Neuroradiological features of patients with bilateral macronodular adrenocortical disease and meningiomas associated or not with genetic variants of ARMC5- a case series.

INTRODUCTION: Meningiomas are the most common primary brain and central nervous system tumors, accounting for approximately 40% of these tumors. The most important exams for the radiological study of meningiomas are computed tomography (CT) and magnetic resonance imaging (MRI). We aimed to analyze the radiological features of patients with meningioma related to the simultaneous presence of bilateral macronodular adrenocortical disease (BMAD), with or without pathogenic variants of ARMC5. METHODS: This study included 10 patients who were diagnosed with BMAD. All of them had a radiological diagnosis of expansive brain lesions suggestive of meningioma. All patients underwent brain MRI and a neuroradiolgist analyzed the following parameters: number, site and size of lesions; presence of calcification, edema and bone involvement. RESULTS AND DISCUSSION: Eight patients presented with germline variants of ARMC5; the other 2, did not. The most significant result was the incidence of multiple meningiomas, which was 50% in BMAD patients, whereas the average incidence described thus far is lower than 10%. Considering location, the 22 tumors in the BMAD patients were 5 convexity tumors (22.7%), and 17 skull base tumors (77.2%), the opposite proportion of patients without BMAD. A total of 40.9% of the tumors had calcification, 9% had cerebral edema and 40.9% had bone invasion due to hyperostosis. The literature describes meningioma calcification in 25% of patients, bone invasion by tumor hyperostosis in 20%, and cerebral edema in approximately 60%. CONCLUSION: Relevant results were found considering the rate of multiple meningiomas and tumor location. This finding reinforces the need for further research into the neurological effects caused by genetic variants of ARMC5 in patients with BMAD.

Can Apparent Diffusion Coefficient (ADC) maps replace Diffusion Tensor Imaging (DTI) maps to predict the volumetric response of meningiomas to Gamma Knife Radiosurgery?

PURPOSE: Noninvasive methods are desired to predict the treatment response to Stereotactic Radiosurgery (SRS) to improve individual tumor management. In a previous study, we demonstrated that Diffusion Tensor Imaging (DTI)-derived parameter maps significantly correlate to SRS response. This study aimed to analyze and compare the predictive value of intratumoral ADC and DTI parameters in patients with meningiomas undergoing radiosurgery. METHODS: MR images of 70 patients treated with Gamma Knife SRS for WHO grade I meningiomas were retrospectively reviewed. MR acquisition included pre- and post-treatment DWI and DTI sequences, and subtractions were calculated to assess for radiation-induced changes in the parameter values. RESULTS: After a mean follow-up period (FUP) of 52.7 months, 69 of 70 meningiomas were controlled, with a mean volume reduction of 34.9%. Whereas fractional anisotropy (FA) values of the initial exam showed the highest correlation to tumor volume change at the last FU (CC = - 0.607), followed by the differences between first and second FU values of FA (CC = - 0.404) and the first longitudinal diffusivity (LD) value (CC = - 0.375), the correlation coefficients of all ADC values were comparably low. Nevertheless, all these correlations, except for ADC measured at the first follow-up, reached significance. CONCLUSION: For the first time, the prognostic value of ADC maps measured in meningiomas before and at first follow-up after Gamma Knife SRS, was compared to simultaneously acquired DTI parameter maps. Quantities assessed from ADC maps present significant correlations to the volumetric meningioma response but are less effective than correlations with DTI parameters.

Bilateral Persistent Primitive Olfactory Arteries Observed During Resection of Olfactory Groove Meningioma: Technical Case Report.

BACKGROUND AND IMPORTANCE: Resection of olfactory groove meningiomas is challenging because of their close proximity with the anterior cerebral circulation. It is important to recognize the vascular variants in procedures at the anterior skull base because inadvertent maneuvers may result in the rupture of these arteries and unexpected bleeding. CLINICAL PRESENTATION: We reported a type 2 persistent primitive olfactory artery with a dural branch of the elongated anterior cerebral artery directly to the ethmoid region, visualized during the surgical removal of an olfactory groove meningioma. CONCLUSION: This is the first report of bilateral persistent primitive olfactory artery demonstrated by operative visualization and confirmed with vascular study. Understanding and recognizing the possible variations of this vascular anatomy is of great importance for anterior skull base surgeries.

Volumetric measurement of intracranial meningiomas: a comparison between linear, planimetric, and machine learning with multiparametric voxel-based morphometry methods.

