Neoplasms of the Meninges James G. Smirniotopoulos, MD

Neoplasms of the Meninges 

James G. Smirniotopoulos, MD 

Pattern Analysis: Location 

• Basic Approach 

‣ Where is the lesion? 

 

Intraaxial 

 

Extraaxial 

 

Intraventricular 

‣ Where is the lesion ? 

 

Supratentorial 

 

Infratentorial 

‣ How old is the patient ? 

 

Child 

 

Adult 

‣ What about Sex? 

Extra-axial ~ Non-Glial 

• Meningioma 

‣ Hemangiopericytoma 

• Schwannoma 

• Pituitary 

• Cysts 

‣ Epidermoid, Dermoid 

‣ Colloid, Craniopharyngioma 

‣ Arachnoid 

• Chordoma 

• Pineal 

Educational Objectives 

• Meningioma is the most common non-glial 

primary tumor 

• Meningioma is the most common 

extraaxial neoplasm 

• Most meningiomas have “typical imaging” 

‣ Hemispheric, homogeneous, broad 

based on the dura, hyperostosis, 

hormonally sensitive 

• Some meningiomas have “atypical 

imaging” 

• Hemangiopericytoma is NOT a 

meningioma 

Meningioma 

• 75% are histologically typical 

• 75% are radiologically typical 

‣ CT 

‣ MR 

‣ Angiography 

• Atypical Imaging =/= Atypical Histology 

• “The atypical appearance of a common 

lesion may be seen more often than the 

classic appearance of an uncommon 

lesion.” 

Primary Meningeal Neoplasms 

• Meningioma (arachnoid cap cell): 

‣ Meningioma (typical and metaplastic) 

‣ Atypical Meningioma 

‣ Anaplastic (Malignant) Meningioma 

 

Papillary Meningioma 

• Mesenchymal (non-meningothelial) 

• Primary Melanocytic Lesions 

• Uncertain Origin 

‣ Hemangiopericytoma (pericyte) 

‣ Hemangioblastoma (mesenchyme) 

Meningeal Tumors: WHO Grades 

• 91% of Meningioma - Grade 1 

‣ Includes most subtypes / metaplastic 

changes 

‣ Transitional, fibroblastic, 

meningothelial 

• 8.3% are ATYPICAL Meningioma - Grade 2 

• Hemangiopericytoma – Grade 2/3 

• Papillary Meningioma - Grade 3 

•

Meningioma - Etiologic Factors 

• Trauma 

• Radiation 

• Viruses 

• Familial (Non-NF2) Meningioma 

• Neurofibromatosis – Type - 2 

‣ MISME Syndrome 

Meningioma - Radiation 

• Low Dose (2000 cGray = 2000 RADS) 

‣ Used for Skull Base Tumors 

‣ Pituitary Adenoma 

Meningioma - Molecular Biology 

• Postulate Tumor suppressor Gene 

• Chromosome 22 – deletion in tumor cells 

‣ Both sporadic and inherited 

‣ W/ or w/o NF-2 

• Homozygous for TWO wild-type copies is 

normal 

• Heterozygous for 22 develops neoplasm 

‣ Because there is a subsequent loss of 

the OTHER wild-type gene 

• Inherited (germline) deletion of 22 

‣ W/Schwannoma = NF2 

Meningiomas 

• 1/7 to 1/4 of all Intracranial Primary 

‣ ~ 6/ 100k / year 

‣ Small ones in ~ 1.4% of autopsies 

• 1/4 – 1/3 of all Intraspinal Tumors 

• Middle age (40-60) 

• Female > Male 

‣ Cranial 2-4:1 

‣ Spinal 4-8:1 

‣ Progesterone receptors in 2/3 

‣ Estrogen receptors less common 

Meningioma – Sharp Margin [Figure 2] 

• Wonton wrapper 

• Tortilla 

• Arepa (Colombia) 

• Sopapilla (Chile) 

• Bolo de milho (Brazil) 

• Pita (Greece and Middle East) 

• Naan (India) 

• Lavaash (Farsi/Iranian) 

• Injera (Ethiopia) 

Meningioma - CT Imaging 

• Non-Contrast 

‣ Sharply Circumscribed 

‣ Homogeneous 

‣ Hyperdense (+/- Ca++) 

 

NOT from psammoma bodies ! 

