Meningiomas

48 important questions on Meningiomas

Approximately what fraction of meningiomas are WHO GRADE 1?

~90%.

Ki-67 / MIB-1 is discussed at tumor board. Is it officially part of WHO grading?

NO (used clinically, not in the formal WHO classification per talk).

Brain invasion upgrades a meningioma to what WHO grade?

GRADE 2 (not Grade 3).
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In meningiomas, “integrated diagnosis” relies most on what components?

AGE/SEX/HISTORY + LOCATION + IMAGING FEATURES + HISTOLOGY (H&E/MARKERS); molecular less central than in gliomas.

Name 5 imaging features supporting an EXTRA-AXIAL meningioma.

DURAL-BASED, CSF CLEFT, VESSELS DISPLACED INWARD, OBTUSE DURAL ANGLE/MENISCUS, PRESERVED GRAY-WHITE JUNCTION (buckling inward), DURAL TAIL, BONE REACTION (any 5).

What is the CSF CLEFT SIGN?

CSF displaced AROUND THE TUMOR MARGIN, implying EXTRA-AXIAL.

Extra-axial lesions typically form an obtuse or acute angle with dura?

OBTUSE.

Dural tail: is it specific for meningioma?

NO.

Dural tail represents what 2 possibilities?

REACTIVE CHANGE and/or TUMOR INVASION.

Typical CT density of meningioma relative to cortex?

ISO- TO MILDLY HYPERDENSE (often described as “vaguely hyperdense”).

Typical MRI T2 signal relative to cortex (as described here)?

Often ISO-INTENSE (can be variable).

List the spectrum of bone reactions with meningioma (most complete).

NONE → REMODELING → HYPEROSTOSIS → PERMEATIVE/MOTH-EATEN DESTRUCTION → TRANSDIPLOIC EXTENSION.

Most classic bone reaction associated with meningioma?

HYPEROSTOSIS.

What is TRANSDIPLOIC EXTENSION?

Tumor grows through diploë into SCALP/EXTRA-CRANIAL soft tissues.

What’s an INTRAOSSEOUS MENINGIOMA and key mimic?

Meningioma involving BONE ONLY; can mimic FIBROUS DYSPLASIA.

Two most common meningioma locations?

CONVEXITY and PARAFALCINE.

Where is a FALCOTENTORIAL meningioma located?

Between FALX and TENTORIUM, POSTERIOR TO PINEAL region.

Most common site for INTRAVENTRICULAR meningioma?

ATRIUM (TRIGONE) OF THE LATERAL VENTRICLE (often called CHOROID PLEXUS MENINGIOMA).

Differentiate OLFACTORY GROOVE vs PLANUM SPHENOIDALE meningioma by location.

OLFACTORY GROOVE = ANTERIOR; PLANUM SPHENOIDALE = MORE POSTERIOR along sphenoid planum.

Tuberculum sellae meningioma classically causes what visual symptom pattern?

JUNCTIONAL SCOTOMA: IPSILATERAL OPTIC NERVE COMPRESSION (vision loss) + CONTRALATERAL NASAL FIELD DEFECT.

Sphenoid wing meningioma: what wording adds surgical value?

Specify MEDIAL VS LATERAL sphenoid wing.

Why does “medial sphenoid wing” matter?

More DIFFICULT TO RESECT; may be INCURABLE even if Grade 1 due to location.

What skull base structure makes some meningiomas essentially unresectable?

CAVERNOUS SINUS involvement/contiguity.

Optic nerve sheath meningioma is located where relative to the optic nerve?

In the SHEATH, NOT within the nerve.

Two growth patterns of optic nerve sheath meningioma mentioned?

LINEAR along sheath or ENGULFING the nerve.

Key intrinsic optic nerve tumor (contrast diagnosis)?

OPTIC GLIOMA.

Imaging clue favoring vestibular schwannoma over meningioma in CPA?

Schwannoma CENTERS ON AND EXPANDS THE IAC; meningioma often SPARES IAC and grows UP/DOWN (but can extend into IAC).

Clinical clue favoring CPA meningioma over schwannoma (from talk)?

FACIAL NUMBNESS (CN V) rather than hearing loss/tinnitus/vertigo.

Other jugular foramen tumor differential to remember?

MENINGIOMA and SCHWANNOMA.

What extension pattern supports jugular foramen meningioma?

Can extend EXTRACRANIALLY into the CAROTID SHEATH; may have EN PLAQUE component.

Foramen magnum meningioma—what critical structure is at risk?

MEDULLA compression.

Why assess venous sinuses in meningioma?

INVASION/ENGULFMENT/OCCLUSION affects resectability and risk of venous infarct.

Surgical pearl: why is complete sinus occlusion sometimes “easier”?

Collaterals often develop; surgeon can resect without needing to preserve the sinus lumen.

What’s the risk if surgeons peel tumor off a partially involved sinus?

VENOUS INFARCT.

Meningiomas can engulf/occlude arteries (e.g., ICA). Why might patients not present with acute infarct?

SLOW OCCLUSION allows collateral compensation.

Does edema extent correlate with meningioma size?

NO.

Give 4 mechanisms of edema in meningioma.

SECRETORY/MICROCYSTIC TUMOR FACTORS, PRESSURE GRADIENT, VENOUS OUTFLOW OBSTRUCTION/VENOUS HTN, PIAL/ICA SUPPLY.

What does “pial supply” imply in meningiomas?

Contribution from ICA/PIAL VESSELS (associated with edema risk in notes).

What is the “mother-in-law sign,” and what tumor is it associated with?

Angiographic sign of MENINGIOMA: “COMES EARLY AND LEAVES LATE”.

Why is pre-op embolization less commonly done now (per talk)?

Shown not to meaningfully change SURGERY APPROACH/DURATION/COMPLICATIONS.

On CTA, what might a meningioma show?

TUMOR BLUSH/ENHANCEMENT (hypervascular).

Name 3 foramina/paths meningiomas commonly extend through.

SUPERIOR ORBITAL FISSURE, FORAMEN ROTUNDUM → PTERYGOPALATINE FOSSA, PORUS TRIGEMINUS/CAVERNOUS SINUS → PREPONTINE CISTERN.

Why avoid calling hemorrhagic/cystic/calcified meningiomas “atypical”?

“ATYPICAL” is a WHO GRADE 2 term; use “UNUSUAL IMAGING FEATURES”.

Two classic settings for MULTIPLE MENINGIOMAS?

POST-RADIATION and NF2.

Radiation-induced meningiomas tend to be what compared with typical?

MORE AGGRESSIVE (per talk).

NF2 classically includes what key bilateral finding?

BILATERAL VESTIBULAR SCHWANNOMAS.

NF2 mnemonic given and what it stands for?

MISME: multiple intracranial/intraspinal MENINGIOMAS, EPENDYMOMAS, SCHWANNOMAS.

Imaging clues that may suggest higher grade behavior (Grade 2/3) per notes?

RECURRENCE, INTERVAL GROWTH, SATELLITE NODULES, BRAIN INVASION, more AGGRESSIVE/IRREGULAR morphology.

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