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Meningiomas are extra-axial tumours and represent the most common tumour of the
meninges. They are a non-glial neoplasm that originates from the arachnoid cap cells of
the meninges. They are typically benign with a low recurrence rate but rarely can be
malignant.
Typical meningiomas appear as dural based masses isointense to grey matter on both T1 and
T2 weighted imaging, and demonstrate vivid contrast enhancement on both MRI and
CT. There are, however, many variants some of which can vary dramatically in their imaging
appearance.
This article is a general discussion of meningiomas and focuses on the imaging findings of
intracranial disease. For spinal disease refer to spinal meningioma.
Epidemiology
Meningiomas are more common in women, with a ratio of 2:1 intracranially and 4:1 in the
spine. Atypical and malignant meningiomas are slightly more common in males. They are
uncommon in patients before the age of 40 and should raise suspicion ofneurofibromatosis
type 2 (NF2) when found in young patients.
Clinical presentation
Many small meningiomas are found incidentally and are entirely asymptomatic. Often they
cause concern as they are mistakenly deemed to be the cause of vague symptoms, most
frequently headaches. Larger tumours or those with adjacent oedema or abutting particularly
sensitive structures can present with a variety of symptoms. Most common presentations
include 8:
headache: 36%
paresis: 22%
frontal: anosmia (although often become very large before becoming symptomatic)
dural venous sinus invasion/dural venous sinus thrombosis (usually this occurs
gradually and even occlusion is asymptomatic, with collateral veins having time to
enlarge)
Pathology
Although the majority of tumours are sporadic, they are also seen in the setting of previous
cranial irradiation and of course in patients with neurofibromatosis type II (NF2) (Merlin
gene on Chromosome 22). Additionally meningiomas demonstrate oestrogen and
progesterone sensitivity and may grow during pregnancy.
They are also divided histologically into 3,8:
meningothelial
psammomatous
microcystic 12
secretory
chordoid
lymphoplasmacyte-rich
metaplastic
mixed type
Oedema may be present associated to some meningiomas and the underlying mechanisms for
this is related to:
venous stasis/occlusion/thrombosis
compressive ischaemia
aggressive growth/invasion
globose: rounded, well defined dural masses, likened to the appearance of a fried
egg seen in profile (the most common presentation)
en plaque: extensive regions of dural thickening
Variants
cystic meningioma
osteoblastic meningioma
chondromatoid meningioma
intraventricular meningioma
more frequently multiple, and typically occur ~35 years after radiotherapy
meningiomas are a much more frequent complication of radiotherapy
compared to sarcomas or gliomas
microcystic meningioma: rare, and are typically very high on T2 weighted imaging
and are more commonly associated with atypical features and adjacent brain oedema 12
Grading
Generally follows the WHO classification for CNS tumours 7,11:
Radiographic features
Meningiomas are located anywhere that meninges are found, and in some places where only
rest cells are presumed to be located. Locations include:
85-90% supratentorial 8
5-10% juxtasellar
5-10% infratentorial
pineal gland
<1% "extradural"
o
parotid gland
skin
Plain film
Plain films no longer have a role in the diagnosis or management of meningiomas.
Historically a number of features were observed, including:
calcification
CT
CT is often the first modality employed to investigate neurological signs or symptoms, and
often is the modality which detects an incidental lesion:
60% slightly hyperdense to normal brain, the rest are more isodense
hyperostosis
o
pneumosinus dilatans
MRI
As is the case with most other intracranial pathology, MRI is the investigation of choice for
the diagnosis and characterisation of meningiomas. When appearance and location is typical,
the diagnosis can be made with a very high degree of certainty. In many instances however
the appearances are atypical.
Meningiomas typically appear as extra-axial masses with a broad dural base. They are usually
homogeneous and well circumscribed, although many variants are encountered.
Signal characteristics include:
T1
o
T2
o
hyperintense: 35-40%
usually correlates with soft textures and hypervascular
tumours
13
variant
o
12
DWI: atypical and malignant subtypes may show greater than expected restricted
diffusion although recent work suggests that this is not useful in prospectively predicting
histological grade 15-16
MR spectroscopy: Usually it does not play a significant role in diagnosis but can
help distinguish meningiomas from mimics. Features include:
o
increased glutamine/glutamate
o
origin
o
CSF vascular cleft sign, which is not specific for meningioma, but helps establish
the mass to be extra-axial; loss of this can be seen in grade II and grade III which
may suggest brain parenchyma invasion
dural tail seen in 60-72% 2 (note that a dural tail is also seen in other processes)
Meningiomas typically narrow arteries which they encase. This is a useful sign to distinguish
a meningioma from a pituitary macroadenoma which will not.
Oedema can be seen and correlates with size, rapid growth, location (convexity and
parasagittal > elsewhere), and invasion in the case of malignant meningiomas.
Angiography (DSA)
mother-in-law sign: "comes early, stays late, very dense", tumour blush
preoperative embolisation: especially skull base, particles are favoured; 7-9 days
prior to surgery
Differential diagnosis
The differential diagnosis largely depends on location, and generally includes otherdural
masses:
cerebellopontine angle
o
acoustic schwannoma
parasellar region
pituitary macroadenoma
craniopharyngioma
elsewhere
haemangiopericytoma
granuloma
sarcoidosis
tuberculosis
extramedullary haematopoeisis
chondrosarcoma
chordoma
Paget's disease
fibrous dysplasia
In the setting of lucent intraosseous meningioma the differential is essentially that of
a solitary lucent lesion of the skull.