Meningiomas (Intracranial) Flashcards
A patient presents with a long history of headache. MRI shows isointense lesion on T1 while hypointense on T2, signal voids showing calcifications, densely enhancing broad-based
attachment to dura, and a dural tail. Hyperostosis of the adjacent bone and homogenously hyperdense lesion on CT of brain are also seen. Meningiomas are the most common primary intracranial tumors in adults, representing 36.4% of CNS tumors
that arise from meningothelial cells of arachnoid membrane. Following statements are correct regarding these tumors except?
● A. Most are slow growing benign tumors, with 32% of incidentally discovered meningiomas showing no growth over 3 years follow-up
● B. They are most commonly located along falx, convexity and sphenoid bone
● C. Psammoma bodies are round, microscopic, calcified structures having a concentric laminated appearance
● D. Chordoid and clear cell subtypes have been assigned grade 1 tumor with low rate of recurrence
● E. The most common subtypes of meningioma are meningothelial, fibrous, and transitional
D. Chordoid and clear cell subtypes have been assigned grade 1 tumor with low rate of recurrence
On histopathology, a meningioma is found to have syncytia-like lobules of epithelioid cells with some nuclei appearing to have holes and pseudoinclusions. Cells resemble arachnoid cap
cells mimicking meningothelial hyperplasia which was found adjacent to the optic glioma. Whorls and psammoma bodies are less frequent in this tumor. What is the most likely subtype of this meningioma?
● A. Meningothelial meningioma
● B. Fibrous meningioma
● C. Transitional meningioma
● D. Psammomatous meningioma
● E. Angiomatous meningioma
A. Meningothelial meningioma
The most common locations of meningioma in brain are parasagittal accounting for 20.8%, then convexity (15.2%) and then tuberculum sellae which accounts for 12.8%, and fourth is the sphenoid wing meningioma which accounts for 11.9%. Which of the following statements is correct regarding sphenoid wing meningioma?
● A. It has three basic categories depending on the origin from the sphenoid wing
● B. Behavior and treatment of lateral sphenoid wing (pterional) meningioma are similar to convexity meningioma
● C. Middle third meningiomas are also called as alar meningioma
● D. Medial (clinoidal) meningiomas tend to encase the ICA and the MCA as well as cranial nerves in the region of the superior orbital fissure and the optic nerve. Total removal of this type is often not possible
● E. All of the above are correct
E. All of the above are correct
A patient presents with anosmia, ipsilateral optic atrophy, and contralateral papilledema (Foster Kennedy syndrome). On further evaluation, the patient is found to have apathy, abulia, urinary incontinence, and memory disturbances. Plain MRI of brain and with IV contrast found olfactory groove meningioma. Why is embolization contraindicated in these tumors?
● A. It is very difficult to embolize these tumors
● B. It gets 70 to 80% of blood supply from anterior cerebral artery which is not embolized due to risk of ophthalmic artery embolization and blindness
● C. It gets 70 to 80% of blood supply from anterior ethmoidal artery which is not embolized due to risk of ophthalmic artery embolization and blindness
● D. Embolization of perforating arteries can lead to loss of olfaction in these cases
● E. Wrong embolization poses high risk of brain stem damage
C. It gets 70 to 80% of blood supply from anterior ethmoidal artery which is not embolized due to risk of ophthalmic artery embolization and blindness
Parasagittal meningiomas are grouped based on AP direction of the superior sagittal sinus and their location along this direction. Anterior meningiomas are found between ethmoidal plate and coronal suture (44%), middle meningiomas are found
between coronal suture and lambdoidal suture accounting for 33%, while posterior meningiomas are found between lambdoid suture and torcular Herophili accounting for 23%. Which of the following statements is not correct regarding Sindou grading system for meningioma invasion of superior sagittal sinus?
● A. Type 1 meningiomas are attached to the lateral wall of sinus
● B. Type 2 meningiomas cause invasion of lateral recess, while type 3 meningiomas cause invasion of lateral wall
● C. Type 4 meningiomas cause invasion of roof of sinus
● D. In type 5, there is incomplete occlusion of sinus with contralateral wall spared
● E. In type 6, there is total sinus occlusion with invasion of contralateral wall
D. In type 5, there is incomplete occlusion of sinus with contralateral wall spared
A patient presents with gradual onset of bitemporal hemianopia, and on examination he is found to have a tumor which originated in the middle cranial fossa, and the site of origin is only 2 cm posterior to that of the olfactory groove meningioma. Which of the following statements is correct regarding these tumors and anatomy of region from where these arise?
