Absence of contrast enhancement in a petroclival meningioma: Case report and systematic literature review
- Department of Neurosurgery, Albany Medical Center, Albany, New York, United States.
- Department of Radiology, Albany Medical Center, Albany, New York, United States.
- Department of Pathology, Albany Medical Center, Albany, New York, United States.
- Department of Otolaryngology and Head and Neck Surgery, Albany Medical Center, Albany, New York, United States.
Department of Neurosurgery, Albany Medical Center, Albany, New York, United States.
DOI:10.25259/SNI_489_2020Copyright: © 2020 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Adedamola Adepoju1, Ananth Narayan2, Mahmoud Aldyab3, David Foyt4, Maria Peris-Celda1. Absence of contrast enhancement in a petroclival meningioma: Case report and systematic literature review. 04-Dec-2020;11:418
How to cite this URL: Adedamola Adepoju1, Ananth Narayan2, Mahmoud Aldyab3, David Foyt4, Maria Peris-Celda1. Absence of contrast enhancement in a petroclival meningioma: Case report and systematic literature review. 04-Dec-2020;11:418. Available from: https://surgicalneurologyint.com/surgicalint-articles/10427/
Background: Meningioma is one of the most common intracranial tumors with well-established radiologic features such as contrast enhancement, dural tail, and hyperostosis on computed tomography and magnetic resonance imaging. Contrast enhancement is usually homogeneous or heterogeneous based on tumor vascularity and underlying histopathology. Even in this context, faint or nonenhancing meningioma is exceedingly rare.
Case Description: A 57-year-old male presented with progressive right hearing loss, disequilibrium, occasional difficulty swallowing, and facial numbness. Imaging demonstrated an extensive hypodense, nonenhancing right cerebellopontine angle mass extending from the interpeduncular, and ambient cisterns to the foramen magnum. The pathological analysis demonstrated a microcystic meningioma WHO Grade I. There are few reported case reports or series of minimal or nonenhancing meningiomas, and a systematic review was performed for these cases. Seven peer-reviewed articles with 14 verifiable cases were identified and reviewed for radiologic features, tumor location, and tumor classification. The majority of minimal or nonenhancing meningiomas were microcystic, and most of them located at the convexity. This is the second case reported of a nonenhancing meningioma at the cerebellopontine angle and petroclival region
Conclusion: Meningioma should be considered a differential diagnosis for nonenhancing lesion at the cerebellopontine and petroclival regions.
Keywords: Cerebellopontine angle, Glial fibrillary astrocytic protein, Meningioma, Microcystic meningioma, Petroclival
Meningioma is one of the most common benign intracranial tumors. The use of neuroimaging has increased the diagnosis of meningioma, and there are classic radiologic features associated with the tumor, including contrast enhancement, dural tail, and hyperostosis of the adjacent bone. On computed tomography (CT), meningiomas are mostly isodense to hyperdense, and about 20% have calcifications.[
History and physical examination
A 57-year-old right-handed male presented with progressive right hearing loss, disequilibrium, occasional difficulty swallowing, and right facial numbness. CT and MRI showed a right cerebellopontine angle tumor extending from the interpeduncular cistern to the foramen magnum. An audiogram revealed moderate right sensorineural hearing loss. Neurological examination demonstrated right decreased hearing, right facial numbness, and a positive Romberg sign.
Noncontrast CT of the head revealed a hypodense right cerebellopontine angle mass extending from the interpeduncular and ambient cisterns to the foramen magnum [
Preoperative images. Axial (a) and coronal (b) noncontrast CT image showing the hypodense cerebellopontine mass extending in the supratentorial space, interpeduncular and ambiens cisterns, and the right Meckel’s cave. (c and d) T1- and T2-weighted coronal MRI showing the extent of the tumor. (e) 3D-FIESTA sequence indicating the extension of the tumor into the internal acoustic canal. (f) Axial diffusion-weighted imaging demonstrating intermediate diffusion signal when compared with CSF. (g) Coronal view of T1-weighted with gadolinium demonstrating faint tentorial enhancement and no enhancement within the tumor. (h) Coronal view of a contrasted CT demonstrating the tentorial enhancement.
A posterior petrosal retrolabyrinthine approach with retrosigmoid and temporal craniotomies was used for the surgical approach in a staged operation (approach and resection in different days). After orotracheal intubation, the patient was placed in a left lateral decubitus position. Bone landmarks and neuronavigation were used for surgical incision planning. Facial nerve monitoring was placed. Incision and opening were made in a layered fashion, and the retrosigmoid and temporal craniotomies were performed as described in Graffeo et al. (2018). With the aid of a surgical microscope, the presigmoid retrolabyrinthine part of the approach was performed. There was no dural opening. The bone flap was reattached, and the incision was closed accordingly. The patient was extubated and was observed on the neurosurgical floor.
