Parasagittal meningioma case reports

A unique case of a 52-year-old male who experienced a spontaneous right parietal lobe intracerebral hemorrhage adjacent to the superior sagittal sinus. Subsequent investigations revealed this to be an ITH due to an underlying WHO-grade I meningioma. This case emphasizes that while ITH in meningiomas is rare, prompt recognition and surgical intervention ensure optimal patient outcomes ¹⁾.

Two cases are reported to demonstrate rapid clinical deterioration resulting in death in individuals with large, grade I, parasagittal meningiomas. Case 1 was a 46-year-old man with a history of headaches and epilepsy who suddenly collapsed and died. A large right frontal parasagittal meningioma with haemorrhage had compressed the brain and lateral ventricle, causing tonsillar herniation. In case 2, a previously well 83-year-old woman presented with a one-week history of progressive dysphagia and dysphasia. She suffered rapid deterioration and was prescribed comfort care. A right-sided parasagittal meningioma had compressed the right superior and middle frontal gyri with posterior displacement and compression of the right precentral gyrus. If a meningioma is found at autopsy, the possibility of a lethal effect should be considered, and evidence of neurofibromatosis type 2 or other associated heritable conditions checked for ²⁾.

A 68-year-old man in good general health presented with a parasagittal meningioma that recurred following subtotal removal and adjuvant fractionated stereotactic radiosurgery (FSR). The scalp above the tumor location was very diseased and precluded a regular craniotomy for tumor removal. A 4-cm craniotomy was made in the midline forehead, where the skin was normal. A rigid endoscope was advanced under neuronavigation through the interhemispheric fissure, which provided good access with limited retraction, until the tumor was encountered at a depth of 7-8 cm. Two surgeons performed the surgery using a “four-hands technique”. The tumor was removed and the insertion area was resected and coagulated.

The surgery was uneventful, with no coagulation or transection of major veins. A subtotal resection was achieved, and the patient recovered with no neurological deficit.

Safe resection of parasagittal meningiomas with a purely endoscopic technique is feasible. This option needs further exploration as an alternative strategy in patients with severely atrophic scalp skin that greatly increases the risk of significant healing complications with calvarian craniotomy ³⁾.

Magill et al. presented three cases to illustrate some of the decision-making and techniques used to reduce complications in the management of these cases treated with an open operation ⁴⁾.

The case of a 34-year-old man with bilateral parasagittal meningioma who developed pulmonary metastases is described. The meningioma was an enormous hypervascular tumor with invasion of the superior sagittal sinus. The tumor was resected completely and histologically diagnosed as transitional meningioma. The Ki-67 labeling index was 5%. Four months after operation, the patient subsequently developed bilateral multiple lung lesions later identified as metastases. The lung lesions were partially removed surgically and histologically diagnosed as meningothelial meningioma WHO grade I. The Ki-67 labeling index was 2%. The histological findings demonstrated that the tumor occupied the arterial lumen and the perivascular space, suggesting that pulmonary tumors might metastasize via the vascular route. The histopathological features and mechanisms of metastasizing meningiomas are reviewed and discussed ⁵⁾.