Me nin gio ma As so cia ted With Acu te and Chro nic Sub du ral Ha ema to ma:
A Ca se Re port
Çe tin Re fik KA YA OĞ LU, Gök şin ŞEN GÜL, Ay kut SE ZER, Sü ley man COŞ KUN, Sen cer DU MAN, İsma il Hak kı AY DIN De part ment of Ne uro sur gery, Me di cal Scho ol, Ata türk Uni ver sity, Er zu rum
✔ A 48-ye ar old wo man pre sen ted with con fu si on, hae dac he and mild right he mi pa re si a. Com pu- te ri zed, to mography scan sho wed a me nin gio ma as so cia ted with fron topa rie tal acu te and chro nic sub du ral ha ema to ma (SDH). Mag ne tic Re so nan ce Ima ging re vea led a pa ra sag gi tal tu mo ur with ip si la te ral acu te and chro nic SDH. Emer gent cra nio tomy was per for med and me nin gio ma with SDH was re mo ved. The ope ra ti ve and his to lo gi cal fin dings in di ca ted that the tu mo ral tis su e was the so ur ce of SDH.
Key words: Me nin gio ma, sub du ral ha ema to ma, sur gi cal tre at ment J Nervous Sys Surgery 2008; 1(3):169-172
Akut ve Kronik Subdural Hematomla Birlikte Görülen Menenjioma: Bir Olgu Sunumu
✔ 48 yaşında kadın hasta konfüzyon, başağrısı ve hafif sağ hemiparezi şikayetleri ile müracaat etti. Bilgisayarlı Tomografi (BT) sol frontoparietal akut ve kronik subdural hematom (SDH) ile birlikte olan menenjiomayı gösterdi. Manyetik Rezonans Görüntüleme (MRG) akut ve kronik SDH ile birlikte aynı tarafta olan parasagittal yerleşimli tümörü açığa çıkardı. Acil kraniotomi yapıldı ve SDH ile birlikte olan meninjioma boşaltıldı. Operatif ve histolojik bulgular SDH kaynağının tümöral doku olduğunu gösterdi.
Anahtar kelimeler: Menengioma, subdural hematom, cerrahi tedavi J Nervous Sys Surgery 2008; 1(3): 169-172
H
ae mor ra ges as so cia ted with in trac ra ni al ne op lasm are ra re events. The in ci den- ce of spon ta neo us hae morr ha ge has be en re por ted in ap pro xi ma tely 4 % of all tu mo- urs, mo re in ma lig nant pa to logy such as gli ob- las to mas, oli go den drog lio mas or me tas ta tic car- si no mas (2,7,8-10).Be nign in trac ra ni al tu mo urs li ke me nin gio mas ra rely pre sent with hae morr ha ge, and the in ci den ce is abo ut 1.3 % of all me nin gio mas (2,7-9). Hae morr- ha ge as so cia ted with me nin gio mas may re ma in con fi ned wit hin the the tu mo ur it self or wit hin the
sur ro in ding bra in pa rench yma or ex tend in to the su ba rach nid spa ce. In such a ca se, the blee ding may re sult in a me re su ba rach no id hae morr ha ge (SAH) or pre sent as a SDH, af ter ha ving pe net ra ted the arach no id mem bra ne. Acc tu ally, SAH is the most com mon lo ca ti on fol lo wed by the in tra ce reb ral and in tra tu mo ral lo ca ti on (3,6-9,14). The oc cu ren ce of iso la ted SDH is very ra re (14).
In this ar tic le, a ra re ca se of fron to-pa rie tal con- ve xity me nen gio ma as so cia ted with in both acu- te SDH and crho nic SDH is re por ted.
Sinir Sistemi Cerrahisi / Cilt 1 / Sayı 3, 2008 169
Sinir Sistemi Cerrahisi Derg 1(3):169-172, 2008
CASE REPORT
The 48- ye ar old wo man was ad mit ted to our cli nic in July 2005 with a long his tory of hea- dac he, comp li ca ted wit hin two we eks be fo re ad mis si on by a right he mi pa re sis and con fu si on.
The re was no his tory of trau ma and she did not re cei ve any an ti co agu lant the rapy. On cli ni cal exa mi na ti on the pa ti ent's cons ci en ce was con fu-
sed and she was nor mo ten si ve. He mi pa re sis was ob ser ved in her right ex tre mi ti es with an ip si la- te ral Ba binsky sign. Pla in cra ni al ro ent ge nog- rams yi el ded nor mal fin dings with no frac tu re li nes or cal ci fi ed le si on. CT sho wed a left fron- to-pa rie tal acu te SDH and SDH as so cia ted with fron tal in tra ce reb ral me nin gi om on the sa me si de. MRI re vea led sub du ral col lec ti on with both hypo in ten se and hype rin ten se com po nently
Figure 1. Axial non-contrast-enhanced computed tomography shows left subdural hematoma with acute and subacute components (a). Contrast-enhanced CT section through the vertex reveals a homogeneously enhanced hyperdense lesion in consistence with menengioma (b).
