Meningioma associated with acute subdural hematoma: A review of the literature.

BACKGROUND: Classically meningiomas present with a gradual onset of symptoms and their acute presentation with hemorrhagic events seems to be a rare event. A review of the literature shows only 18 cases of meningioma associated with acute subdural hematoma. The possible mechanisms of hemorrhage are not yet fully understood. CASE DESCRIPTION: We report a case of sphenoid wing meningioma associated with acute subdural hematoma, without history of trauma. The presence of meningioma was discovered during the surgery. The tumor and hematoma were removed without postoperative complications.
CONCLUSIONS: The authors have discussed the etiology of an acute subdural hemorrhage and reviewed the pertinent literature.

INTRODUCTION

Meningioma usually manifests with a gradual onset of symptoms.[3] Therefore, the acute presentation of meningiomas with hemorrhagic events seems to be a rare event. From case history, it seems that malignant and metastatic tumors are more prone to bleed; therefore, they are the most common neoplasms that show a sudden onset.[21]

Only 18 cases of meningioma with acute subdural hematoma have been reported.[1456791112131415161718192022]

CASE REPORT

A 59-year-old male on prophylactic antiplatelet therapy was admitted to our institute with sudden headache and dysphasia, accompanied by nausea and vomiting. The patient complained of the following influenza symptoms: Weakness, fever, runny nose for the last 7 days. There is no history of traumatic events. Laboratory tests showed coagulation indices within normal limits. Computed tomography scan (CT scan) of the head showed an acute subdural hematoma that extended from the left frontal lobe to the left temporal lobe [Figure 1].

Figure 1

CT scan on admission showing an acute subdural hematoma extending from the left frontal lobe to the left temporal lobe (a, b)

A left pterional craniotomy was performed. A massive acute subdural hematoma was evacuated and an extra-axial lesion was identified on the left sphenoid wing with evidence of tumor bleeding. A Simpson grade I excision was performed. The histopathological diagnosis deposed for angiomatous and papillary meningioma with angio-invasiveness aspects of the dura [Figure 2]. Postoperative magnetic resonance (MR) showed no residual tumor [Figure 3]. Follow-up at 1 year showed no recurrence of the disease in the absence of neurologic deficits.

Figure 2

Photomicrographs of tumor specimens (Hematoxylin and Eosin); the histological diagnosis was angiomatous and papillary meningioma (a) with angio-invasiveness aspects of the dura (b)

Figure 3

Postoperative MR (a-c) in axial, coronal, sagittal views

DISCUSSION

Non-traumatic acute subdural hematoma is an uncommon complication of meningiomas. Currently, only 18 cases have been described in literature.[1456791112131415161718192022]

The average age of patients (60 years) is slightly higher than the normal peak incidence of meningiomas, with a female prevalence (11:7), but the most frequent localization is the convexity.

There is insufficient evidence to show that hypertension and antiplatelet therapy are the factors responsible for bleeding, although hypertension and anticoagulation have been documented as precipitating factors of the hemorrhage in meningiomas [Table 1].[8]

Table 1

Review of the literature of meningioma associated with acute subdural hematoma

Bleeding in a malignant tumor generally results from weakness of neoplastic vessel, infiltration of tumor cells into the vessel, and tendency of the mural endothelium to proliferate, leading to vessel destruction and necrosis.

However, the mechanism leading to hemorrhage associated with meningioma is apparently not the same and not fully understood.[9]

Some authors have emphasized a high risk of hemorrhage in angioblastic and malignant meningiomas, although transitional subtypes are the most common. In angioblastic meningiomas, it has been assumed that the thin-walled vessels are too fragile, causing easy bleeding. In malignant meningiomas, like other anaplastic tumors, direct invasion or endothelial proliferation by the tumor may obstruct the vascular channel, producing congestion and necrosis, resulting in hemorrhage, which can extend into subdural space.[12]

In syncytial meningiomas, the bleeding is probably related to the presence of intratumoral vasoactive substances released, such as histamine, which could induce vasodilatation and tumoral hemorrhage.[7]

The mechanical stretching and distortion of bridging veins by meningiomas may also be associated with hemorrhage.[12]

Some authors do not believe there is a relationship between histological subtype and high risk of hemorrhage, but everyone seems to agree that age and sex of the patient do not show significant relationship with the hemorrhagic event.[10]

The role of the location of the meningioma is controversial. According to Worm et al., the localization of the tumor in the cerebral convexity increases the risk of hemorrhage.[22] On the contrary, Chakis et al. believe that the site of the meningioma does not seem to influence the occurrence of hemorrhage,[2] although most of the cases reported in the literature are located in the convexity.

CONCLUSION

In our case, the lesion invaded the dura and destroyed the bone. In our opinion, the bone changes are the origin of the hemorrhage in the case presented. Acute subdural hematomas caused by meningiomas have high mortality, and although meningiomas tend to evolve slowly, radical excision should be recommended.

Moreover, the presence of a meningioma should always be suspected in the presence of non-traumatic acute subdural hematoma.