PURPOSE: To compare the accuracy of three volumetric methods in the radiological assessment of meningiomas: linear (ABC/2), planimetric, and multiparametric machine learning-based semiautomated voxel-based morphometry (VBM), and to investigate the relevance of tumor shape in volumetric error. METHODS: Retrospective imaging database analysis at the authors' institutions. We included patients with a confirmed diagnosis of meningioma and preoperative cranial magnetic resonance imaging eligible for volumetric analyses. After tumor segmentation, images underwent automated computation of shape properties such as sphericity, roundness, flatness, and elongation. RESULTS: Sixty-nine patients (85 tumors) were included. Tumor volumes were significantly different using linear (13.82 cm3 [range 0.13-163.74 cm3]), planimetric (11.66 cm3 [range 0.17-196.2 cm3]) and VBM methods (10.24 cm3 [range 0.17-190.32 cm3]) (p < 0.001). Median volume and percentage errors between the planimetric and linear methods and the VBM method were 1.08 cm3 and 11.61%, and 0.23 cm3 and 5.5%, respectively. Planimetry and linear methods overestimated the actual volume in 79% and 63% of the patients, respectively. Correlation studies showed excellent reliability and volumetric agreement between manual- and computer-based methods. Larger and flatter tumors had greater accuracy on planimetry, whereas less rounded tumors contributed negatively to the accuracy of the linear method. CONCLUSION: Semiautomated VBM volumetry for meningiomas is not influenced by tumor shape properties, whereas planimetry and linear methods tend to overestimate tumor volume. Furthermore, it is necessary to consider tumor roundness prior to linear measurement so as to choose the most appropriate method for each patient on an individual basis.

Application of neuronavigation system in intracranial meningioma surgery: a retrospective analysis of 75 cases.

OBJECTIVE: Neuronavigation is an extremely common and useful system in intracranial surgeries. It is used to determine the pre-operative incision, perform the most appropriate craniotomy, and provide intraoperative guidance. However, its use in meningioma surgery is controversial, and there is a dilemma whether it is necessary. This study was performed to determine the effect of neuronavigation in meningioma surgery. MATERIALS AND METHODS: Information related to pre-operative clinical evaluation and use of neuronavigation, neuroimaging, intraoperative tumor and surgical related information, and post-operative outcomes of 75 consecutive patients with meningiomas between January 2015 and 2020 were retrospectively collected. The values between groups were statistically compared. RESULTS: There were no significant differences in pre-operative patient and tumor characteristics between the groups. In cases using neuronavigation, the mean operative time, craniotomy size, and blood loss during tumor resection were significantly lower, and post-operative hospital stay was shorter in these patients (p < 0.05). However, there were no differences in post-operative complications and clinical outcomes. CONCLUSION: The use of neuronavigation in meningioma surgery reduces blood loss during surgery, reduces the surgical time, and shortens the post-operative hospital stay. Thus, we conclude that the neuronavigation system is useful in meningioma surgery.

OBJETIVO: La neuronavegación ha tomado su lugar como un sistema muy común y útil para cirugías intracraneales. Este estudio se realizó para revelar su efecto en la cirugía de meningioma. MATERIALES Y MÉTODOS: Se recopiló retrospectivamente información relacionada con la evaluación clínica preoperatoria, neuroimagen, información relacionada con el tumor y la cirugía intraoperatoria y los resultados posoperatorios de 75 casos consecutivos con meningiomas entre enero de 2015 y 2020. Los valores entre grupos se compararon estadísticamente. RESULTADOS: No hubo diferencias significativas en las características preoperatorias de los pacientes y las características del tumor entre los grupos. En los casos en los que se utilizó neuronavegación, el tiempo operatorio medio, el tamaño de la craneotomía y la pérdida de sangre durante la resección del tumor fueron significativamente menores, y la estancia hospitalaria postoperatoria fue más corta en estos pacientes (p < 0.05). Sin embargo, no hubo diferencia en las complicaciones postoperatorias y los resultados clínicos. CONCLUSIÓN: El uso del sistema de neuronavegación en la cirugía del meningioma reduce la pérdida de sangre durante la cirugía, acorta el tiempo quirúrgico y reduce la estancia hospitalaria postoperatoria. Creemos que el sistema de neuronavegación es útil en la cirugía del meningioma.

Comparative analysis of somatostatin analog uptake between successfully irradiated and non-irradiated meningiomas.

