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NEUROIMAGE
Year : 2016  |  Volume : 64  |  Issue : 1  |  Page : 190-192

Post-traumatic meningiomas—Myth or reality?


Department of Neurosurgery, Kasturba Medical College, Manipal, Karnataka, India

Date of Web Publication11-Jan-2016

Correspondence Address:
Rajesh Parameshwaran Nair
Department of Neurosurgery, Kasturba Medical College, Manipal - 571 604, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.173667

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How to cite this article:
Nair RP, Upadhyaya S, Ganapathy S, Menon GR. Post-traumatic meningiomas—Myth or reality?. Neurol India 2016;64:190-2

How to cite this URL:
Nair RP, Upadhyaya S, Ganapathy S, Menon GR. Post-traumatic meningiomas—Myth or reality?. Neurol India [serial online] 2016 [cited 2019 Aug 23];64:190-2. Available from: http://www.neurologyindia.com/text.asp?2016/64/1/190/173667


A 55-year-old woman presented to the outpatient department with occasional holocranial headaches for 1 year and blurring of vision for the past 6 months. The headaches had increased in intensity over the past 6 months and were associated with visual obscuration and diurnal variation, suggestive of raised intracranial pressure. On eliciting the previous medical history, it was evident that she had a history of burr hole evacuation of a right frontotemporoparietal subacute subdural hematoma [Figure 1] following sustenance of trivial trauma, 2 years ago. On general examination, her vital parameters were stable, and neurological examination was unremarkable except for the fundus examination showing an early papilledema. A computed tomographic (CT) scan of the brain (plain and contrast) showed a homogenously enhancing extra-axial, well-circumscribed lesion [Figure 2] and [Figure 3] in the region of the previous right frontal burr hole. The lesion seemed to be arising from the frontal burr hole. A review of the previous CT scans, including the postoperative scans [Figure 4], showed no such lesion. She underwent a craniotomy and Simpson grade 2 excision of the tumor, and was symptom free in the postoperative period. Intraoperative findings were consistent with a post-traumatic meningioma present at the burr hole site and adherent to the inner membrane of the chronic subdural hematoma [Figure 5],[Figure 6],[Figure 7],[Figure 8]. Trauma as an etiology for meningiomas has been described by Cushing and Eisenhardt [1],[2] as early as in 1922; however, meningiomas as a sequel to traumatic injury are rarely encountered and documented in literature. Most meningiomas arise spontaneously from the arachnoidal cap cells, which are usually clustered around the dural folds. Extrinsic factors have been implicated in the development of meningiomas, which include the Melnick virus, previous irradiation, genetic factors, and rarely, trauma.[1],[3],[4] Post-traumatic meningiomas have been a controversial subject from the time of General Wood, who observed the development of a parasagittal meningioma in himself, 12 years after sustaining trauma.[5] Ewing and Zulch et al.,[6],[7] have proposed a useful criteria to link lesions to prior trauma, which include the following points: The patient being in a good health prior to trauma; established head injury; co-localization of the site of trauma and tumor; reasonable time lapse between the injury and the development of tumor; histological diagnosis of the tumor; induction of meningioma by the process of wound healing; and, contrast CT or MRI performed during the course of treatment for the initial trauma showing no evidence of the tumor.[8]
Figure 1: Preoperative (2--year--old scan) plain CT of the brain (axial, coronal, and sagittal images) showing a right fronto--temporo--parietal subacute subdural hematoma with significant mass effect in the form of compression of the right lateral ventricle and midline shift with gross cerebral edema

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Figure 2: Recent plain CT of the brain (axial, coronal, and sagittal images) showing an isodense lesion in the region of the right frontal burr hole site with surrounding hypodensity suggestive of edema

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Figure 3: Contrast CT of the brain (axial, coronal, and sagittal images) showing a heterogenously enhancing lesion with a dural tail and the last block showing the sagittal cut in bone window with the tumor arising in the vicinity of the burr hole

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Figure 4: Postoperative contrast CT of the brain (axial image) showing gross removal of the hematoma with no evidence of any lesion near the burr hole site

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Figure 5: Intraoperative color plate (purple arrow) showing the dural opening made previously to evacuate the subdural hematoma

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Figure 6: Intraoperative color plate (yellow and blue arrow) showing the dural edges held up with a pair of biopsy forceps to demonstrate the underlying inner membrane

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Figure 7: Intraoperative color plate (specimen in toto) with the green arrow showing the dural opening made previously and the purple star showing the meningioma adherent to it

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Figure 8: Intraoperative color plate (specimen in toto) with the yellow star showing the reflected dura and the pink hexagon marking the inner membrane of the chronic subdural hematoma along with a blue arrow showing the meningioma adherent to the inner membrane

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Our case met all these criteria. Moreover, very rarely has such an early detection of tumor been documented. Various theories have been postulated for the occurrence of these lesions at the previous sites of trauma. These include: (a) Overproliferation of arachnoidal cells as a part of wound healing, and (b) chronic inflammation caused by the presence of foreign bodies (as hypothesized by Barnett et al.,)[9] or by granuloma formation, which might have led to meningeal irritation, cellular atypia, and eventually neoplasm formation. A post-traumatic meningioma is also explained by a possible neoplastic meningeal tissue transformation during the reparative process. Arachnoidal cells have been shown to undergo a dysplastic change and this finding has also suggested a strong cause–effect relationship.

Though trauma has often been implicated as a possible risk factor for the development of meningiomas, several large series do not support this link. Despite this opinion by most of the authors,[4],[10] we would like to strongly recommend the need for a thorough clinical and radiological workup in patients with severe head trauma, especially those with skull fractures, so as to correlate the occurrence of these late-appearing lesions with the previous trauma.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Cushing H, Eisenhardt L. Meningiomas. Their classification, regional behavior, life history and surgical end results. Bull Med Libr Assoc 1938;27:185.  Back to cited text no. 1
    
2.
Turner OA, Laird AT. Meningioma with traumatic etiology—report of a case. J Neurosurg 1965;24:96-8.  Back to cited text no. 2
    
3.
Altinörs N, Cetin A, Pak I. Scalp meningioma: Case report. Neurosurgery 1985;16:379-80.  Back to cited text no. 3
    
4.
Black PM. Meningiomas. Neurosurgery 1993;32:643-57.  Back to cited text no. 4
    
5.
Ljunggren B. The case of General Wood. J Neurosurg 1982;56:471-4.  Back to cited text no. 5
    
6.
Ewing J. Modern attitude toward traumatic cancer. Arch Pathol 1935;19:690-728.  Back to cited text no. 6
    
7.
Zuülch KJ, Meinel HD. The biology of brain tumours. In: Vinkin PJ, Bruyn GW, editors. Tumours of the Brain and Skull Part I. Handbook of Clinical Neurology. Vol. 16. Amsterdam, North Holland: Elsevier Science Publishers; 1974. p. 1-56.  Back to cited text no. 7
    
8.
Moorthy RK, Rajshekhar V. Development of glioblastoma multiforme following traumatic cerebral contusion: Case report and review of literature. Surg Neurol 2004;61:180-4.  Back to cited text no. 8
    
9.
Barnett GH, Chou SM, Bay JW. Posttraumatic intracranial meningioma: A case report and review of the literature. Neurosurgery 1986;18:75-8.  Back to cited text no. 9
    
10.
Annegers JF, Laws ER Jr, Kurland LT, Grabow JD. Head trauma and subsequent brain tumors. Neurosurgery 1979;4:203-6.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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