Two days later, he returned to the operating room for resection of the tumor and was positioned as described above. Neuromonitoring, including brainstem auditory evoked potential, was utilized for ipsilateral facial, glossopharyngeal, and accessory nerves. The incision and the bone flap were reopened. The retrosigmoid dura was opened in a curvilinear fashion, and the CSF was drained from the cisterna magna to relax the posterior fossa. The tumor was identified as a greyish mass with moderate vascularity and soft consistency, and resection was performed with an ultrasonic aspirator. In the posterior fossa, the vestibulocochlear, facial, and lower cranial nerves were identified posterior to the tumor, whereas the abducens nerve was found within the tumor. The trigeminal nerve was displaced superiorly against the tentorium. The infratentorial portion of the tumor was completely resected through the retrosigmoid part of the approach. The presigmoid and the temporal dura mater were opened, and the tentorium was divided after ligation of the superior petrosal sinus.[
He had a right partial forth, and sixth nerve palsies and mild facial weakness (House-Brackman 2) after surgery. A postoperative CT scan is shown in [
Intraoperative pictures and postoperative imaging after tumor resection. (a and b) intraoperative pictures demonstrating a grayish pink tumor of moderate vascularization anteromedial to cranial nerves VII, VIII, XI, and X. The cranial nerves IV and VI were embedded within the tumor and preserved. CN, cranial nerves. Axial (c) and coronal (d) non contrast postoperative CT images showing the posterior petrosal approach. Axial FIESTA (e) and coronal (f) T1-weighted with contrast postoperative MRI images showing the extent of tumor resection, a small portion of meningioma was left in Meckel’s cave.
Grossly, the tumor appeared tan to pink. Microscopically, the tissue had lobulated architecture, mixed with prominent loose myxoid microcystic background and minor angiomatous changes. The lobulated component contained meningothelial whorls [
(a) Hematoxylin and eosin (×4) stained fragments of tissue with the proliferation of bland ovoid to epithelioid cells, with pink cytoplasm and indistinct cell borders. The whorled appearance is better appreciated. Nuclei appear to have some size variability, but no significant atypia or anaplasia is identified. The cystic pattern and angiomatous changes are also evident (×40). (b) Vimentin: Immunohistochemical staining for Vimentin shows a strong, diffuse cytoplasmic staining pattern. (c) Cyclin-D1: Immunohistochemical staining for Cyclin-D1 shows a diffuse staining pattern. (d) Reticulin: Immunohistochemical staining for reticulin shows an epithelioid staining pattern. (e) GFAP: Immunohistochemical staining for GFAP shows a strong, diffuse cytoplasmic staining pattern. (f) KI-67: Immunohistochemical staining for GFAP shows scattered positive staining, corresponding to a low proliferation index estimated to be <2%.
A systematic review of the literature for minimal or nonenhancing meningioma was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. Search items including “nonenhancing meningioma,” “unenhanced meningioma,” and more broadly “enhancing meningioma” were entered into the online databases PubMed and web of science. The search returned 652 total peer-reviewed articles, and each item was reviewed to evaluate for cases with minimal or nonenhancing meningioma. Screening guidelines included recoverable English-written articles with basic demographic and radiographic information, including images to support the interpretation of radiographic features. The last query was 04 April 2020. Selection and reporting biases are acknowledged. Cystic and necrotic meningioma was excluded from the review. Minimal enhancement was defined as faint or hardly noticeable contrast enhancement on radiologic images or interpretation. Seven articles, including case reports and case series, had 14 verifiable cases included in the systemic review [
Meningioma is a common intradural tumor that avidly enhances with contrast. Almost all meningiomas either enhance homogeneously or heterogeneously. The meningioma presented in this report had faint enhancement with contrast, which is very rare. Dural tail, found in 72% of meningioma,[
The histology and the immunostaining demonstrated that the tumor was a microcystic meningioma. The tumor stained for typical meningioma markers such as Vimentin, Reticulin, and Cyclin D1.[
Meningioma is one of the most incidentally diagnosed intracranial lesions.[
Microcystic meningioma is rare WHO Grade 1 meningioma, and it constitutes about 1.6% of all intracranial meningiomas. Although the microcystic type comprised the majority of the minimally enhancing meningiomas, only 10.2% of microcystic meningiomas had a faint enhancement in MRI, and thus, the majority of them had typical radiological features of meningiomas.[
Meningioma should be considered a differential diagnosis for a non-enhancing lesion at the cerebellopontine and petroclival regions.
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