‣ Broad Dural Surface 

‣ Bone Changes (Hyperostosis) 

• Enhanced CT 

‣ Homogeneous Enhancement 

Meningioma – Early CT [Figure 3] 

Figure 3 A & B 

Meningioma – with classic features of hyperdensity 

and hyperostosis. 

Psammomatous Meningioma 

[Figure 4] 


Meningioma – parasagittal. 

Meningioma - “En plaque” 

• En plaque (like a flat bread) 

• Pancake 

• Crepe 


Spinal masses. 

Neuroradiology 

1289 

Neoplasms of the Meninges

Meningioma: Vasogenic Edema 

• VASCULAR 

‣ Parasitization of MCA, etc. 

‣ Compression of cortical aa./vv. 

• COMPRESSIVE TRAUMA 

• SECRETORY EFFECT 

• “TRANSCORTICAL FLOW” 

‣ Close apposition of tumor to brain 

‣ Thinned cortex 

‣ +/- infiltration of brain 

‣ Fluid gradient from meningioma into 

brain 

Meningioma and Edema [Figure 5] 

Figure 5 A, B & C 

Meningioma. WHO Grade 1 – benign, yet with 

extensive vasogenic edema. 

Meningioma and Edema 

Edema and Prognosis 

• Edema =/= Histology 

• Edema =/= Size 

• Edema ~ Pial Vascularity 

• Edema IS Related to Resectability 

‣ Smaller “pseudocapsule” 

‣ Surgical “cleavage plane” 

‣ Tumor “sticks” to underlying brain 

• Resectability IS Related to Prognosis 

• Edema IS INDIRECTLY Related to 

Prognosis 

Meningiomas: MR Imaging 

• “Meningiomas are ISO-intense.” 

‣ Usually on T1W 

‣ Vary pulse sequence to see 

• EXTRA-axial Features 

‣ Gray-matter buckling 

‣ Pseudo-capsule of vessels 

‣ Meningeal/dural “TAIL” 

• GADOLINIUM ENHANCEMENT 

Tentorial Meningioma [Figure 6] 

Meningioma: Peri-tumoral Edema 

• Male > Female (p = 0.026) 

• Hyperintense to GM on T2W (p = 0.016) 

• Pial blood supply (p = 0.001) 

‣ Statistically significant 

• Pathology 

‣ Grade 1: 23/79 cases had edema 

(32% G1) 

‣ Grade 2-3: 7/79 had edema (87% G2- 

3) 

Lee K, Joo W, Rha H, et al: Peritumoral brain 

edema in meningiomas … 

Surgical Neurology 2008;69:350-5. 


Gross Courtesy Tom Naidich, Mt. Sinai, NY. 

Meningioma – Pre and Post Gd 

[Figure 7] 


Frontal Meningioma - notice the bone thickening 

(hyperostosis) under the center of the lesion. 

Neoplasms of the Meninges 1290 

Neuroradiology

MR Signal and Meningioma Types 

• Most are Isointense to GM 

‣ On both T1W & T2W 

• Hyperintense to GM on T1W 

‣ “Lipoblastic” (Fatty) Meningioma 

‣ Hemorrhage into Meningioma 

• Hypointense on T2W 

‣ Fibroblastic 

‣ Transitional 

• Hyperintense on T2W 

‣ Meningothelial 

‣ “Angioblastic” 

• Microcystic (“Humid”) 

Meningioma - Dural Tail [Figure 8] 

Dural tail: Histology [Figure 9] 

Figure 9 

Dural Tail: Differential Diagnosis 

• Extraaxial Lesions 

‣ Meningioma 

 

Most common lesion w/dural tail 

 

Most common lesions overall 

‣ Schwannoma 

‣ Hemangiopericytoma 

‣ Sarcoidosis 

‣ Dural Lymphoma and metastases 

‣ Gumma (syphilis) 

• Intraaxial Lesions 

‣ Pleomorphic Xanthoastrocytoma 

‣ Superficial cerebral astrocytoma 

‣ GBM (rare) 

Cavernous Sinus Meningioma 

[Figure 10] 

Figure 8 A, B, C & D 

Meningioma - Dural Tail. 