OBJECTIVE: To evaluate whether there is a significant difference in somatostatin analog uptake in meningiomas treated or not with radiation therapy. METHODS: A cross-sectional study was performed comparing measurements of somatostatin analog (68Ga-DOTATATE) uptake in two independent groups of ten patients each - one consisting of patients with meningiomas previously treated with radiation therapy and another comprising patients who had never been submitted to radiation therapy. All patients underwent PET/CT and MRI scans in an interval shorter than 24 hours between exams. RESULTS: A total of 32 meningiomas from 20 patients were analyzed, all presenting significant somatostatin analog uptake in different degrees. The uptake levels of somatostatin analog were similar between the lesions treated or not with radiation therapy, and the mean values of SUVmax were 27.62 and 24.82, respectively (p=0.722). For SUVmean, the values were 16.20 and 14.82, respectively (p=0.822). CONCLUSION: Comparative analysis between the groups showed no significant differences in degree of somatostatin analog uptake in successfully irradiated and non-irradiated meningiomas.

Myxofibrosarcoma: Another mimicker of meningioma.

Primary intracranial malignant fibrous histiocytoma (MFH), or myxofibrosarcoma, is an extremely rare condition, with only a few cases reported in the literature. We report a case of a dural-based myxofibrosarcoma in a previously healthy 42-year-old man that was initially presumed to be an atypical meningioma. The findings based on conventional and advanced magnetic resonance sequences, including diffusion-weighted imaging, perfusion weighted imaging and proton magnetic resonance spectroscopy, as well as histopathological aspects, are discussed.

Microsurgical Resection of Giant Petroclival Meningioma via the Posterior Petrosal Approach: 2-Dimensional Operative Video.

Petroclival meningiomas are challenging deep-seated lesions related to many critical neurovascular structures of the skull base.1-5 We present the case of a 45-year-old male presenting with a 3-year history of progressive headache associated gradually with multiple cranial nerves deficits and progressive tetraparesis leading to use of a wheelchair (Video 1) Preoperative magnetic resonance imaging demonstrated a mass highly suggestive of a giant left petroclival meningioma. Considering worsening of symptoms and impressive mass effect, microsurgical resection employing the posterior petrosal approach was performed. Mastoidectomy with skeletonization of semicircular canals and a craniotomy approaching both posterior and middle cranial fossae were done. Dural incision at the base of the temporal lobe was communicated to other incision in the presigmoid dura by ligation and sectioning of superior petrosal sinus. Tentorium was cut all the way toward the incisura, with attention to preserve the fifth nerve along its division and fourth nerve in the last cut. After a complete tentorium incision, the presigmoid space enlarged, exposing both supratentorial and infratentorial spaces. The lesion was totally resected employing microsurgical techniques. Postoperative magnetic resonance imaging demonstrated complete tumor resection. The patient experienced improvement of complaints and no new neurologic deficit on follow-up. The posterior petrosal approach gives great exposure and a more lateral angle of attack to the ventral surface of brainstem, allowing in this case to approach the whole tumor attachment. Informed consent was obtained from the patient for the procedure and publication of this operative video. Anatomic images were courtesy of the Rhoton Collection, American Association of Neurological Surgeons/Neurosurgical Research and Education Foundation.

Sphenoid Wing Meningiomas with Secondary Cavernous Sinus Invasion: Surgical Results and Algorithm for Treatment at a Single Brazilian Center.

BACKGROUND: Sphenoid wing meningiomas with cavernous sinus invasion (SWMCSI) are challenging tumors. The preservation of quality of life and cranial nerve function is one of the most relevant aspects of treating patients with SWMCSI. METHODS: A retrospective study was conducted for surgery performed between 2008 and 2021, including 36 patients presenting with SWMCSI. The data from surgical intervention, Simpson grade of resection, tumor location, and morbimortality related to the surgery was reviewed. We examined the medical records, operative reports, radiologic examinations, and follow-up information. RESULTS: The group comprised 29 women and 7 men with an average age of 61 years (range, 31-87 years). The mean follow-up period was 75 months (range, 1-170 months). Simpson grade I and II resections were obtained in 80% of cases. The meningiomas were World Health Organization (WHO) grade 1 in 94% of cases, WHO grade 2 in 3%, and WHO grade 3 in 3%. The overall mortality was 5.5%. Permanent cranial nerve deficits occurred in 8% of cases, transient cranial nerve deficits in 22%, cerebrospinal fistula in 16.5%, and hemiparesis in 2.7%. The recurrence/regrowth rate was 14% during the follow-up period. The Karnofsky Performance Status 100 and 90 was 92%. CONCLUSIONS: The surgical treatment of symptomatic SWMCSI is an effective treatment modality with low morbimortality and good long-term control of the disease. Visual impairment is the most common abnormality, affecting preoperative and postoperative quality of life of patients with SWMCSI. Training in the microsurgical laboratory is essential for safe surgical approaches in this area.

