Meningioma Clinical Presentation
- Author: Georges Haddad, MD; Chief Editor: Tarakad S Ramachandran, MBBS, MBA, MPH, FAAN, FACP, FAHA, FRCP, FRCPC, FRS, LRCP, MRCP, MRCS more...
Meningiomas produce their symptoms by several mechanisms. They may cause symptoms by irritating the underlying cortex, compressing the brain or the cranial nerves, producing hyperostosis and/or invading the overlying soft tissues, or inducing vascular injuries to the brain. The signs and symptoms secondary to meningiomas may appear or become exacerbated during pregnancy but usually abate or improve in the postpartum period.
Irritation: By irritating the underlying cortex, meningiomas can cause seizures. New-onset seizures in adults justify neuroimaging (eg, MRI) to exclude the possibility of an intracranial neoplasm.
Compression: Localized or nonspecific headaches are common. Compression of the underlying brain can give rise to focal or more generalized cerebral dysfunction, as evinced by focal weakness, dysphasia, apathy, and/or somnolence.
Stereotypic symptoms: Meningiomas in specific locations may give rise to the stereotyped symptoms listed in the Table. These stereotypical symptoms are not pathognomonic of meningiomas in these locations; they may occur with other conditions or lesions. Conversely, meningiomas in these locations may remain asymptomatic or produce other unlisted symptoms. Table. Symptoms and Signs Associated with Meningiomas in Specific Locations
Table. (Open Table in a new window)
Location Symptoms Parasagittal Monoparesis of the contralateral leg Subfrontal Change in mentation, apathy or disinhibited behavior, urinary incontinence Olfactory groove Anosmia with possible ipsilateral optic atrophy and contralateral papilledema (this triad termed Kennedy-Foster syndrome) Cavernous sinus Multiple cranial nerve deficits (II, III, IV, V, VI), leading to decreased vision and diplopia with associated facial numbness Occipital lobe Contralateral hemianopsia Cerebellopontine angle Decreased hearing with possible facial weakness and facial numbness Spinal cord Localized spinal pain, Brown-Sequard (hemispinal cord) syndrome Optic nerve Exophthalmos, monocular loss of vision or blindness, ipsilateral dilated pupil that does not react to direct light stimulation but might contract on consensual light stimulation; often, monocular optic nerve swelling with optociliary shunt vessels Sphenoid wing Seizures; multiple cranial nerve palsies if the superior orbital fissure involved Tentorial May protrude within supratentorial and infratentorial compartments, producing symptoms by compressing specific structures within these 2 compartments Foramen magnum Paraparesis, sphincteric troubles, tongue atrophy associated with fasciculation
Vascular: This presentation, although rare, should be considered. Meningiomas of the skull base may narrow and even occlude important cerebral arteries, possibly presenting either as transient ischemic attack (TIA)–like episodes or as stroke.
- Intraventricular meningiomas may present with obstructive hydrocephalus.
- Meningiomas in the vicinity of the sella turcica may produce panhypopituitarism.
- Meningiomas that compress the visual pathways produce various visual field defects, depending on their location.
- Rarely, chordoid meningiomas can present with hematologic disturbances, namely Castleman syndrome.
The physical findings mirror the aforementioned symptoms and include signs due to raised intracranial pressure, involvement of cranial nerves, compression of the underlying parenchyma, and involvement of bone and subcutaneous tissues by the meningioma.
Raised intracranial pressure leads to papilledema, decreased mentation and, ultimately, to brain herniation.
Involvement of the cranial nerves may lead to anosmia, visual field defects, optic atrophy, diplopia, decreased facial sensation, facial paresis, decreased hearing, deviation of the uvula, and hemiatrophy of the tongue.
Compression of the underlying parenchyma may give rise to pyramidal signs that are exemplified by pronator drift, hyperreflexia, positive Hoffman sign, and presence of the Babinski sign. Parietal-lobe syndrome may occur if the parietal lobes are compressed.
- Compression of the dominant (usually left) parietal lobe may give rise to Gerstmann syndrome: agraphia, acalculia, right-left disorientation, and finger agnosia.
- Compression of the nondominant (usually right) parietal lobe leads to tactile and visual extinction and neglect of the contralateral side.
- Compression of the occipital lobes leads to a congruent homonymous hemianopsia.
Spinal meningiomas may give rise to a Brown-Sequard syndrome (ie, contralateral decreased pain sensation, ipsilateral weakness, decrease in position sense), sphincteric weakness and, ultimately, complete quadriparesis or paraparesis.
Trauma and viruses have been investigated as possible causative agents for development of meningiomas. However, no definitive proof has yet been found.