The upper right image shows branching hypointensities 

that may represent flow voids from tumor vessels. 

Dural Tail 

• Curvilinear enhancement 

• “Dural flair” 

• First reported w/meningioma 

• First reported to be neoplastic invasion 

• What is it REALLY? 

‣ Thickening of the dura 

‣ Vasocongestion of the dura 

‣ Edema of the dura 


Cavernous Sinus Meningioma with extensive dural 

enhancement along the tentorium. 

Meningioma CT & MR Features 

• Mass effect 88% 90% 

• Extraaxial Location 42% 70% 

• Broad Dural Attach. 74% 98% 

• Typical Dense./Intensity 92% 74% 

• Hyperostosis 10% 14% 

• Homogeneous 76% 76% 

• Enhancement 96%(78%) 96%(80%) 

(Homogeneous) 

• Meningeal. Enhance (tail) 2% 50% 

• “Capsule” 14% 68% 

Neuroradiology 1990;32:467-73. 


1291 


Other Locations for Meningioma 

• Intraventricular 

• Orbit 

‣ Intraconal 

‣ Periorbital 

• Nasal Cavity 

Intraventricular: ~ 5% [Figure 11] 

• Usually Adult 

• F > M 

• Usually Lateral Ventricle 

• Usually Trigone/Atrium 

• ALWAYS attached to Choroid Plexus 

• Vascular pedicle from choroid 

Figure 11 


Meningioma – Supplied by branches of the ECA, 

showing classic spoke-wheel vascularity. 

Intraventricular 

Meningioma. 

Figure 13 

Optic Nerve Meningioma 

Meningioma Arterial Supply 

• External Carotid 85% 

• Internal Carotid 63% 

• Tumor Blush 95% 

Meningioma 

– Venous 

phase, showing 

persistent and 

dense tumor 

blush. 

Delayed Washout [Figure 14] 

Meningioma - Angiography – Transit 

Time [Figure 12] 

• Blush or Stain 

‣ Early arterial 

‣ Prominent in VENOUS phase 

‣ Capillaries/sm. arterioles 

‣ (Too small to see individually) 

• Venous Filling 

‣ Characteristic if delayed 

‣ May fill with or before Nl. veins 

Meningioma - Angiography – Long 

Transit Time [Figure 13] 

• Venous Filling (Stattin, 1996) 

‣ 170 Meningiomas 

‣ Delayed in 136 (80%) 

‣ With Nl. vv. In 10 (6%) 

‣ Earlier in 24 (14%) 

‣ (8 in early arterial phase) 

• Leeds & Taveras (1969) 

‣ EDV in 6/36 (16%) 

Figure 14 A to E 

MR Perfusion study, showing delayed washout from 

meningioma. Courtesy of Dra. Perla Salgado, Mexico 

City, Mexico. 


Neuroradiology

Meningioma: Effect on Skull 

[Figure 15] 

• Hyperostosis (15-25%) 

‣ With or without micro invasion 

• Pressure Erosion 

‣ Periosteal remodeling 

• Bone Destruction 

‣ Microscopic invasion 

Meningioma: Mostly Intraosseous 

[Figure 17] 

Figure 17 A, B & C 

57 y.o. woman, long Hx of seizures. 

Figure 15 

Variable patterns of hyperostosis from meningioma: 

Inner table, inner and outer table, diploic space, 

combinations. 

Hyperostosis [Figure 16] 

Meningioma Hyperostosis 

• Does NOT mean invasion of bone 

• Implies CHRONICITY 

‣ And benign behavior 

• Skull Base 

‣ Invasion via HAVERSIAN CANALS 

Meningioma: Atypical Imaging (Yet, 

typical Histology) 

Meningioma – WHO 1 [Figure 18] 


Hyperostosis from meningioma. 

