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|LETTER TO EDITOR
|Year : 2021 | Volume
| Issue : 5 | Page : 1442-1443
Intraparenchymal Cystic Meningioma - A Rare Occurrence with a Clinical Significance
Batuk D Diyora, Gagan Dhall, Bhagyashri U Bhende, Mazharkhan Mulla
Department of Neurosurgery, LTMMC and LTMG Hospital, Sion, Mumbai, Maharashtra, India
|Date of Submission||29-Dec-2017|
|Date of Decision||14-Mar-2018|
|Date of Acceptance||19-Apr-2020|
|Date of Web Publication||30-Oct-2021|
Batuk D Diyora
Department of Neurosurgery, LTMMC and LTMG Hospital, Sion, Mumbai - 400 022, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Diyora BD, Dhall G, Bhende BU, Mulla M. Intraparenchymal Cystic Meningioma - A Rare Occurrence with a Clinical Significance. Neurol India 2021;69:1442-3
We describe the case of a 67-year-old male with an intraparenchymal cystic meningioma. He was brought to our casualty with left-sided weakness and altered sensorium. Fundus examination revealed bilateral grade 3 papilledema. Magnetic Resonance Imaging (MRI) showed a solid/cystic mass lesion of about 4.8 × 3.6 × 3.6 cm. in the region of right basal ganglia [Figure 1]. The solid component was homogenously enhancing, whereas the cystic component showed a peripheral rim enhancement. Excision of this deep-seated solid/cystic lesion was planned via extended right pterional craniotomy through the trans-sylvian trans-insular approach. Complete excision of both solid and cystic components was ensured [Figure 2]. The histopathological diagnosis was atypical meningioma [Figure 3]. The cyst wall contained neoplastic cells similar in nature to the solid tumor (i.e. Nauta type 2 cyst).
|Figure 1: Magnetic resonance imaging scan of brain showing 4.8 × 3.6 × 3.6 cm size mass lesion in right basal ganglion region. The lesion had solid and cystic components. The solid component appeared hypointense on T1 and T2 weighted images and the cystic component appeared hypointense on T1 weighted images and hyperintense on T2 weighted images (a-c). On intravenous gadolinium administration, the solid component was homogenously enhancing while the cystic component showed a peripheral rim enhancement (d)|
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|Figure 2: Intra operative photograph showing cystic (a) and solid (b) component of the tumor exposed through trans sylvian trans insular approach. Well capsulated whitish yellow mass lesion excised completely (c)|
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|Figure 3: Photomicrograph showing meningothelial cells with high cellularity, moderate nuclear pleomorphic vesicular nuclei with prominent nucleoli. (Hematoxylin-eosin stain)|
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Meningiomas without a dural attachment have been classified into intraventricular meningiomas, pineal region meningiomas, deep sylvian meningiomas, intraparenchymal or subcortical meningiomas, and others. Intraparenchymal meningiomas are rare intracranial tumors and only 39 cases of intraparenchymal meningiomas have been reported in the literature. Various postulates given for its origin are – from arachnoid cells related to the pia mater covering the intraparenchymal blood vessels, from the sulcal pia mater, from the intraparenchymal arachnoid cell rests of migration defects, from the ectopic meningothelial cells, or due to the cellular de-differentiation as postulated for the intradiploic and cutaneous meningiomas. Intraparenchymal meningiomas have a predilection for male sex and cerebrum. Incidence is equal on either side. Meningiomas with intra or extra tumoral cysts have been categorized as cystic meningiomas. Cystic meningiomas are also rare with a reported incidence of about 1.6%–7%. Comparatively, they are more common in the pediatric population., The incidence of cyst formation in meningioma is highest in infancy, and in more than 50% cases, there is no dural attachment, they are located on the convexity and the cyst is larger than the tumor. Cyst formation is one of an important finding in intraparenchymal meningioma and the incidence is around 69%. The presence of an associated cyst is an uncommon imaging feature of meningiomas that may make it difficult to distinguish this tumor from a primary intra-axial glial neoplasm. The presence of peritumoral edema can also be a misleading finding.
As with other meningiomas, the primary treatment is surgery. Complete tumor resection is the most important factor in prevention of tumor recurrence. Even if neuroimaging does not show enhancement of the cyst wall, resection of the entire cyst wall is optimum. However, the cyst wall is often tightly adherent to the surrounding brain tissue, making its dissection difficult. Tumors that cannot be completely resected such as those that have a deep location, large size, are adherent to vital structures, as well as those that could potentially result in an extensive invasion of the adjacent structures or cause severe blood loss during resection should be treated with radiation therapy.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]