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Typical Meningioma (TM)

Last Updated: March 27, 2020

Figure 1: This right frontal meningioma demonstrates low T2 signal intensity and is inciting hyperostosis along the inner table of the right frontal calvarium and along the anterior falx. A hyperintense CSF cleft is also present on T2WI (left) that characterizes this as an extra-axial mass. On contrast-enhanced T1WI (right), this lesion shows adjacent dural thickening and enhancement representing a “dural tail”.

Figure 2: This meningioma is well circumscribed, obviously extra-axial and mildly hyperintense on FLAIR (top row right). The mass demonstrates moderate enhancement and adjacent dural thickening and enhancement representing “dural tail”. There is also restricted diffusion on DWI (bottom), which may or may not be present in meningiomas but often aids in identification when present.

Figure 3: This intra-osseous meningioma is visible predominantly as sclerosis and expansion of the left sphenoid wing on CT (top row left). Mass effect on the left orbit and low signal sclerosis in the left sphenoid wing is also visible on T1WI (top row right). Only with contrast (bottom) are the en plaque enhancing components obvious in the left middle cranial fossa and in the lateral extraconal space of the left orbit.

Basic Description

  • Benign, slow-growing extra-axial tumor arising from arachnoid meningothelial (“cap”) cells
  • Most common primary adult intracranial neoplasm

Pathology

  • WHO grade I
  • Overwhelming majority are supratentorial (~90%): parasagittal, convexity, sphenoid wing, olfactory groove
  • Infratentorial (~10%): most commonly within the CPA cistern
  • Optic nerve sheath or intraventricular locations may be seen
  • Uncommonly arise extracranially: sinonasal, parotid, intraoasseous, or skin
  • Single or multiple
  • Associated with Neurofibromatosis type 2 (NF-2)
  • “Tumor to tumor” metastases to meningioma may be seen (“collision tumor”), most commonly from breast or lung

Clinical Features

  • Adults are most commonly affected (40-60 years); children in cases of NF-2
  • Female gender predilection (M:F 1:2-3)
  • Presenting symptoms dependent on tumor size and location
    • Majority of TMs are asymptomatic
    • Mass effect on adjacent structures resulting in seizures, hemiparesis, visual field defects, cranial nerve defects
  • Treatment: serial imaging if small, asymptomatic; surgical resection including dural tail if symptomatic

Imaging

  • General
    • Well-marginated, smooth extra-axial mass with broad dural attachment
    • ± Bucking or hyperostosis of adjacent cortex
    • Avid, homogeneous enhancement is typical
    • Intra-osseous extension and dural venous sinus involvement or compression may be present
  • CT

    • Well-marginated, iso- to hyperdense mass with broad dural attachment
    • Variable patterns of calcification common (focal, diffuse, rim, etc.)
    • Hypodense peritumoral edema sometimes present
    • ± Hyperostosis of adjacent bone
  • MRI

    • T1WI: iso- to hypointense mass; hyperintense areas of calcification
    • T2WI: variable signal intensity; ± cystic areas and hyperintense “CSF cleft” separating tumor from adjacent brain
    • FLAIR: hyperintense peritumoral edema may be present
    • T2*GRE: hypointense signal “blooming” related to calcification
    • DWI: variable reduction in diffusivity
    • T1WI+C: avid, homogeneous enhancement; ±“dural tail” (nonspecific finding)
    • MR Venogram: evaluate patency and involvement of dural venous sinuses
    • MR spectroscopy: elevated alanine at short echo times results in triplet peaks at 1.3-1.5 ppm

Imaging Recommendations

  • MRI without and with IV contrast; MR spectroscopy may be helpful to differentiate from other tumor types if ambiguous

For more information, please see the corresponding chapter in Radiopaedia.

Contributor: Rachel Seltman, MD

DOI: https://doi.org/10.18791/nsatlas.v1.03.01.28

References

Bosch MM, et al. Optic nerve sheath meningiomas in patients with neurofibromatosis type 2. Arch Ophthalmol. 2006;124:379-385.

Buetow MP, et al. Atypical, typical, and misleading features in meningioma. Radiographics 1991;11:1087-1106.

Lin BJ, et al. Correlation between magnetic resonance imaging grading and pathological grading in meningioma. J Neurosurg. 2014;121:1201-1208.

Osborn AG, Salzman K L, Jhaveri MD. Diagnostic Imaging (3rd ed). Philadelphia, PA: Elsevier, 2016.

Shibuya M. Pathology and molecular genetics of meningioma: recent advances. Neurol Med Chir (Tokyo). 2015;55:14-27.

Takeguchi T, et al. The dural tail of intracranial meningiomas on fluid-attenuated inversion-recovery images. Neuroradiology. 2004;46:130-135.

Zhang H, et al. Perfusion MR imaging for differentiation of benign and malignant meningiomas. Neuroradiology. 2008;50(6):525-530.

Zhang H, et al. Preoperative subtyping of meningiomas by perfusion MR imaging. Neuroradiology. 2008;50:835-840.

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