Fi gu re 2. Tur bo spin-ec ho T2-we igh ted co ro nal MR ima ge shows hypo in ten se me nen gio ma and sub du ral he ma to ma with dif fe rent types of he morr ha gic ele ments wit hin it (a). Axi al FLA IR ima ge al so re ve als dif fe rent he morr ha gic ele ments wit hin left pa rie tal sub- du ral he ma to ma (b).
a b
a b
170 Sinir Sistemi Cerrahisi / Cilt 1 / Sayı 3, 2008
Ç. R. Kayaoğlu, G. Şengül, A. Sezer, S. Coşkun, S. Duman, İ. H. Aydın
as so cia ted with fron tal me nin gi om. The pa ti ent was ope ra ted ur gently. A lar ge par ti ally li qu efi- ed sub du ral clot was eva cua ted by cra nio tomy.
In ad di ti on, the me nin gio ma was to tally re sec- ted. His to lo gi cal in ves ti ga ti on co fir med that tu mor was a tran si tio nal me nen gio ma. The pa ti- ent re co ve red comp le tely.
DISCUSSION
Spon ta neo us hae morr ha ge in me nin gio ma is un com mon and is not re la ted to sex, age, blo od dyscra si a, hyper ten si on, or tu mo ur lo ca ti on (2,4-6).
He morr ha ge as so cia ted with me nin goi mas oc curs in less than 2 % of all bra in tu mo urs.
This may ta ke the form of eit her su ba rach no id, in tra ce reb ral, in tra tu mo ral, in tra ven tri cu lar or sub du ral blee ding (2,7-9,15). The most com mon type of blee ding is SAH fol lo wed by in tra ce reb- ral he morr ha ge and an ti tu mo ral he morr ha ge
(2,5,6-9). The pre sen ta ti on of a me nin gio ma with SDH is less com mon. In 1994, Po po vic et al (13) re vie wed a to tal of 41 ca ses of me nin gio ma as so- cia ted with SDH pub lis hed in li te ra tu re. Par ti cu- larly, me nin gi om wit hin both acu te and chro nic com pe nents of SDH is ex tre mely ra re in li te ra tu re li ke bi la te ral chro nic SDH (1). Our ca se had a me nin gio ma as so cia ted with both acu te and chro- nic com po nents of SDH. Ac cor ding to our li te ra- tu re sur vey, this ca se is the first di ag no sed one.
The pat hoph ysi olo gi cal mec ha nisms of blee ding in me nin gio mas are not fully un ders to od. Se ve ral hypo te se; inc lu ding ex ces si ve or unu su al blo od ves sels, di rect vas cu lar inv si on by the tu mo ur cells, ex ten si ve tu mo ur in farc ti on, stretc hing and rup tu re of sub du ral ve ins and the fra gi lity of ar te- ri al and ve no us walls du e to ra pid tu mo ur growth ha ve be en pro po sed (10,16). The most com mon hypot he sis is the rup tu re of the ex ces si ve or the unuu al blo od ves sels (2). This is ba sed on his to lo- gi cal fin dings such as we ak thin-wal led ves sels or di rect pe ri tu mo ral vas cu lar ero si on by the tu mo- ur. Ho we ver, only a few of the tu mo urs show
ab nor mal vas cu la tu re blee ding (6,12).
The prog no sis of pa ti ents with me nin gio ma as so cia ted acu te he morr ha ge is ge ne rally po or.
Ap pro xi ma tely half of such pa ti ents di e ir res- pec ti ve of he morr ha ge type. Fac tors res pon sib le for the mor bi dity and mor ta lity ha ve not be en pre ci sely iden ti fi ed. Ho we ver, the most fre qu- ently re por ted fac tor af fec ting prog no sis is the cli ni cal sta te of the pa ti ent at on set. Sur gi cal in ter ven ti on must be per for med with me nin gi- om as so cia ted hae morr ha ge be cau se even mi nor he morr ha ges cau se ra pid in crea ses in in trac ra ni- al pres su re. This con di ti on of ten oc curs par ti cu- larly in pa ti ents with lar ger tu mo ur (11).
In conc lu si on, me nin gio mas as so cia ted with SDH are ex tre mely ra re. The de tec ti on of SDH in abs cen ce of trau ma ne ces si ta tes the exc lu si on of a vas cu lar ano maly or a tu mo ur. Sur gi cal exp- lo ra ti on, whe ne ver ne ces sary, sho uld be con duc- ted be fo re ir re ver sib le bra in da ma ge has oc cu- red.
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