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|LETTER TO EDITOR
|Year : 2012 | Volume
| Issue : 5 | Page : 549-550
Meningioma mimics chronic subdural hematoma: A case report and discussion of differential diagnosis
Cong Wu1, Jianpin Liu2, Chaohua Yang1
1 Department of Neurosurgery , West China Hospital, Sichuan University, Chengdu, P.R. China
2 Department of Pathology, West China Hospital, Sichuan University, Chengdu, P.R. China
|Date of Web Publication||3-Nov-2012|
Department of Neurosurgery , West China Hospital, Sichuan University, Chengdu, P.R. China
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Wu C, Liu J, Yang C. Meningioma mimics chronic subdural hematoma: A case report and discussion of differential diagnosis. Neurol India 2012;60:549-50
The location and growth pattern of meningiomas can vary substantially and potentially be misdiagnosed.  But they have seldom been reported to mimic chronic subdural hematoma (CSDH).
A 75-year-old female presented with amnesia of 20 days duration. She had suffered a head injury from a fall 6 months prior to her hospital visit and did not seek medical attention as she had no obvious symptoms. In the 20 days prior to this admission, she developed amnesia, including difficulty to find her way back home. Physical exam at admission showed no obvious signs except a hard prominence at the left frontal region. A non-contrast brain computed tomography (CT) scan revealed a hypo-dense, crescent-shaped lesion at the left temporal region beneath the skull inner lamina with marked thickening of nearby bone tissue [Figure 1]a. Based on the history of head trauma and CT features a diagnosis of CSDH considered.
An emergency burr-hole craniotomy was performed to evaculate the hematoma. Intra-operative findings revealed sclerotic hyperplasia of the left temporal bone and the presence of a solid yellow mass, but no hematoma was found. With the family permission we were able to do a tissue biopsy but were not permitted to remove the mass by expanded operation. Postoperative magnetic resonance imaging (MRI) showed iso- and hyper-signal intensity on T1- and T2-weighted images, respectively [Figure 1]b and c. Pathological examination confirmed meningothelial meningioma (World Health Organization (WHO) Grade I) with skull invasion. Immunohistological examination showed positive for epithelial membrane antigen (EMA), vimentin and 1% Ki-67 positive rate. The postoperative period was uneventful and she was discharged one week after the surgery. At 7 months follow-up, the amnestic symptoms had aggravated and she developed right side motor weakness. Even at this stage the family refused further surgical treatment as they considered it too risky for the patient.
As we look back to the diagnostic evaluation of the case, the patient's age, head trauma history and CT features all support CSDH. However, the uncommon thickening of the skull indicated a complication. We initially hypothesized that an organized hematoma may cause hyperplasia of skull. But a search of the literature indicated that skull thickening associated with CSDH was rare. ,, In contrast, hyperostosis is a common consequence of adjacent or invasive meningiomas.  Furthermore, the postoperative MRI confirmed "dural tail sign". Especially, the sagittal scan presented a prominent, homogeneous enhanced lesion which could not be detected in axial or coronal view [Figure 1]d-f. This suggests that if a CT scan presents an organized CSDH, a three-dimensional MRI should also be done not only to detect whether the structure is fully liquid but also for differential diagnosis. Another consideration is dural metastasis, which may mimic both meningioma and CSDH. , But those patients are often diagnosed with a malignant disease as dural metastases are usually in the late stage of manifestation. Additionally, intracranial tumors both primary and metastatic, may be associated with intracranial hemorrhage. In some rare cases, the tumors could also cause CSDH and conceal themselves around or inside the hematoma.  Those CSDHs are often refractory to treatment and may present with heterogeneous signals in a T1-weighted MRI, which may require contrast enhanced scans to reveal the possible lesions.
|Figure 1: (a) Initial CT scan showed crescent-shaped and hypo-dense lesion on left side with severe midline shift and marked thickening of nearby frontal temporal parietal bone; (b-f) Post operation MRI showed homogeneous enhanced lesion with "dural tail sign"; only a sagittal view divulges a prominent mass|
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In conclusion, a first impression of results from CT scans of patients who have suffered head injuries can on occasion be misleading. We suggest that comprehensive considerations, including differential diagnosis, along with modesty and prudence be used to appropriately diagnose these patients for the best possible health outcomes.
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