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Case 378

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A 46 years-old female patient, previously healthy, attended the Emergency Department reporting loss of muscular strength in upper limbs, especially on the left and “feeling faint”. She denies use of drugs or medications. Upon admission, she had a blood pressure of 190 x 100 mmHg, with no other changes in physical examination. Afterwards, magnetic resonance imaging (MRI) of the brain was requested (Images 1-4).

After analyzing the case and the imaging exams presented, what is the most likely diagnosis?

a) Glioblastoma multiforme

25%

b) Astrocytoma

25%

c) Meningioma

25%

d) Brain metastasis

25%
   

Image analysis


Image 1: Magnetic resonance imaging (MRI) of the brain, weighted in FLAIR, axial section. Hyperintense rounded lesion (highlighted by green line), measuring 8.0 cm in its largest diameter, well-defined, located on right parieto-occipital region adjacent to the meninges.

Image 2: Magnetic resonance imaging (MRI) of the brain, T1-weighted, axial section. Rounded lesion (highlighted by green line), measuring 8.0 cm in its largest diameter, well-defined, located on right parieto-occipital region in continuity with the meninges.

Image 3: Magnetic resonance imaging (MRI) of the brain, T2-weighted, coronal section. Hypointense rounded lesion (highlighted by green line), measuring 8.0 cm in its largest diameter, well-defined, located on right parieto-occipital region in continuity with the meninges.

Image 4: Magnetic resonance imaging (MRI) of the brain, T2-weighted, axial section. Rounded lesion (highlighted by green line), measuring 8.0 cm in its largest diameter, well-defined, located on right parieto-occipital region adjacent to the meninges.

Highlights

      - The immutable risk factors for meningioma include adult women in menacme period, history of breast cancer and african american descent;

      - Female gender, hormone replacement therapy and oral contraceptives are recognized risk factors associated with development of meningioma;

      - The definitive diagnosis is histological, but the therapeutic indication does not depend on the performance of the biopsy. Symptoms, age, comorbidities, localization, size and the type of tumor should be considered;

      - The appearance of meningioma on MRI is a single well-defined lesion. It can be adjacent or continuous with the meninges, hypointense on MRI T2-weighted and hyperintense on MRI weighted in FLAIR;

      - The treatment of meningioma could be conservative if the tumor is small and the patient has no symptoms. In this case, periodical monitoring of its evolution is feasible;

References

      - Wiemels J, Wrensch M, Claus EB. Epidemiology and etiology of meningioma. J Neurooncol 2010; 99:307.

      - Morris Z, Whiteley WN, Longstreth WT Jr, et al. Incidental findings on brain magnetic resonance imaging: systematic review and meta-analysis. BMJ 2009; 339:b3016.

      - Umansky F, Shoshan Y, Rosenthal G, et al. Radiation-induced meningioma. Neurosurg Focus 2008; 24:E7.

      - Claus EB, Calvocoressi L, Bondy ML, et al. Exogenous hormone use, reproductive factors, and risk of intracranial meningioma in females. J Neurosurg 2013; 118:649.

      - Niedermaier T, Behrens G, Schmid D, et al. Body mass index, physical activity, and risk of adult meningioma and glioma: A meta-analysis. Neurology 2015; 85:1342.

      - Sahm F, Schrimpf D, Olar A, et al. TERT Promoter Mutations and Risk of Recurrence in Meningioma. J Natl Cancer Inst 2016; 108.

      - Nowosielski M, Galldiks N, Iglseder S, et al. Diagnostic challenges in meningioma. Neuro Oncol 2017; 19:1588.

      - Umansky F, Shoshan Y, Rosenthal G, et al. Radiation-induced meningioma. Neurosurg Focus 2008; 24:E7.

      - Braganza MZ, Kitahara CM, Berrington de González A, et al. Ionizing radiation and the risk of brain and central nervous system tumors: a systematic review. Neuro Oncol 2012; 14:1316.

      - Rogers L, Barani I, Chamberlain M, et al. Meningiomas: knowledge base, treatment outcomes, and uncertainties. A RANO review. J Neurosurg 2015; 122:4.

Author

Luiz Gustavo de Faria Ferreira, 5th year medical student at UFMG.

E-mail: gustavoff96[at]gmail.com

Supervisors

Aluizio Augusto Arantes Junior, neurosurgeon and preceptor of Neurosurgery residency at Clinics Hospital of UFMG

E-mail: aluizio_arantes[at]uol.com.br

 

Carlos Magno da Silva, Neuroradiologist at Clinics Hospital of UFMG

E-mail:carlosbresil[at]hotmail.com

Reviewers

Leandra Prates Diniz, Lara Hemerly De Mori, André Luiz Marzano de Assis, Aristeu Mascarenhas da Fonseca, Maria Cecília Landim Nassif, Professor José Nelson Mendes Vieira e Professor Júlio Guerra Domingues.

Translated by

Raphael Dias, 5th year medical student at UFMG.

E-mail: diasraphaelf[at]gmail.com

Test question

(CESPE/UNB - 2009) A 24-years old female patient presented visual loss and sensitivity changes in both lower limbs two weeks before the appointment with no previous infections or vaccination. The neurological examination showed significant visual loss in both eyes, moderated weakness and hyperreflexia of the lower limbs, with bilateral positive Babinski’s sign and sensitive levels in T4-T5. She had no control over her fecal and urinary sphincters. According to the hypothetical case described, the alternative which contains the most likely diagnostic hypothesis is:

a) Hypertensive encephalopathy

25%

b) Devic’s disease

25%

c) Reversible posterior leukoencephalopathy

25%

d) Parassagital frontal meningioma

25%

e) Shilder’s disease

25%
   

Commentics

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