“En plaque” Meningioma 

• Meningioma: 

‣ Intradural soft-tissue mass 

‣ Extradural soft-tissue mass 

• Fibrous Dysplasia: 

‣ Intra-osseous lesion 

‣ No extra-osseous mass 


Meningioma with typical histology – yet aggressive 

radiologic appearance. 


1293 


Meningioma Atypical Imaging 

• Focal Lucency Outside (arachnoid cyst) 

• Focal Lucency Inside (necrosis, cyst) 

• Hypodensity (“humid”, lipoblastic) 

• Focal Hyperdensity (metaplasia, 

hemorrhage) 

• Heterogeneous 

• Hyperintensity on T1W 

• Hyperintensity on T2W 

Hemangiopericytoma [Figure 20] 

• Syn: “angioblastic meningioma” 

• Cell of Origin – perivascular pericyte of 

Zahn and/or Zimmerman 

• < 1% of primary CNS 

• M 1.4:1 F 

• Age – 40’s 

• Dural based, bone destruction, lobulated 

Fatty Metaplasia [Figure 19] 


WHO Grade 1 Meningioma with Fatty Metaplasia. 

Meningioma with Cysts 

• Inside of neoplasm 

‣ (rim enhancement) 

• Between tumor and brain 

‣ (”arachnoid cysts”) 

• Inside Brain 

‣ PIA separates tumor from brain 

‣ ?? Results of chronic Edema 

‣ Vacuolization of White Matter 

Meningioma: Atypical Histology 

• Atypical Meningioma ~ 5-7% 

• Anaplastic Meningioma ~ 1-3% 

• ~ 0.2% / 100k per year 

• Higher incidence of Recurrence 

• Shorter time to Recurrence 

• “Atypical Histology” 

‣ Necrosis 

‣ Excessive mitoses 

‣ Invasion into brain* 

“Malignant Meningioma” 

• < 3% of all Meningioma 

• Anaplastic (Malignant) Meningioma 

• Papillary Meningioma 

• “Benign” Metastasizing Meningioma 

• Hemangio-Peri-Cytoma (HPC) 

• Malignant Fibrous Histiocytoma MFH) 


Figure 20 A, B, C & D 

Hemangiopericytoma. WHO 2,3 

Top: Lobulated Mass - narrow attachment base. 

Hemangiopericytoma (HPC) 

• Narrow dural base (“Mushrooming”) 

• No Hyperostosis 

• No Calcification in tumor 

• Lobulated (not hemispheric) 

• Internal Signal Voids (on MRI) 

‣ Irregular and multiple 

Meningioma: Radiologic Features - CT 

• Feature Benign/”Malignant” 

• Homogeneous Enhance 72% / 36% 

• Heterogeneous Enhance 23% / 64% 

• Hyperostosis 18% / 7% 

• Calcification 27% / 0% 

• “Mushrooming” 0% / 57% 

‣ Narrow attachment and larger “cap” 

‣ Invaginating into brain 

Parkway Delight vs. Rueben 

• Parkway Delight Rueben 

• Pastrami Corned Beef 

• Coleslaw Sauerkraut 

• Thousand Island Russian 

• Muenster Swiss cheese 

• Pumpernickel Rye Bread 

Neuroradiology

HPC vs. Meningioma 

HPC 

Meningioma 

Narrow base Broad base 

Lobulated Hemispheric 

Heterogeneous Homogeneous 

Bone destruction, Hyperostosis 

No Ca++ 

Psammomatous, 

No Ca++ 

Irregular vessels Spoke Wheel vessels 

Meningioma 

• The 4H+ Tumor 

• Homogeneous 

• Hyperdense 

• Homogeneous enhancement 

• Hemispheric shape 

• Hyperostosis 

• Hormonally modulated 

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Neuroradiology

Neoplasms of the Meninges James G. Smirniotopoulos, MD

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