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 »  Introduction
 »  Case report
 »  Discussion
 »  References

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Year : 2000  |  Volume : 48  |  Issue : 3  |  Page : 285-7

Calcified falx meningioma.


Departments of Neurosurgery, Histopathology and Radiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Correspondence Address:
Departments of Neurosurgery, Histopathology and Radiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

  »  Abstract

A totally calcified mid third falcine meningioma in an elderly male patient is presented. An uneventful enmasse excision was performed. Advantages of positioning on ipsilateral side for paramedian extracerebral lesions are highlighted.

How to cite this article:
Mathuriya S N, Vasishta R K, Khandelwal N, Pathak A, Sharma B S, Khosla V K. Calcified falx meningioma. Neurol India 2000;48:285


How to cite this URL:
Mathuriya S N, Vasishta R K, Khandelwal N, Pathak A, Sharma B S, Khosla V K. Calcified falx meningioma. Neurol India [serial online] 2000 [cited 2020 Dec 2];48:285. Available from: https://www.neurologyindia.com/text.asp?2000/48/3/285/1518




   »   Introduction Top

Meningiomas are one of the commonest benign extracerebral lesions which constitute 10 to 20% of intracranial tumours of adults.[1] Calcification, ossification, bone invasion, bone infiltration and osteoblastosis are the usual features associated with these tumours.[2],[3],[4] On an exhaustive review of English literature, the authors could not find a case describing totally calcified intracranial meningioma without changes in the calvarium. This patient did not have any involvement of parietal bone.


   »   Case report Top

A 60 year old truck driver presented with three months history of left focal seizures. The seizure commenced as tingling and numbness of left foot, involved the lower limb and then progressed to upper limb. Consequently he experienced left sided tonic clonic movements. The frequency of seizures was once a week. Postictal motor deficit used to last for 3 to 10 days followed by total recovery. Neurological examination revealed mild left spastic hemiparesis (power 4/5) with cortical sensory impairment. All other neurological functions including ocular fundi were normal. Blood, serum analysis and X-ray chest did not suggest any abnormality. Plain skull films [Figure. 1] showed a calcification (7x5 cms) which was dense at the centre and fluffy at the periphery. CT demonstrated a right posterior parietal calcified mass which was homogeneously dense in the centre and heterogeneous at periphery. There was no contrast enhancement and cerebral oedema [Figures. 2] and [Figures. 3]. [Right] parietal craniotomy was carried out in right lateral position. The dura was infiltrated over a small area in right parasagittal region, but there was no involvement of overlying bone. Arachnoid was dissected off the adjoining medial cortical surface. This led to spontaneous separation of right parietal lobe from the tumour by gravity. Hence, an intact removal of the tumour along with its falcine attachment could be achieved without any brain retraction.
Histopathological examination showed a calcified meningioma rich in psammoma bodies with only small foci reminiscent of meningothelial cells [Figure. 4].
Postoperative period was uneventful. Three months later, he experienced a left focal fit which could be controlled by adding phenobarbitone 60 mg daily to the pre existing phenytoin 300 mg daily. A follow up CT scan of brain at 18 months after surgery was normal.


   »   Discussion Top

Bone involvement in meningiomas is well known, which may be a localised calvarial hyperostosis or may even be away from the tumour site.[5] Cushing and Eisenhardt mentioned the incidence of ossification in meningiomas as 1%.[2] Hyperosteosing meningiomas have been identified and 2.6 to 6.7% of them were located in the cranial vault.[2] Osteomatous meningiomas constitute around 1% and are mostly located in the spine.[3] Meningiomas arise from arachnoid cap cells which are derived from neural crest.[6] The skull bone, various visceral and cranial cartilages also arise from neural crest. Cushing and Eisenhardt described meningiomas containing both bone and cartilage.[2] The ossification may be enchondral, intramembraneous or tumour calcinosis.[2] The changes resulting from bony invasion by tumour include hyperaemic congestion of Haversian canals, venous stasis and mechanical pressure. The meningioma cells may undergo metaplastic change to osteoblasts.[3],[7] The latter may be responsible for osteomatous changes in the tumour itself, because the basic cell i.e. neural crest cell has potential to differentiate.[5] Calcification is a usual feature in psammomatous meningioma. Psammoma bodies originate from endothelial cells of obliterated blood vessels. Collagenisation of centre of meningiotheliomatous whorls and supportive connective tissue is followed by hyalinization and calcification of whorls, secretory products of arachnoidal cells and necrotic tumour cells. Calcium apatite crystals are intimately admixed with collagen fibres. Calcium and iron play an apparent role in mineralization process.[8]
Sometimes calcification is located distant from the lesion.[5] This indicates that there may be some humoral factor e.g. growth factor or isoenzyme responsible for calcification. Bony isoenzyme alkaline phosphatase (AP) have been postulated to be synthesized in meningiomas in considerable amount along with other enzymes.[5] This enzyme has ossifying properties and has been implicated in mineralisation of bone.[5] A good correlation could be established amongst the tumour content of AP and calcification in a study conducted in 40 patients.[5] Hence, this could be one of the major factors in calcifications of meningioma.[7]
These lesions are neither curettable nor cuttable hence removal is possible by drilling or enmasse excision. The latter is safe if a large working space is available without much handling of cerebral tissue. The same is applicable for benign lesions with clear cut arachnoid planes around. This is possible with surgery in side-down position for posterior and midthird and a few anterior third falcine lesions. Paramedian cortex after arachnoid dissection falls away from falcine lesion by gravity providing thereby an adequate working space. The resection is further eased by drilling a hole through the calcified tumour to pass a suture for retracting it away from cortex which facilitates resection in toto.

 

  »   References Top

1.Black PM : Meningiomas. Neurosurgery 1993; 32 : 643-657.   Back to cited text no. 1    
2.Cushing H, Eisenhardt L : Meningiomas. Their classification, regional behaviour, life history and surgery and results. New York Hafner 1962; 19-55..   Back to cited text no. 2    
3.deCaro R, Giordano R, Parenti A : Osteomatous meningioma-report of two cases. Acta Neurochiru 1982; 60 : 313-317.   Back to cited text no. 3    
4.DeSantis A, Rampini P, Villani R et al : Hyperostosing meningiomas of the cranial vault. J Neurosurg Sci1980; 21 : 151-154.   Back to cited text no. 4    
5.Heick A, Mosdal C, Jorgensen K et al : Localized cranial hyperosteosis of meningiomas : a result of neoplastic enzymatic activity? Acta Neurol Scand 1993; 87 : 243-247.   Back to cited text no. 5    
6.Landow H, Kabat EA, Newman W : Distribution of alkaline phosphatase in normal and neoplastic tissues of the nervous system. Arch Neurol Psychiatry1942; 48 : 518-530.   Back to cited text no. 6    
7.Pompli A, Derome PJ, Visot A et al : Hyperostasing meningiomas of the sphenoidal ridge. Clinical features, surgical therapy and long-term observations : review of 49 cases. Surg Neurol1982; 17 : 411-416.   Back to cited text no. 7    
8.Russel DS, Rubinstein LF : In : Pathology of tumours of the nervous system. Edition V. Williams and Wilkins Baltimore. 1989; 467-468.   Back to cited text no. 8    

 

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