Sphenoid Ridge Meningioma Presenting as Acute Cerebral Infarction
A 52-year-old man with no significant prior medical history was brought to our emergency room with drowsy mental status that lasted ten hours after the onset of left hemiparesis and dysarthria. The patient's left extremities were weak, and muscle power was of grade 4 in upper and lower limbs. Brain computed tomography (CT) and magnetic resonance examinations revealed acute cerebral infarction in the right MCA territory and an extra-axial mass with homogenous enhancement in the medial portion of the right sphenoid ridge (). Magnetic resonance angiogram showed complete occlusion of the right ICA terminus (). The infarction included the right uncus, insula, medial occipitotemporal gyrus, basal ganglia, corona radiate, and precentral gyrus (). The tumor, which was consistent with a sphenoid ridge meningioma, encased and compressed the right ICA terminus. Cerebral angiography demonstrated complete occlusion of the right proximal M1 portion with slightly limited collateral circulation to the right MCA territory and a radiographic blush from the surrounding meningioma (). Flow in the right MCA had been partially reconstituted by supply from the ipsilateral anterior cerebral artery and the posterior cerebral artery, but was much reduced. A CT perfusion study obtained shortly after arrival showed dramatic prolongation of time to peak and mean transit time of the right MCA territory, indicating obviously decreased regional cerebral blood flow in the involved territory ().\nThe patient was admitted and started on dual antiplatelet therapy, induced hypertension, and volume expansion. However, over the ensuing 48 hours, the left hemiparesis deteriorated steadily to muscle power grade 2 in upper and lower limbs, and follow-up magnetic resonance imaging demonstrated enlargement of the area of the diffusion weighted abnormality (). Emergency extracranial-intracranial (EC-IC) bypass was performed uneventfully. We have adopted a "double-barrel" technique whereby both branches of the superficial temporal artery are joined with MCA recipients to augment flow to the whole territory of the MCA, while leaving the tumor as is (). The patient awoke in the recovery room with exhibited a dramatic improvement of his preoperative weakness over the next 48 hours. He was maintained on oral aspirin at 100 mg/day and clopidogrel at 75 mg/day. CT perfusion scans obtained on the 14th postoperative day revealed improved cerebral blood flow in the involved territory (). At the time of writing the plan was to follow the tumor. We are considering a gamma knife radiosurgery for meningioma, if needed.