The role of inflammation (eg, posttraumatic insult) resulting in the upregulation of COX-2 has been investigated in the tumorogenesis of meningiomas.
On the other hand, the role of radiation in the genesis of meningiomas has been shown.
Patients subjected to low-dose irradiation for tinea capitis may develop multiple meningiomas decades later in the field of irradiation.
High-dose cranial irradiation may induce meningiomas after a short latency period.
Genetic causes have been implicated in the development of meningiomas.
The best-characterized and most common genetic alteration is the loss of the NF2 gene ( NF2) on chromosome 22q  . NF2 encodes a tumor suppressor known as merlin (or schwannomin).
Of interest, the meningioma locus is close to but probably different from the gene responsible for NF2.
Up to 60% of sporadic meningiomas were found to harbor NF2 mutations.
Other cytogenetic alterations are chromosomal loss of 1p, 3p, 6q, and 14q.
Loss of chromosome 10 is associated with increased tumor grade, shortened time to recurrence, and shortened survival.
Progression to anaplastic meningioma has been associated with involvement of chromosomal site 17q.
The following events were found to be associated with higher grades of meningiomas: loss of the tumor suppressor in lung cancer-1 gene ( TSLC-1), loss of progesterone receptors, increased expression of cyclooxygenase 2 and ornithine decarboxylase.
Monosomy of chromosome 7 is a rare cytogenetic change. However, it is frequently reported in radiation-induced meningiomas.
The invasive potential of meningioma cells seems to be reflected by a balance between the expression of matrix metalloproteinases (MMPs) and tissue inhibitors of MMPs (TIMPs).
The most consistent chromosomal abnormality isolated in meningiomas is on the long arm of chromosome 22.
IMP3, an oncofetal RNA-binding protein, has been identified as a potential biomarker in patients who have a high risk of recurrent meningioma. 
Several findings suggest an association between hormones and the risk for meningiomas, including increased incidence in women versus men and the presence of estrogen, progesterone, and androgen receptors on some of these tumors. However, the exact nature of this relationship and its implication on the management of meningiomas remain under investigation.
According to a systematic review of the literature, individuals who are overweight or obese and those who do not engage in physical activity have an increased risk for meningioma. With normal weight used as the reference group, being overweight (BMI, 25 to 29.9) was associated with a 20% increased risk for meningioma, and obesity (BMI, 30 or more) was associated with a 50% increased risk. In contrast, being overweight or obese was not related to glioma.[13, 14]
Whether cell phone use increases the risk of meningiomas (and of brain tumors in general) remains of great interest, especially with the recent tremendous increase in the use of these devices worldwide. At present, the available data do not support such an association; however, all published studies have relatively small sample sizes and a short period of follow-up.
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|Parasagittal||Monoparesis of the contralateral leg|
|Subfrontal||Change in mentation, apathy or disinhibited behavior, urinary incontinence|
|Olfactory groove||Anosmia with possible ipsilateral optic atrophy and contralateral papilledema (this triad termed Kennedy-Foster syndrome)|
|Cavernous sinus||Multiple cranial nerve deficits (II, III, IV, V, VI), leading to decreased vision and diplopia with associated facial numbness|
|Occipital lobe||Contralateral hemianopsia|
|Cerebellopontine angle||Decreased hearing with possible facial weakness and facial numbness|
|Spinal cord||Localized spinal pain, Brown-Sequard (hemispinal cord) syndrome|
|Optic nerve||Exophthalmos, monocular loss of vision or blindness, ipsilateral dilated pupil that does not react to direct light stimulation but might contract on consensual light stimulation; often, monocular optic nerve swelling with optociliary shunt vessels|
|Sphenoid wing||Seizures; multiple cranial nerve palsies if the superior orbital fissure involved|
|Tentorial||May protrude within supratentorial and infratentorial compartments, producing symptoms by compressing specific structures within these 2 compartments|
|Foramen magnum||Paraparesis, sphincteric troubles, tongue atrophy associated with fasciculation|
|WHO Grade||Histological Subtype||Histological Features|
|I||Meningothelial, fibroblastic, transitional, angiomatous, microcystic, secretory, lymphoplasmacytic metaplastic, psammomatous||Does not fulfill criteria for grade II or III|
|II (Atypical)||Chordoid, clear cell||4 or more mitotic cells per 10 hpf and/or 3 or more of the following: increased cellularity, small cells, necrosis, prominent nucleoli, sheeting, and/or brain invasion in an otherwise Grade I tumor|
|III (Anaplastic)||Papillary, rhabdoid||20 or more mitoses per 10 hpf and/or obviously malignant cytological characteristics such that tumor cell resembles carcinoma, sarcoma, or melanoma|