19.Thompson LD, Gyure KA. Extracranial sinonasal
tract meningiomas: a clinicopathologic study of 30 cases
with a review of the literature. The American journal of
surgical pathology 2000;24:640-650.
20.Thompson LDR, Bouffard J-P, Sandberg GD, Mena
H. Primary ear and temporal bone meningiomas: a
clinicopathologic study of 36 cases with a review of the
literature. Modern pathology : an official journal of the
United States and Canadian Academy of Pathology, Inc
2003;16:236-245.
21.Chang CY, Cheung SW, Jackler RK. Meningiomas
presenting in the temporal bone: the pathways of spread
from an intracranial site of origin. Otolaryngology--
head and neck surgery : official journal of American
Academy of Otolaryngology-Head and Neck Surgery
392 Agrawal et al Intracranial-extracranial meningioma
1998;119:658-664.
22.Batsakis JG. Invasion of the microcirculation in head
and neck cancer. The Annals of otology, rhinology, and
laryngology 1984;93:646-647.
23.Panjvani SI, Gandhi MB, Sarvaiya AN, Chaudhari
BR, Gupta GS. An Extracranial Invasive Meningioma
Mimicking Malignant Bone Tumor–“Carpet
Meningioma”. 2013.
24.Saloner D, Uzelac A, Hetts S, Martin A, Dillon W.
Modern meningioma imaging techniques. Journal of
neuro-oncology 2010;99:333-340.
25.Naguib SM, Shalaby AMR. Differentiation of
meningiomas from histologic mimics via the use of
claudin-1. Pan Arab Journal of Neurosurgery:10.
26.Condra KS, Buatti JM, Mendenhall WM, Friedman
WA, Marcus Jr RB, Rhoton AL. Benign meningiomas:
primary treatment selection affects survival.
International Journal of Radiation Oncology* Biology*
Physics 1997;39:427-436.
27.Possanzini P, Pipolo C, Romagnoli S, et al. Primary
extra-cranial meningioma of head and neck: clinical,
histopathological and immunohistochemical study of
three cases. Acta otorhinolaryngologica Italica : organo
ufficiale della Societa italiana di otorinolaringologia e
chirurgia cervico-facciale 2012;32:336-338.
28.Crawford TS, Kleinschmidt-DeMasters BK, Lillehei
KO. Primary intraosseous meningioma. Case report.
Journal of neurosurgery 1995;83:912-915.
29.Inagaki K, Otsuka F, Matsui T, Ogura T, Makino H.
Effect of etidronate on intraosseous meningioma.
Endocrine journal 2004;51:389-390.
30.Mirimanoff RO, Dosoretz DE, Linggood RM,
Ojemann RG, Martuza RL. Meningioma: analysis of
recurrence and progression following neurosurgical
resection. Journal of neurosurgery 1985;62:18-24.
31.Stafford SL, Perry A, Suman VJ, et al. Primarily
resected meningiomas: outcome and prognostic factors
in 581 Mayo Clinic patients, 1978 through 1988. Mayo
Clinic proceedings Mayo Clinic 1998;73:936-942.