Resection of meningiomas in a different location (sphenoid wing and tuberculum sellae) through a single craniotomy report of a case and review of the literature.

Meningiomas are the most frequent extra-axial tumors of the nervous system. Multiple meningiomas are defined as the presence of two or more lesions that appear simultaneously or not, in different intracranial location, without association to neurofibromatosis. Each lesion must be evaluated individually for treatment, which consists in microsurgical resection in most cases. A 59-year-old woman presented with neurological symptoms from different anatomical site. Two extra-axial tumors of different location, at right sphenoid wing and the other in the tuberculum sellae were identified. Microsurgical resection was decided in one-step surgery, using the same craniotomy for both lesions with complete resection.

Los meningiomas son los tumores extraaxiales más frecuentes del sistema nervioso. Los meningiomas múltiples o meningiomatosis (MM) se definen como la presencia de 2 o más lesiones que aparecen simultáneamente o no, en diferente localización intracraneal, sin asociación con neurofibromatosis. Cada lesión debe ser evaluada de manera individual para su tratamiento. Presentamos una paciente con meningiomatosis. La sintomatología era muy variada de localizaciones anatómicas diferentes. En los estudios de imagen, se identificaron tumores extra axiales de diferente localización, una lesión alar y otra del tubérculo sellar. Se decidió la resección microquirúrgica en un solo tiempo, mediante la misma craneotomía.

Rare Case of Young Patient with Intraventricular Angiomatous Meningioma

Pediatricmeningiomas are rare and account for only 2.2% of the central nervous system (CNS) tumors. In this age group, they aremore frequently located in atypical sites, such as, mainly, the ventricular system, with a frequency of 8.8 to 13.6%. Adding this to the fact that the angiomatous subtype constitutes only 2.1% of allmeningiomas, the rarity of the case reported here is corroborated. We report a 17-year-old female patient diagnosed with intraventricular angiomatous meningioma; she underwent surgical resection of the tumor in the body and frontal horn of the right lateral ventricle, and there were no neurological sequelae. With a follow-up of 26 months, there was no recurrence and the patient had clinical stability. Intraventricular tumors usually have slow growth and reach a considerable size until they cause symptoms and then are diagnosed. In addition, the deep location of the tumor and its proximity to eloquent areas make these tumors a neurosurgical challenge. The angiomatous subtype, due to the presence of hypervascularization (consisting of > 50% of vascular components), may, in some cases, hinder surgical resection as well as be erroneously diagnosed. However, surgical treatment aimed at total resection of the lesion remains the conduct of choice in the case reported here, especially in patients in the first two decades of life, in which the use of radiation is avoided. Specifically when it comes to the surgery, we chose a transcalosal approach that allows a good transoperative visualization of the lesion when located in the body and frontal horn of the lateral ventricle.

Sarcoidosis Mimicking Skull Base Meningioma

Sarcoidosis is a systemic disease characterized by granulomatous inflammation. Pulmonary and lymphatic granulomatous involvement are common.We present a rare case report of involvement of the central nervous system affecting the ocular region and mimicking optic nerve sheath meningioma. We report the case of a 79-year-old female patient with progressive visual impairment with an evolution of 4 years. Amagnetic resonance imaging scan of the cranium with gadolinium and intense homogeneous contrast enhancement revealed an expansive lesion in the right optic nerve, at the height of the optic canal. The patient was submitted to the neurosurgical approach with lesion biopsy, which showed sarcoidosis of the central nervous system. Due to the rarity of central nervous system involvement, the diagnosis of this pathologymay unfortunately be postponed. The present article aims to elucidate this pathology as a differential diagnosis of retro-orbital tumors.

Petroclival Meningiomas: A Simple System That Could Help in Selecting the Approach.

BACKGROUND: Petroclival meningiomas (PCM) represent a neurosurgical challenge due to their strategic location close to the brainstem. OBJECTIVE: To assess the applicability of a retrosigmoid approach (RSA) by analyzing the degree of displacement of the middle cerebellar peduncle (MCP) elicited by PCM. METHODS: Patients with PCM were prospectively included and divided into those whose imaging studies showed that the posterior end of the MCP was displaced by the tumor and were eligible for and underwent RSA (group A) and those who were not eligible for RSA and who underwent surgery via a posterior transpetrosal approach (group B). We compared tumor behavior, clinical characteristic of patients and surgical results. RESULTS: Twenty patients with PCM were enrolled and allocated to group A (n = 15) or group B (n = 5). The clinical manifestations were more severe in group B; tumors in this group were larger and gross total removal was achieved in only 1 patient (20%). In comparison, in 12 cases on group A, tumors could be totally removed (80%) and all of these patients could recover their quality of life after surgery. CONCLUSION: To our knowledge, this study is the first to consider displacement of the MCP when establishing a suitable surgical approach for PCM. Our results suggest that the RSA becomes increasingly suitable when peduncle displacement is greater. By using this method, it was also possible to identify two types of tumors: petroclivals (group A) and clivopetrosals (group B), that show some specific clinical and surgical differences.

