Neurology India Medknow Publications on behalf of the Neurological Society of India ISSN: 0028-3886 EISSN: 1998-4022 Vol. 58, Num. 6, 2010, pp. 977-978

Neurology India, Vol. 58, No. 6, November-December, 2010, pp. 977-978

Letter to Editor

A rare association of meningioma with intratumoral bleed and acute subdural hematoma

G Lakshmi Prasad, SR Ramdurg, A Suri, AK Mahapatra

Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
Correspondence Address: G Lakshmi Prasad, Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India, daduaiims@gmail.com

Date of Acceptance: 11-Oct-2010

Code Number: ni10282

PMID: 21150084
DOI: 10.4103/0028-3886.73769

Sir,

Intratumoral bleed is an unusual association of intracranial tumours; incidence varies from 5% to 10% ^[1] commonly seen with malignant gliomas, metastasis, and pituitary adenomas. Tumor bleed in meningiomas is uncommon and a concomitant non-traumatic acute subdural hematoma (SDH) is even rare.

A 73-year-old man presented to the emergency department with altered sensorium of about four hours duration and three episodes of vomiting. There was no history of trauma or other associated co-morbidities. His Glasgow Coma Scale score was 7/15 (E2 V1 M4). Non-contrast computed tomography (NCCT) scan of the head revealed a hyper-dense extra-axial lesion arising from the right sphenoid wing extending into the supratentorial compartment, with significant mass effect and midline shift to the left. There was also evidence of tumor bleed and ipsilateral acute SDH in the basifrontal region [Figure - 1]. A right-sided fronto-temporo-parietal craniotomy and Simpson's grade II excision of the tumor with evacuation of the SDH was performed. At operation, about 50-70 ml of clotted blood was present in the subdural space, with no evidence of neo-vascular membrane. A greyish white extra-axial tumor with areas of recent haemorrhage was present arising from the sphenoid wing. A postoperative NCCT scan of the head done on the first day showed complete evacuation of the SDH along with removal of the meningioma [Figure - 2]. The patient was discharged in a stable condition.

The most common site of tumor associated bleed is the subarachnoid space including the intraventricular cavity, with the intracerebral and intratumoral locations ^[2] being next frequent. Subdural space as a location of meningioma associated hemorrhage is rare and usually co-exists with haemorrhage in other locations. There have been only isolated reports of association of meningioma with an acute SDH. ^[3],[4] The exact aetiopathogenesis of intratumoral bleed in meningiomas is still unclear, and the possible mechanisms include endothelial proliferation, subsequent vascular occlusion and distal necrosis; angiomatous-like areas with thinned and friable vascular walls; histamine-associated intratumoral hemorrhage as in mast cell-rich meningioma and bleeding from a neo-vascular membrane. The mechanical stretching and distortion of the bridging veins by meningiomas have been proposed as a mechanism for the subdural hematoma formation, the other being the spread of the tumor bleed to the surrounding space. These patients should be offered immediate operative management so that the patients can get the maximum benefit.

References

1.	Wakai S, Yamakawa K, Manaka S, Takakura K. Spontaneous intracranial hemorrhage caused by brain tumour: Its incidence and clinical significance. Neurosurgery 1982;10:437-44.  Back to cited text no. 1  [PUBMED]
2.	Cheng MH, Lin JW. Intracranial meningioma with intratumoral hemorrhage. J Formos Med Assoc 1997;96:116-20.   Back to cited text no. 2  [PUBMED]
3.	Chaskis C, Raftopoulos C, Noterman J, Flament Durand J, Brotchi J. Meningioma associated with subdural hematoma: Report of two cases and review of the literature. Clin Neurol Neurosurg 1992;94:269-74.   Back to cited text no. 3
4.	Goyal A, Singh AK, Kumar S, Gupta V, Singh D. Subdural hemorrhage associated with falcine meningioma. Neurol India 2003;51:419-21.  Back to cited text no. 4  [PUBMED]

Copyright 2010 - Neurology India

The following images related to this document are available:

Photo images