Elsevier

World Neurosurgery

Volume 92, August 2016, Pages 588.e17-588.e21
World Neurosurgery

Case Report
Intramedullary Recurrence of a Thoracic Meningioma—Presentation of an Unusual Case and Review of the Literature

https://doi.org/10.1016/j.wneu.2016.01.073Get rights and content

Background

Spinal meningiomas are typically extra-axial, slow-growing, benign tumors that arise from the arachnoid cap cells. Intramedullary spinal meningiomas are exceedingly rare with few cases reported in the literature.

Case Description

A 64-year-old man with a history of grade I thoracic meningioma at the T4 level resected initially in 1989 and who required reoperation in 2013 for intradural, extramedullary recurrence of tumor presented again in 2015 with gait difficulty. Magnetic resonance imaging revealed a soft tissue mass at the T3 to T4 levels on the left side of the canal that was mildly enhancing on T1 contrasted sequences. The patient was taken to the operating room, where a purely intramedullary recurrence was discovered without extramedullary extension or a dural-based attachment. The intramedullary tumor was completely resected, and postoperatively the patient recovered well and was at his neurologic baseline. The patient ultimately underwent proton beam radiotherapy because this tumor, although benign, had recurred twice.

Conclusions

Intramedullary spinal meningiomas, particularly intramedullary low-grade recurrence of a previously extramedullary tumor, are rare phenomena. Although the pathogenic mechanisms are not well understood, intramedullary recurrence as described in this patient may reflect extrinsic factors related to prior surgical resections in addition to histologic progression. When operating on recurrent extramedullary lesions, aggressive arachnoid dissection may predispose patients to unusual patterns of recurrence.

Section snippets

Background

Spinal meningiomas are typically extra-axial, slow-growing, benign tumors that arise from the arachnoid cap cells. They represent ∼25% of primary spinal cord tumors and commonly present in middle-aged women.1 Complete surgical resection is usually curative, with recurrence rates between 3% and 15% reported in the literature.2, 3, 4 They usually arise in the midthoracic region and classically grow intradurally, but also extramedullary, to compress the spinal cord and nerve roots. Intramedullary

Case Description

The patient is a 64-year-old man with a history of World Health Organization (WHO) grade I thoracic meningioma at the T4 level resected initially in 1989 and who required reoperation in 2013 for intradural, extramedullary recurrence of tumor that clinically manifested as left lower-extremity weakness and gait dysfunction. The patient recovered well from the second operation but presented again in 2015 with gait difficulty. On physical examination, the patient had a stable T4 sensory level and

Discussion

The current patient had previously undergone 2 resections of an extramedullary thoracic meningioma at the same level. Within 2 years after his second surgery, he developed an intramedullary recurrence of the meningioma at the same level. Intramedullary spinal cord meningiomas are an extremely rare entity, with only 12 reported cases found on our literature search (Table 1).7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 The median age of reported intramedullary spinal meningiomas was 47, and 58% of

Conclusion

In conclusion, intramedullary spinal meningiomas, particularly intramedullary low-grade recurrence of a previously extramedullary tumor, are rare phenomena. Although the pathogenic mechanisms of intramedullary meningioma development are not well understood, intramedullary recurrence as described in this patient may reflect extrinsic factors related to prior surgical resections in addition to histologic progression. When operating on recurrent extramedullary lesions, aggressive arachnoid

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    Conflict of interest statement: The authors have no financial disclosures or conflicts of interest to report.

    Matthew A. Piazza and Ashwin G. Ramayya contributed equally to this manuscript.

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