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LETTER TO EDITOR
Year : 2014  |  Volume : 62  |  Issue : 1  |  Page : 77-78

Diaphragma sella meningioma presenting with posterior cerebral artery infarct: Case report and review of literature


Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India

Date of Submission02-Dec-2013
Date of Decision18-Dec-2013
Date of Acceptance26-Jan-2014
Date of Web Publication7-Mar-2014

Correspondence Address:
Paritosh Pandey
Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.128335

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How to cite this article:
Shetty R, Sharma RM, Pandey P. Diaphragma sella meningioma presenting with posterior cerebral artery infarct: Case report and review of literature. Neurol India 2014;62:77-8

How to cite this URL:
Shetty R, Sharma RM, Pandey P. Diaphragma sella meningioma presenting with posterior cerebral artery infarct: Case report and review of literature. Neurol India [serial online] 2014 [cited 2019 Nov 22];62:77-8. Available from: http://www.neurologyindia.com/text.asp?2014/62/1/77/128335


Sir,

Meningiomas are common benign intracranial tumors and being slow-growing tumors they often present with features of elevated intracranial pressure (ICP) or neurological deficit. However, it is very rare for a meningioma to present with cerebral infarction. [1],[2],[3] We report one such case.

A 55-year-old female patient presented with rapidly progressive worsening of vision in bilateral eyes and progressive drowsiness. She had been having localized forehead headache for many years and worsening of vision for last 6 months. On examination, she was drowsy, but obeying simple commands, in the left eye no perception of light, finger counting close to face in the right eye and no focal deficits. Computed tomography (CT) scan of the head revealed a large extra-axial tumor (4 cm × 4 cm × 3 cm) arising from the region of diaphragma sella causing mass effect on midline structures and also a hypodensity (infarct) in the entire posterior cerebral artery (PCA) territory. Magnetic resonance imaging brain showed a large tumor arising from diaphragma sella, hypointense on T1-WI, hyperintense on T2-WI, with homogenous enhancement, suggestive of diaphragm sella meningioma with mass effect on both the anterior cerebral arteries (ACA), internal carotid arteries (ICA) and PCAs [Figure 1]a-c. In addition, there was a PCA territory infarction on the left side with diffusion restriction and fluid attenuated inversion recovery hyperintensity [Figure 1]d and e. Magnetic resonance (MR)-angiography showed occlusion of left PCA [Figure 1]f.
Figure 1: (a-c) Magnetic resonance imaging (MRI) axial, coronal and sagittal sequences showing a large diaphragm sella meningioma with retrosellar extension; (d) diffusion-weighted MRI showing acute infarct in left posterior cerebral artery (PCA) territory; (e) fl uid attenuated inversion recovery images showing the tumor as well as left PCA infarct; (f) MRA showing left P1 segment occlusion

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She was taken up for left sided pterional craniotomy and excision of menigioma. The optic nerves were displaced superior-laterally and were separated from the tumor. The attachment was found to be over the diaphragm sella and after detaching the same, the tumor was excised completely. She made an uneventful recovery, and her right eye vision improved. A postoperative CT scan did not show any residual lesion or hematoma. At 3-month follow-up, she was well, except for the visual deficits.

Suprasellar meningiomas typically present with visual symptoms and raised ICP. [4] However, meningiomas presenting with ischemic stroke is very rare. Even when there is encasement and occlusion of large intracranial arteries by meningiomas, there is usually enough collateral supply, because the stenosis or occlusion is very gradual. There have been reports of meningiomas presenting as transient ischemic attacks. [5],[6],[7] However ischemic stroke as the presenting feature is extremely rare. Komotar et al. [2] in their study have reported two patients with meningioma presenting with infarct. Both patients had ICA encasement by the tumor and had middle cerebral artery territory infarct. They estimated the incidence of meningiomas presenting with cerebral infarct at 0.19%. Masuoka et al. [8] have reported a patient with small planum sphenoidale meningioma with ACA infarct. The right A2-segment of ACA was occluded by the tumor and caused an ACA infarct with resultant leg weakness. In all previous reported cases, the infarct was in anterior circulation. This was probably the first case of PCA in a patient with suprasellar meningioma.

In this patient, there might be two mechanisms for PCA infarct. On mechanism might be direct involvement and infiltration of PCA with the tumor causing occlusion and infarct. However, there was no such evidence at surgery. The other mechanism might be possibly compression of left PCA from the tumor causing stasis and thrombosis of PCA, leading to infarct. MR-angiogram in this case showed occlusion of left PCA causing infarct. Another less likely mechanism might be meningioma causing raised ICP, leading to transtentorial herniation causing PCA infarct. However, in this case there is no such evidence on imaging.

 
  References Top

1.Mathis S, Bataille B, Boucebci S, Jeantet M, Ciron J, Vandamme L, et al. A rare cause of stroke in young adults: Occlusion of the middle cerebral artery by a meningioma postpartum. Case Rep Neurol Med 2013;2013:652538.  Back to cited text no. 1
    
2.Komotar RJ, Keswani SC, Wityk RJ. Meningioma presenting as stroke: Report of two cases and estimation of incidence. J Neurol Neurosurg Psychiatry 2003;74:136-7.  Back to cited text no. 2
    
3.Bito S, Sakaki S. Case of middle fossa meningioma with rapid development of symptoms due to obstruction of the middle cerebral artery. No To Shinkei 1971;23:953-7.  Back to cited text no. 3
    
4.Kwancharoen R, Blitz AM, Tavares F, Caturegli P, Gallia GL, Salvatori R. Clinical features of sellar and suprasellar meningiomas. Pituitary 2013; PMID number PMID: 23975080 Published ahead of print.  Back to cited text no. 4
    
5.Oluigbo CO, Choudhari KA, Flynn P, McConnell RS. Meningioma presenting with transient ischaemic attacks. Br J Neurosurg 2004;18:635-7.  Back to cited text no. 5
    
6.Cameron EW. Transient ischaemic attacks due to meningioma - Report of 4 cases. Clin Radiol 1994;49:416-8.  Back to cited text no. 6
    
7.Ueno Y, Tanaka A, Nakayama Y. Transient neurological deficits simulating transient ischemic attacks in a patient with meningioma - Case report. Neurol Med Chir (Tokyo) 1998;38:661-5.  Back to cited text no. 7
    
8.Masuoka J, Yoshioka F, Ohgushi H, Kawashima M, Matsushima T. Meningioma manifesting as cerebral infarction. Neurol Med Chir (Tokyo) 2010;50:585-7.  Back to cited text no. 8
    


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