Case Report: Meningioma with Intra-tumoural Haemorrhage Secondary to Ruptured Distal Anterior Cerebral Artery Aneurysm
A 34-year-old male was suffering from a mild headache and had difficulty sleeping for a month prior to his admission to hospital. In addition, he complained of difficulty in focusing his thoughts. Early in the morning of the day he came to the hospital, he said that he woke up with the worst headache of his life. He had no other neurological symptoms, and his past medical history was unremarkable.\nIn the emergency department at the University of Alberta Hospital, the patient was in pain, but he was otherwise haemodynamically stable with a Glasgow Coma Score of 15 and no neurological deficits.\nA computed tomography (CT) scan revealed a rounded mass of 3.3 cm within the intra-hemispheric region, and it was associated with acute haemorrhage, which was predominantly in the right postero-medial frontal area (Fig. ). Therefore, the patient was admitted to the neurosurgery step-down unit for monitoring. A cerebral angiography revealed displaced peri-callosal arteries on both sides with mild opacification of the midline lesion from a distal branch of the left middle meningeal artery. No associated vascular abnormalities were observed (Fig. ).\nBrain magnetic resonance imaging (MRI) with and without contrast revealed an intra-hemispheric falcine enhancing extra-axial mass that measured 3.8 × 3.2 × 3.6 cm. The most likely diagnosis was a meningioma. The mass itself was composed of 2 components. One enhancing component was present in the middle and left portions of the tumour, which was iso-intense to grey matter in all sequences. Along the right lateral margin, there was a nonenhancing component, which was dark on T2-weighted sequences and contained multiple foci of increased T1 signal. This was in line with a haemorrhage (Fig. ).\nDuring his stay in the hospital, the patient’s clinical condition remained stable, and second conventional angiogram was obtained, which revealed no vascular abnormalities that differed from those in the previous study.\nBecause MRI revealed significant swelling around the haemorrhage, a delayed elective surgery was planned. The patient was then discharged home with steroids and anticonvulsants. Four weeks later, a pre-operative cerebral angiogram, which was conducted for the purpose of tumour embolisation, did not reveal any appropriate targets for embolisation; rather, a 3-mm saccular aneurysm was noticed with a left internal artery injection from the distal left pericallosal artery (Fig. ).\nOn the next day, with the patient’s consent, an endovascular embolisation of the aneurysm was performed with N-butyl-2-cyanoacrylate, and no complications were encountered. On the following day, the patient underwent a surgery for resection of the tumour. The craniotomy was performed through a bifrontal incision. The tumour was midline attached to the falx. Normally we would prefer a midline approach from the nondominant side (right side). However, there were two large bridging veins on the right side and a clear corridor on the left. We approached the tumour from the left. The tumour was evident within one centimeter of the cortical surface. There was obvious hemosiderin staining around the tumour posteriorly, however the tumour was easily dissected from the surrounding brain without significant adherence. At the deepest margin of the tumour the pericallosal arteries were embedded within the tumour base. As a result a small rim of tumour was left attached to the preserved pericallosal vessels.\nThe patient was discharged home 3 days after the procedure, and a follow-up cerebral angiogram showed no recurrence of the aneurysm. The final pathology confirmed the diagnosis of a World Health Organization grade-I meningioma with embolisation material within the tumour (Fig. ).