Meningioma Diagnosis

They are usually benign neoplasms, with characteristic pathologic and imaging features. However, there are several important histologic variants of meningioma, and even a histologically typical meningioma can have unusual or misleading radiologic features that may not be suggestive of meningioma. The typical meningioma is a homogeneous, hemispheric, markedly enhancing extraaxial mass located over the cerebral convexity, in the parasagittal region, or arising from the sphenoid wing. Meningiomas may originate in unexpected locations such as the orbit, paranasal sinus, or ventricles or be entirely intraosseous (within the calvaria). Unusual imaging features such as large meningeal cysts, ring enhancement, and various metaplastic changes (including fatty transformation) can be particularly misleading. Because meningiomas are so common, the radiologist must be aware of their less frequent and uncharacteristic imaging features in order to suggest the correct diagnosis in cases that are atypical 1).

The cross-sectional imaging modalities, MRI and CT, have improved in resolution and fidelity. These modalites now provide not only improved structural information but also insights into functional behavior. MRI has, in particular, proven to have powerful capabilities in evaluating meningiomas because of the ability to assess soft tissue characteristics such as diffusion and vascular supply information, such as perfusion. Recent investigational advances have also been made using a combination of X-ray fluoroscopy for selective catheterization followed by MR perfusion measurement performed with intra-arterial injection of contrast. Together all these modalities provide the radiographer with powerful capabilities for evaluating meningiomas 2).

May show: calcifications within the tumor (in ≈ 10%), hyperostosis or blistering of the skull (including floor of frontal fossa with olfactory groove meningiomas), enlargement of vascular grooves (especially middle meningeal artery).

see Intracranial meningioma CT

The aim of a study was to evaluate the clinical value of multislice 3-dimensional computed tomographic angiography (3D-CTA) in the preoperative assessment of intracranial meningiomas. A total of 331 cases with meningiomas confirmed by CT and MRI were examined using 3D-CTA. The locations of the tumors were observed to be as follows: parasagittal and falcine in 125 cases, sphenoidal in 39 cases, in the olfactory groove in 19 cases, tentorial in 21 cases, parasellar in 33 cases, petroclival in 29 cases, intraventricular in 7 cases and on the convexity of the brain in 58 cases. The reconstructed images were processed by shaded volume rendering, maximum intensity projection and color-shaded surface display. The 3D-CTA images were used to imitate the surgical approach. Surgery was performed according to the information provided in the 3D-CTA images. 3D-CTA provided clear 3D images of the meningioma and the relationship with the adjacent vessels and the skull base, and demonstrated the optimal surgical approach for removing the neoplasm. The results of 3D-CTA corresponded extremely well with the surgical observations. 3D-CTA is able to provide 3D images of the meningioma, adjacent vessels and the bones in the skull base. Furthermore, 3D-CTA supplies information vital in the selection of the optimal surgical approach and information that aids the management of the sinus during the surgery. 3D-CTA is of great value in the preoperative evaluation of meningiomas 3).

Intracranial meningioma MRI.

The ability of preoperative MRI-sequences to predict the consistency of intracranial meningiomas has not yet been clearly defined.

Romani et al., prospectively studied 110 meningioma patients operated on in a single center from March 1st to the 25th of May 2012. Demographic data, location and size of the tumor, peritumoral edema, T1 weighted image, T2 weighted image, proton density weighted (PDWI), fluid-attenuated inversion recover (FLAIR) sequences, and arterial spin labeling (ASL) perfusion were studied and compared with the gray matter signal to predict meningioma consistency. Diffusion tensor imaging (DTI) with fractional anisotropy (FA) and mean diffusivity (MD) maps were included in the preoperative MRI. Meningioma consistency was evaluated by the operating surgeon who was unaware of the neuroradiological findings.

In univariate analysis, meningioma size (diameter > 2 cm) and supratentorial or sphenoidal wing location were more frequently associated with hard-consistency meningiomas (p < 0.05). In addition, isointense signal on MD maps (p = 0.009), hyperintense signal on FA maps, and FA value > 0.3 (p = 0.00001) were associated with hard-consistency tumors. Age and sex, T1WI, T2 weighted image, PDWI, FLAIR, or ASL perfusion sequences and peritumoral edema were not significantly associated with meningioma consistency. In logistic regression analysis, the most accurate model (AUC: 0.9459) for predicting a hard-consistency meningioma shows that an isointense signal in MD-maps, a hyperintense signal in FA-maps, and an FA value of more than 0.3 have a significant predictive value.

FA value and MD and FA maps are useful for prediction of meningioma consistency and, therefore, may be considered in the preoperative routine MRI examination of all patients with intracranial meningiomas 4).

ASL-PWI may provide a reliable and noninvasive means of predicting angiographic vascularity of meningiomas. It may thus assist in selecting potential candidates for preoperative digital subtraction angiography and embolization in clinical practice 5).

see Apparent diffusion coefficient in meningioma.

Intracranial meningioma angiography.

see Positron emission tomography for intracranial meningioma.

68Ga-DOTATATE PET for meningioma diagnosis

68Ga-DOTATATE PET for meningioma diagnosis

Buetow MP, Buetow PC, Smirniotopoulos JG. Typical, atypical, and misleading features in meningioma. Radiographics. 1991 Nov;11(6):1087-106. PubMed PMID: 1749851.
Saloner D, Uzelac A, Hetts S, Martin A, Dillon W. Modern meningioma imaging techniques. J Neurooncol. 2010 Sep;99(3):333-40. doi: 10.1007/s11060-010-0367-6. Epub 2010 Sep 1. Review. PubMed PMID: 20809250; PubMed Central PMCID: PMC2945460.
Zhao X, Yu RT, Li JS, Xu K, Li X. Clinical value of multi-slice 3-dimensional computed tomographic angiography in the preoperative assessment of meningioma. Exp Ther Med. 2013 Aug;6(2):475-478. Epub 2013 Jun 6. PubMed PMID: 24137211; PubMed Central PMCID: PMC3786818.
Romani R, Tang WJ, Mao Y, Wang DJ, Tang HL, Zhu FP, Che XM, Gong Y, Zheng K, Zhong P, Li SQ, Bao WM, Benner C, Wu JS, Zhou LF. Diffusion tensor magnetic resonance imaging for predicting the consistency of intracranial meningiomas. Acta Neurochir (Wien). 2014 Oct;156(10):1837-45. doi: 10.1007/s00701-014-2149-y. Epub 2014 Jul 8. PubMed PMID: 25002281.
Yoo RE, Yun TJ, Cho YD, Rhim JH, Kang KM, Choi SH, Kim JH, Kim JE, Kang HS, Sohn CH, Park SW, Han MH. Utility of arterial spin labeling perfusion magnetic resonance imaging in prediction of angiographic vascularity of meningiomas. J Neurosurg. 2016 Sep;125(3):536-43. doi: 10.3171/2015.8.JNS151211. Epub 2016 Jan 29. PubMed PMID: 26824378.
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