Simpson Grade I Resection of Type II Clinoidal Meningioma Through Cranio-orbital Zygomatic Approach: 2-Dimensional Operative Video.

Clinoidal meningiomas have been considered as a separate entity with distinguishing clinical, radiological, and surgical considerations.1-2 Surgical mortality and morbidity associated with anterior clinoidal meningiomas has remained high in the past, with radical resection considered unattainable.3 However, the extent of surgical removal is clearly the most determining factor in tumor recurrence and progression. Clinoidal meningiomas have been classified into 3 types according to their origin from the dura surface of the anterior clinoid and subsequent arachnoidal rearrangement around the parasellar neurovascular structures.1 In type II, there is an arachnoidal plane that allows the tumor dissection from the encased carotid artery and its branches and the optic nerve. In this type, the involvement of the cavernous sinus is limited to the external wall, which can also be removed. Hence, these tumors are amenable to Simpson grade I resection (tumor, dura, and bone). Approaching through the multidirectional axis provided by the cranio-orbital zygomatic approach allows safe exposure of the tumor and vascular control.4-5 Proximal carotid control is obtained in the petrous carotid canal, the invaded anterior clinoid is removed by and large extradurally, and the Sylvian fissure is split wide open to establish dissecting planes with the middle cerebral artery branches. The optic canal is opened, and tumor extension is removed.6 The invaded outer wall of the cavernous sinus and superior orbital fissure is removed. We demonstrate this technique in a 48-yr-old patient who consented for surgery and publication of images. All images at 2:27, center and right images at 2:46, and all images at 2:58, reused with permission from LWW, from Al-Mefty, Operative Atlas of Meningiomas. Left image at 2:46 reprinted from Surg Neurol, Vol 60/issue 6, Arnautovic KI, Al-Mefty O, Angtuaco E, A combined microsurgical skull-base and endovascular approach to giant and large paraclinoid aneurysms, pp. 504-520, Copyright 1998, with permission from Elsevier. Image at 8:21 reprinted from Al-Mefty,1 Clinoidal meningiomas, by permission from JNSPG.

Atypical Charles Bonnet syndrome secondary to frontal meningioma: a case report.

BACKGROUND: Charles Bonnet Syndrome (CBS) is a rare clinical entity that is classically composed of visual hallucinations in the context of an altered optic pathway with preservation of reality judgment. This case aims to present the association of visual hallucinations with complex alterations of the nervous structures adjacent to the visual pathway and an atypical clinical presentation, thus explaining the possible mechanisms involved in the generation of these symptoms. CASE PRESENTATION: A 43-year-old man presents seeking care due to visual hallucinations with partial preservation of reality judgment and symptoms compatible with a major depressive disorder, including irritability and diminished hygiene habits. He has a history of complete gradual loss of vision and hyposmia. Due to poor treatment response during hospitalization, an MRI was obtained, which showed a frontal tumor lesion with meningioma characteristics adjacent to the olfactory groove and compression of the optic chiasm. He underwent surgical resection of the lesion, which remitted the psychotic symptoms, but preserving the visual limitation and depressive symptoms. CONCLUSIONS: The presence of visual hallucinations, without other psychotic features as delusions, is a focus of attention for basic structural pathologies in the central nervous system. Affection at any level of the visual pathway can cause CBS. When finding atypical symptoms, a more in-depth evaluation should be made to allow optimization of the diagnosis and treatment.

Extracerebral Pterional Metastasis from Malignant Meningioma: A Case Report

Anaplastic or malignant meningiomas that are classified as World Health Organization (WHO) grade III account for less than 1% of all meningiomas diagnosed. Despite the aggressive course, distant metastases are a rarity, occurring in only 0.1% to 0.2% of cases. We report the case of a 56-year-old woman who presented with parasagittal benign meningioma that underwent malignant transformation along with metastasis into the right orbitosphenoid region. The clinical, radiological, and histopathological aspects are highlighted, with an emphasis on the natural history of meningiomas.