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Case 317

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A 76-year-old male patient was taken by family members to medical care at a Basic Health Unit with an intermittent memory alteration (possibly lost in the peridomiciliary environment) starting 2 years ago. In addition, he complained of progressive deterioration of gait and episodic headache, both with 1 year of evolution. He is hypertensive with inadequate control. Referred to HC-UFMG for hospitalization, after the accomplishment of computed tomography (CT) of the encephalon.

Based on the clinical history and the presented images, the most probable diagnosis is:

a) Glioblastoma multiforme

25%

b) Metastasis dural

25%

c) Meningioma

25%

d) Arachnoid cyst

25%
   

Image Analysis

Image1: CT brain, axial view at the sealing/supraselar level, without intravenous contrast medium. Expansive right parassellar formation, with predominantly defined limits and slightly irregular contours, with scattered calcifications of permeation (blue marking), measuring 5.0 cm x 4.8 cm (yellow contorn).

 

Image 2: CT scan of the brain, axial view at the suprasellar level, after intravenous injection of iodinated contrast medium. Right parassellatory lesion, with defined limits, with calcifications of permeation (blue marking) showing intense homogeneous contrast enhancement (yellow marking) associated with ipsilateral ventricle collapse. Undefined limits of the middle cerebral artery and carotid cerebral artery. Contralateral deviation of the pellucid septum, about 8.0 mm from the median line. Signs of perilesional edema (red marking).

 

Image 3: MRI of encephalon in T2 sequence (axial section). Homogeneous solid and expansive right parasselar lesion, in the sphenoid wing region, with defined limits, compressing the adjacent brain, without evidence of invasion. Small perilesionic accumulation (CSF rhyme), inferring its extra-axial or extraparenchymal location (red arrows). There are hypersignals in white matter on the side the lesion (yellow mark), being able to correspond to the edema or gliose.

 

Image 4: Magnetic resonance imaging (MRI) in T1 sequence after administration of intravenous contrast (gadolinium), sagittal view on the right parasselar level. Solid expansive lesion, well delimited, with intense and homogeneous contrast enhancement. Signal presence of dural tail (green marking). 

Highlights

- Meningioma is the most common non-glial primary intracranial tumor, with a higher incidence in women;

- May be asymptomatic or have nonspecific, slow-evolving symptoms;

- In case of clinical suspicion, a CT scan of the skull or MRI of the brain with subsequent histological confirmation is indicated;

- At CT and MRI, it usually presents as a partially calcified extra-axial mass, arising from the dura mater, being intensely enhanced by the contrast;

- Risk factors: previous cranial irradiation and neurofibromatosis type 2;

- Treatment may be expectant or surgical, depending on the extent and location of the tumor.

References

-Park JK. Epidemiology, pathology, clinical features, and diagnosis of meningioma [internet]. 2017. [Accessed on: Sep. 23. 2017]. Available at: https://www.uptodate.com/contents/epidemiology-pathology-clinical-features-and-diagnosis-of-meningioma

- Kasper, DL. et al. Harrison Internal Medicine, VI and II. 19th. Edition. Rio de Janeiro: McGrawHill, 2017.

- Haddad G. Meningioma [internet]. 2017. [Accessed on: Sep. 23. 2017]. Available at: https://emedicine.medscape.com/article/1156552-overview

- Rocha, Antônio José da; Vedolin, Leonardo; Creative Commons License Brain. Rio de Janeiro: Elsevier, 2012 (Brazilian College of Radiology and Diagnostic Imaging).

Author

Lucas José Resende - Academic of the 11th period at Universidade Federal de Minas Gerais 

E-mail: lucasresende.ufmg [at] gmail.com 

Supervisors

Arthur Adolfo Nicolato, neurosurgeon physician.

 

Carlos Magno da Silva, neuroradiologist at HC-UFMG.

E-mail: carlosbresil [at] hotmail.com

Reviewers

Luísa Bernardino, Rafael Valério, Ariádna Andrade Saldanha, Bernardo Finotti, Prof. Pedro Augusto Lopes Tito, Prof. José Nelson M. Vieira, Profa. Marino Parisotto Viviane Santuari

Translated by 

Luana Fonseca de Almeida, 4th year medical student at Universidade Federal de Minas Gerais.

E-mail: luana.fonseca.almeida[at]gmail.com

Test question

(HC - UFPR) (Specific Test / 2016) - Meningiomas are usually benign tumors of slow growth. The most common location of intracranial meningiomas in adults is:

a) Parasagittal

25%

b) In the convexity

25%

c) Intraventricular

25%

d) In the olfactory groove

25%

e) In the cavernous sinus

25%
   

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