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|LETTER TO EDITOR
|Year : 2016 | Volume
| Issue : 6 | Page : 1351-1354
Pediatric intraparenchymal meningioma: A review of literature
Chinmaya Dash1, Ambuj Kumar1, Ramesh S Doddamani1, Madhu Rajeshwari2, Mehar C Sharma2, Bhawani S Sharma1
1 Department of Neurosurgery, All India Institute of medical Sciences, New Delhi, India
2 Department of Pathology, All India Institute of medical Sciences, New Delhi, India
|Date of Web Publication||11-Nov-2016|
Ramesh S Doddamani
Department of Neurosurgery, All India Institute of medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Dash C, Kumar A, Doddamani RS, Rajeshwari M, Sharma MC, Sharma BS. Pediatric intraparenchymal meningioma: A review of literature. Neurol India 2016;64:1351-4
Meningiomas are rare tumors in the pediatric population accounting for approximately 1 to 2% of all intracranial neoplasms in this age group. An intraparenchymal meningioma, which consists of a meningioma without a dural tail and is surrounded by the normal brain parenchyma is very rare, with very few case reports available in the literature. We report one such case and present a pertinent literature review.
A 16-year-old male child presented with a history of multiple seizures. The last seizure occurred 4 months back, and the patient was seizure free after starting oral phenytoin tablets. Patient had no neurological deficits on examination.
Magnetic resonance imaging (MRI) revealed a tumor, which was hypointense on T1-weighted image (T1WI), iso to hypointense on T2WI, present in the right cingulate and superior frontal gyrus. There were areas of blooming on susceptibility weighted imaging (SWI), which corresponded to the areas of calcification on noncontrast computed tomography (CT) scan of the head. A heterogenous enhancement was seen on post-contrast scan [Figure 1]. Considering the radiology, a preoperative diagnosis of oligodendroglioma was made.
|Figure 1: (a) Non-contrast computed tomography (NCCT) of the head showing the tumor in the right medial frontal lobe with calcification. (b) T1-weighted image (T1WI) axial section showing the hypointense tumor within the cortex. (c) T2WI axial section showing the hypointense tumor in close proximity to the anterior cerebral artery without any perilesional edema. (d and e) Contrast enhanced images, axial and coronal section, showing the heterogeneous enhancement in the tumor. (f) Susceptibility weighted imaging showing blooming in areas corresponding to the calcified areas on plain CT scan of the head|
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The patient underwent a right frontal craniotomy, an interhemispheric approach, and excision of the tumor. The tumor was present in the right medial frontal lobe surrounded by normal brain parenchyma. Resection of the overlying cortex was done to approach the tumor. The superficial part of the tumor was firm and fibrous, and calcification was present in the deeper portion of the tumor. A branch of the anterior cerebral artery (ACA), which was adjacent to the tumor, was injured during the surgical dissection, as there was a very poor plane of cleavage between the tumor and the vessel; the injured vessel was secured with ligaclips. Circumferential dissection around rest of the tumor did not reveal any attachment to the dura. The part of the tumor that was densely adherent to the tumor was left behind to preserve the vessel.
The histopathological examination revealed a transitional meningioma infiltrating into the surrounding brain parenchyma. There was no necrosis, pleomorphism, or appreciable mitotic activity [Figure 2]a and [Figure 2]b. Dura was not present in any of the sections. Tumor cells were immunopositive for epithelial membrane antigen [Figure 2]c. MIB1 labelling index was low [Figure 2]d. Patient had an uneventful recovery in the postoperative period and was discharged in a stable condition. At a 3-month follow up, the patient was doing well with no deficits. A follow up contrast-enhanced MRI of the brain is awaited.
|Figure 2: Photomicrograph showing features of a transitional meningioma with focal psammomatous calcification (a, haematoxylin and eosin [H and E], ×100). Tumor is infiltrating into the adjacent cortex (b, H and E, ×200). Tumor cells are immunopositive for epithelial membrane antigen (c, immunohistochemistry [IHC] staining, ×200). MIB1 labelling index is low (d, IHC, ×400)|
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Meningiomas arise from meningothelial cells and are generally dural based. The term 'intraparenchymal meningioma' is used for tumors that arise within the brain tissue and are not dural based. The key feature on neuroimaging is the absence of the dural tail. It is postulated that intraparenchymal meningiomas arise from the arachnoid cells of the perforating vessels as they enter the surface of the brain or sulci., The sylvian fissure, the intraventricular location, and the pineal region are the common sites where a meningioma may arise without a dural tail., A total of 33 cases of intraparenchymal meningiomas have been reported in the literature, and pediatric meningiomas account for 19 of these cases ,, [Table 1]. The most common symptom noticed in the literature review is seizure, as occurred in our case. In contrast to the female predilection noted for adult meningiomas, no such association for intraparenchymal meningioma has been noticed in the literature review. Various characteristics such as cyst formation, presence of peritumoral edema, and absence of dural attachment may cause a confusion in the diagnosis based on neuroimaging alone in the preoperative period. Challenges in this case were the fibrous nature of the tumor and the calcified nature of the deeper portion of the tumor, which made debulking of the tumor and attempts to collapse its walls into the tumor cavity and away from the brain, difficult. In addition, the poor plane of cleavage between the tumor and vessel made separation of the tumor from vessel adventitia difficult and resulted in iatrogenic injury to the vessel. Characeteristics of all pediatric meningiomas are summarized in [Table 1] (however, primary sylvian fissure meningiomas and meningiomas secondary to underlying meningiomatosis have been excluded). Intraparenchymal meningioma in the pediatric population is a rare entity. Meningiomas should not be branded as “extra-axial lesions” and a diagnosis of an intraparenchymal meningioma should also be kept in mind for an intra-axial lesion in the pediatric population. This has implications in the surgical management as well as in prognostication of such patients.
|Table 1: Cases of pediatric intraparenchymal meningioma available in literature|
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[Figure 1], [Figure 2]