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Neurology India, Vol. 51, No. 3, July, 2003, pp. 419-420 Subdural hemorrhage associated with falcine meningioma Goyal A, Singh AK, Kumar S, Gupta V, Singh D Correspondence Address: Code Number: ni03141 ABSTRACT A case of falcine meningioma associated with acute subdural hemorrhage is reported. The possible mechanisms of hemorrhage in the case are discussed. We believe that an early recognition and surgery can prevent neurological deterioration. INTRODUCTION Intracranial tumors presenting with hemorrhage constitute 3.9% of all tumors, more in malignant pathology such as metastatic tumors or gliomas.[1] Benign intracranial tumors like meningiomas rarely present with hemorrhage, and the reported incidence is about 1.3% of all meningiomas.[2] There are several hypotheses explaining the probable cause of the hemorrhage.[3],[4],[5],[6] We present a case of falcine meningioma with convexity acute subdural hemorrhage, and discuss the management strategy. CASE REPORT A 66-year-old male presented with complaints of generalized headache for the last 2 years. But for the last 4 days the intensity of the headache increased markedly and was associated with vomiting. Neurological examination revealed no focal abnormality, except for bilateral papillodema. Biochemical and hematological investigations were within the normal range. Computerized tomography (CT) scan showed a falcine meningioma and an acute subdural hemorrhage on the same side [Figure-1]. During surgery, a large partially liquefied subdural clot was evacuated. In addition, the vascular falcine meningioma was totally resected. The patient recovered well after surgery and was relieved of his symptoms. Histopathology confirmed that the tumor was a transitional meningioma. DISCUSSION Spontaneous hemorrhage associated with meningioma is uncommon. It is unrelated to the sex and age of the patient, presence of systemic hypertension or the tumor location.[5],[6],[7],[8],9] Intracerebral, subdural and subarachnoid hemorrhage have all been reported in conjunction with intracranial meningiomas.[5],[6] In a review of 45 cases on the subject, Kohli et al[5] identified the hemorrhage to be outside the tumor confines in 35 cases and in 16 of these cases the hemorrhage was intracerebral in location. The most common type of bleeding was subarachnoid hemorrhage followed by intracerebral hemorrhage and intratumoral hemorrhage. Helle and Conley[4] reported a higher risk of hemorrhage in angioblastic and malignant meningioma. Several hypotheses concerning spontaneous hemorrhage in meningiomas have been proposed. The most common hypothesis is the rupture of the abnormal vascular networks of tumor. This is based on histological findings such as weak thin-walled vessels or direct peritumoral vascular erosion by the tumor.[4],[5],[9],[10],[11],[12] However, only a few of the tumors show abnormal vasculature bleeding. Rapid growth of the tumor or venous thrombosis leading to tumor necrosis has been implicated. Gruskiewicz et al mentioned that necrosis of the tumor can cause direct breakdown of the tumor vessels and subsequent hemorrhage.[11] Another hypothesis proposed by Askenasy et al is that enlarged, tortuous feeding arteries are less resistant to blood pressure changes and susceptible to rupture.[13],[14] Rupture of the bridging veins secondary to their stretch is also a probable cause of hemorrhage.[8] Kim et al[15] identified infarction of the meningioma in cases with hemorrhage.[4],[11],[16] They speculated that as the tumor infarction progresses, rupture of the peritumoral vessels occurs eventually. Events like seizures or a rapid change in the blood pressure may also act as contributory factors. Coagulopathy, seizures, trauma and malignant transformation of the meningioma have also been considered as possible causes of hemorrhage in a meningioma.[7],[13] ACKNOWLEDGEMENTS Dr. Goyal is working as a Senior Research Associate under CSIR, Delhi and is posted at the G.B.Pant Hospital, Delhi. We acknowledge their help and support. REFERENCES
Copyright 2003 - Neurology India. Also available online at http://www.neurologyindia.com The following images related to this document are available:Photo images[ni03141f1.jpg] |
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