Wandering Woman With a Meningioma

Rafael Ilyayev, MD
Vanessa Rojas, PGY-1
Michael Megally, PGY-2
Volume 55 - Issue 2 - February 2015

An 81-year-old woman is brought to the emergency room by emergency medical services after pedestrians found her roaming the streets in her pajamas. She is unable to provide any medical information due to her profound dementia. She is not oriented to place or time but is pleasant in communication and denies any headache, head injury, or loss of consciousness. The patient is otherwise stable and asymptomatic. 

Physical examination, vital signs, and laboratory work-up are all normal. 

A head computed tomography (CT) scan is performed to check for any acute pathology that may account for the patient’s altered mental status. The scan shows a large meningioma that measures approximately 5 cm x 5 cm. 

Discussion. A meningioma is a benign tumor of arachnoid origin. Meningiomas account for 15% of all brain tumors, and most grow in a spherical or lobulated form (Figures 1 and 2). Although magnetic resonance imaging (MRI) is the preferred method of visualization, CT scans often are successful and used to diagnose meningiomas, since they will not show up on plain skull radiographs. The preferred treatment for this condition is surgical resection of the tumor; other forms of treatment include tumor embolization.1,2

An epidural hematoma occurs when trauma causes a vessel to rupture in the brain.1 Subsequently, blood accumulates in the space between the dura matter and the skull, leading to a rise in intracranial pressure. It can also be venous in origin, which occurs in one-third of cases. 

On an unenhanced CT scan, epidural hematomas appear as a high-density hemorrhagic collection under the skull, which causes mass effects that may cause the underlying cortex to be distorted. It has a biconvex appearance that does not cross the suture lines but may cross the midline. Underlying skull fractures, most commonly located in the frontotemporal region, can also often be seen. If necessary, the recommended treatment is surgery to remove the bleed and relieve the intracranial pressure.3,4

A glioblastoma multiforme is a highly anaplastic, highly cellular tumor that arises from glial cells and infiltrates the brain rapidly.3 The tumor is made up of poorly differentiated, round, or pleomorphic cells that are multinucleated, have cellular atypia, and are anaplastic. When seen on CT, it often has an irregular ring-enhancing appearance with significant brain edema. It typically involves the white matter but can spread to the corpus callosum and involve both hemispheres. Treatment is often multimodal, which means it includes surgery followed by chemotherapy, anti-angiogenic agents, and corticosteroids for symptoms.5

Central nervous system involvement, occurring with tuberculosis, is another possibility.4 This is often seen in parts of the world with high endemic rates of tuberculosis and in immunocompromised patients. It often occurs after infection with Mycobacterium tuberculosis; in these cases, there is a well-circumscribed mass composed of granulation tissue that may occur in the cerebral hemispheres, cerebellum, brainstem, or perimeningeal spaces. Multiple lesions are often present on imaging. 

On MRI, ring-enhancing lesions are seen, but these lesions can also involve the basal cistern and the meninges, causing dilatation of the ventricles. The treatment at this point is a combination of antitubercular drugs, which includes isoniazid, rifampin, ethambutol, or streptomycin. Surgery is reserved in cases of medical failure.6 

References:

  1. Whittle I, Smith C, Navoo P, Collie D. Mengiomas. Lancet. 2004;363(9420):1535-1543.
  2. Annegers, JF, Schoenberg BS, Okazaki H, Kurkland LT. Epidemiologic study of primary intracranial neoplans. Arch Neurol. 1981;38(4):217-219.
  3. Chen M, Pope T, Ott D. Basic Radiology. New York, NY: McGraw-Hill Medical; 2011. 
  4.  McKean, S, Ross J, Dressler, D, et al. Principles and Practice of Hospital Medicine. New York, NY: McGraw-Hill Medical; 2012.
  5. Ropper A, Samuels M. Adam and Victor’s Principles of Neurology. New York, NY: McGraw-Hill Professional; 2009.  
  6. Longo D, Fauci A, Kasper D, et al. Harrison’s Principles of Internal Medicine. New York, NY: McGraw-Hill Professional; 2012.