● A. This tumor is tuberculum sellae meningioma
● B. Tuberculum sellae is the bony elevation between the chiasmatic sulcus and the sella turcica
● C. Planum sphenoidale, which is the anterior margin of charismatic sulcus, is the demarcation between anterior and middle cranial fossa
● D. Posteriorly growing tuberculum sellae meningioma can mimic pituitary macroadenoma
● E. All of the above
E. All of the above
Which of the following is an environmental risk for development of meningioma?
● A. Ionization radiation such as children exposed to ionizing radiation while treating leukemia
● B. Hormonal exposure such as in women receiving hormonal replacement therapy
● C. Mutation of NF2 tumor suppresser gene on chromosome 22q12.2
● D. Those which are associated with NF2 or NF1
● E. Mutations in AKT1, TRAF7, and SMO
A. Ionization radiation such as children exposed to ionizing radiation while treating leukemia
Meningiomas characteristically have external carotid artery feeders. What are some notable exceptions where they are fed from the ICA?
● A. Low frontal median meningiomas, for example, olfactory groove, are fed from ethmoidal branches of the ophthalmic artery
● B. Suprasellar meningiomas may also be fed by large branches of the ophthalmic arteries
● C. Parasellar meningiomas tend to be fed from the ICA while secondary vascular supply may be derived from pial branches of the anterior, middle, and posterior cerebral arteries
● D. Petroclival meningiomas are supplied via the artery of tentorium also known as artery of Bernasconi and Cassinari
● E. All of the above
E. All of the above
A patient with meningioma is symptomatic, with significant growth on serial imaging (more than 2.5 mm increase in diameter over 1 year) and marked perilesional edema. Excision was done. Postoperative images showed residual tumor with histology report showing anaplastic lesion. Hence, this patient was given postoperative radiotherapy and further treated with MRI-guided laser interstitial thermal therapy. Which of the following is incorrect regarding Simpson grading system for removal of meningioma?
● A. Grade 1 is macroscopically complete removal with excision of dural attachment and abnormal bone, not including sinus resection when involved, with recurrence rate of 9%
● B. Grade 2 is macroscopically complete removal with endothermy coagulation of dural attachment, with recurrence of 19%
● C. Grade 3 is macroscopically complete removal without resection or coagulation of dural attachment or its extradural extension, with recurrence of 29%
● D. Grade 4 is partial removal, removing tumor in situ, with recurrence rate of 44%
● E. Grade 5 is simple decompression with biopsy
A. Grade 1 is macroscopically complete removal with excision of dural attachment and abnormal bone, not including sinus resection when involved, with recurrence rate of 9%
Anterior third parasagittal meningiomas can be approached through bicoronal flap with safe division of sinus in this location while posterior to coronal suture, the sinus cannot be divided because of risk of venous drainage compromise. Meningiomas are often very bloody. What is the general principle of meningioma surgery?
● A. Early interruption of arterial blood supply of tumor
● B. Avoid excessive retraction of brain by doing internal decompression of tumor
● C. Dissecting the capsule from the brain
● D. Removal of attached bone and dura when possible
● E. All of the above
E. All of the above
Meningiomas are the most common primary intracranial tumors that arise from meningothelial cells of which of the following?
● A. Dura
● B. Arachnoid
● C. Pia
● D. Ependymal lining of ventricles
● E. Radial cells
B. Arachnoid
What are the round, microscopic, calcified structures having concentric, laminated appearance, possibly formed as a tumoricidal defense mechanism, found in meningiomas called?
● A. Psammoma bodies
● B. Mallory bodies
● C. Michaelis Gutmann bodies
● D. Schiller Duval bodies
● E. Verocay bodies
A. Psammoma bodies
Multiple meningiomas are associated with which of the following?
● A. Neurofibromatosis II
● B. Tuberous sclerosis
● C. Von Hippel Lindau syndrome
● D. Li Fraumeni syndrome
● E. Sturge Weber syndrome
A. Neurofibromatosis II
What is the grading criteria for WHO grade 2 meningiomas?
● A. 1–4 mitotic figures in 10 consecutive HPF each of 0.16 mm2
● B. 4–19 mitotic figures in 10 consecutive HPF each of 0.16 mm2
● C. 20–25 mitotic figures in 10 consecutive HPF each of 0.16 mm2
● D. 25–30 mitotic figures in 10 consecutive HPF each of 0.16 mm2
B. 4–19 mitotic figures in 10 consecutive HPF each of 0.16 mm2
What is the most common location of meningiomas?
● A. Parasagittal
● B. CP angle
● C. Olfactory groove
● D. Intrasylvian
● E. Tuberculum sellae
A. Parasagittal
