Neurology India Medknow Publications on behalf of the Neurological Society of India ISSN: 0028-3886 EISSN: 1998-4022 Vol. 51, Num. 2, 2003, pp. 263-265

Neurology India, Vol. 51, No. 2, April-June, 2003, pp. 263-265

Case Report

Simultaneous occurrence of multiple meningiomas in different neuraxial compartments

H. S. Bhatoe
Department of Neurosurgery, Command Hospital (CC), Lucknow-226002, India.
E-mail: hsbhatoe@indiatimes.com

Accepted on 18.10.2001.

Code Number: ni03082

ABSTRACT

The simultaneous occurrence of multiple meningiomas in different neuraxial compartments is rare. A 35-year-old female patient had multiple meningiomas involving both the supratentorial compartments and in the upper dorsal spine. The patient underwent excision of 2 cranial and 2 spinal meningiomas, and has remained asymptomatic over a follow-up period of 18 months.

Key Words: Supratentorial, Multiple meningioma, Spinal tumor.

The term multiple meningioma is used to describe the simultaneous or sequential appearance of 2 or more independently situated meningiomas, not necessarily of the same pathologic subtype. In the pre-CT (computed tomography) era, the frequency of multiple meningiomas without neurofibromatosis was reported to be less than 3%.^1,2 Since the introduction of CT scan, the frequency of multiple meningiomas has ranged between 4.5% and 10.5%.^3,4 Nevertheless, the concomitant occurrence of multiple intracranial and spinal (S) meningiomas in the same patient is rare. A case having 4 meningiomas is reported.

CASE REPORT

A 35-year-old female patient had a three-month history of generalized headaches and progressive stiffness and weakness of all four limbs. She had no stigmata of neurofibromatosis. On examination, she had bilateral papilloedema, left-sided lower motor neuron type facial paresis and sensorineural hearing impairment. There was spastic grade 3-4 quadriparesis. T1 and T2 weighted magnetic resonance imaging (MRI) showed an isointense mass in the left infratentorial-cerebellopontine angle. Contrast enhanced MRI revealed small multiple meningiomas over the parietal parasagittal and convexity regions on both sides and a large meningioma arising from the tentorium (Figures 1a & 1b). MRI spine showed two isointense tumors on T1& T2 at D1 & D3 region, one lying ventral and the other lying dorsal to the cord, sandwiching the cord between them (Figure 2). The spinal tumors were excised initially and 4 days later, the left tentorial meningioma was resected by left temporal craniotomy. After 2 weeks, a nodular parasagittal vertex meningioma was excised. Following the surgeries, she showed symptomatic improvement.

Histological examination of the 2 spinal meningiomas revealed atypical and fibroblastic meningioma respectively. The tentorial meningioma was of the transitional variety, while the parasagittal tumor was a meningothelial meningioma. At a follow-up after 18 months, she is asymptomatic.

DISCUSSION

Multiple meningiomas were first described by Anfimow and Blumenau.⁵ Cushing and Eisenhardt² classified them as a discrete clinical entity. Multiple meningiomas were associated with neurofibromatosis.⁶ However, the current concept is that these tumors are due to inherent multicentricity of the dural foci, possibly influenced by hormonal factors.⁷ The incidence of multiple intracranial meningiomas in the post-CT era has been reported to be between 5.4 and 8.9%, while the incidence as seen in autopsy series is between 8.2 and 16.9 %. The majority of these are located in a hemicranial distribution.^3,8 Multiple spinal meningiomas are rarer than multiple cranial (C) meningiomas.⁹ Multiple meningiomas occurring in different neuraxial compartments are distinctly rare, with only 17 well-documented cases reported in world literature (Table 1). Only 4 of these occurred in males (M:F-1:4), out of which 2 were children. The relationship between isolated multiple meningiomas and neurofibromatosis is unsettled. In cases with reported cranial and spinal meningiomas, 5 (27.77%) had more than 1 intracranial tumor^10-13 and only 2 reports (mentioned earlier)^14,15 had more than 1 spinal tumor.

Operative management of multiple meningiomas occupying both cranial and spinal compartments poses special problems. A decision is made regarding which lesion, or lesions should be removed initially. Small or asymptomatic tumors may be followed up with serial imaging. Histologically, each of these tumors may be a different variant of meningioma.

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