Radiography
Findings
In most patients, no findings are present on plain radiographic examination. Plain skull images may demonstrate calcification in meningiomas of the skull base or convexity. Meningiomas displayed reactive hyperostosis without connection to the size of the tumor. Rare osteolysis is associated with the benign and aggressive meningiomas.
Degree of Confidence
Most plain skull radiographs do not depict signs. Meningiomas en plaque have diffuse hyperostosis, more frequently observed over the sphenoid wing and pterion. This finding results in a high degree of confidence.
False Positives/Negatives
Calcification within the tumor is a considerably less frequent plain radiographic manifestation; therefore, false-negative results occur. Most patients with brain meningiomas do not undergo x-ray imaging because the diagnosis has been made directly by using CT or MRI.
Computed Tomography
Findings
CT scanning has several advantages in the imaging of meningiomas. Invasion of surrounding dura frequently provokes an osteoblastic response, causing hyperostosis.
CT is the imaging modality used best for demonstrating calcification of meningiomas (see Image 15 , 23). The CT nature of the calcification may be nodular, fine and punctate, or dense. Histologic studies have demonstrated calcification in up 45% of meningiomas.
CT is effective in showing hyperostosis, bone destruction, and erosion at the site of the dural attachment (see Images 2-4). Hyperostosis is seen in 15-20% of patients.
CT can show acute tumor hemorrhage and widened vascular grooves in the calvarium.
Homogeneous masses with attenuation similar to the surrounding brain make up 25-33% of meningiomas (see Images 5-6). The remainder are hyperattenuating compared with the brain. Meningiomas can exhibit extensive edema. Inhomogeneous enhancement can result due necrosis or rare hemorrhage. Edema is absent in 50% of patients because of slow growth, but it may be extensive. Edema predominantly affects white matter, and it resembles fingers of low attenuation units.
Contrast-enhanced CT displays moderate-to-strong homogeneous enhancement in most tumors (see Images 7-8). Steinhoff et al observed a nodular blush in 97%, a mixed inhomogeneous blush in 0.5%, and a ring blush in 1.5%. In a study by Naidich of 136 patients, tumor blush was nodular and nearly homogeneous in 70% of patients, inhomogeneous in 24% of patients, and ringlike in 2% of patients (see Images 2-4).
Peripheral cysts resulting from trapped CSF can be present (see Image 1).
Cystic components of the meningiomas may be present inside the tumor or between the tumor and the adjacent brain, so-called trapped CSF (see Image 2).
Degree of Confidence
Meningiomas are well-circumscribed peripheral or falcine masses that deform the brain. About 90% of meningiomas are demonstrated on CT. The main role of CT, as opposed to other imaging modalities, is the demonstration of adjacent bone changes and calcification within the lesion.
Atypical CT features are the primary reason for preoperative misdiagnosis. Posterior fossa meningiomas may be missed by CT, as will be some en plaque lesions. CT can fail to demonstrate cystic changes in intracranial meningiomas. CT features, such as irregular areas of nonenhancing mass and well-defined regions of persistent low attenuation, are the reason for preoperative misdiagnosis.
False Positives/Negatives
False-negative findings can occur with cystic changes in brain meningiomas. False-positive findings can occur with large dural calcification, which can mimic the disease.
Magnetic Resonance Imaging
Findings
An important advantage of MRI in the imaging of meningiomas is its superior resolution of different types of soft tissue, and its multiplanar capability,, MR angio, and 3D reconstrucction. (see Images 24-25). MRI can demonstrate tumor vascularity, arterial encasement, venous sinus invasion, and the relationship between the tumor and surrounding structures. It is particularly advantageous in depicting the juxtasellar area and the posterior fossa and in demonstrating the rare presence of disseminated disease via the CSF. The multiplanar capability is often the best means to visualize the broad contact of tumors to the meninges, tumor capsules, and meningeal contrast enhancement adjacent to the tumor (see Images 9-13).
On nonenhanced T1-weighted images, most meningiomas have no signal intensity difference compared with cortical gray matter. Fibromatous meningiomas may be more hypointense than the cerebral cortex. Meningiomas are hyperintense on T2-weighted images (see Images 11-13). T2-images also show the extent of edema. Multiple meningioma occurred between 5-40% (see Images 26-27).
On MRI and CT, meningiomas exhibit the same enhancement appearance after the injection of contrast medium. Intense enhancement is seen in 85% of tumors.
A ring appearance may represent a capsule (see Images 9-10).
Meningiomas have a collar of thickened, enhancing tissue that surrounds their dural attachment; this is also known as a dural tail. This sign represents thickened dura which may be either reactive or neoplastic. A dural tail occurs in approximately 65% of meningiomas and 15% of other peripheral tumors; therefore, it is a good predictor of lesion identity. While this radiographic feature is not specific for meningiomas, it is highly suggestive of the diagnosis.
Histologic subtypes may have different MRI appearances, but this does not suffice for a histologic diagnosis by using MRI.
Hyperintensity on T2-weighted images indicates soft tumor consistency and microhypervascularity. This is seen more often in aggressive, angioblastic, or meningothelial tumors. T2-weighted signal intensity is best correlated with both the histology and consistency of the meningioma. Generally, low-intensity portions of the tumor on T2-weighted images indicate a more fibrous and harder character (eg, fibroblastic meningiomas), whereas higher-intensity portions indicate a softer character (eg, angioblastic tumor).
A typical meningioma is a homogeneous, markedly enhancing extraaxial mass it may show meningeal cysts, ring enhancement, fatty transformation, and en plaque morphology. Malignant meningioma may invade the calvarium and cerebral parenchyma 1%).
Most of the meningiomas can be diagnosed by MRI, however 1HMRSI can yield more informative about metabolic materials changes in tumor cells. MRS reveals lactate in embolized areas of the meningioma immediately after embolization. Lipids are not observed before the 3rd day after embolization and are always associated with avascular and soft tissue at the time of surgery.
If gadolinium enhancement is used, keep in mind the following warning. Gadolinium-based contrast agents (gadopentetate dimeglumine [Magnevist], gadobenate dimeglumine [MultiHance], gadodiamide [Omniscan], gadoversetamide [OptiMARK], gadoteridol [ProHance]) have recently been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). For more information, see the eMedicine topic Nephrogenic Fibrosing Dermopathy. The disease has occurred in patients with moderate to end-stage renal disease after being given a gadolinium-based contrast agent to enhance MRI or MRA scans. As of late December 2006, the FDA had received reports of 90 such cases. Worldwide, over 200 cases have been reported, according to the FDA. NSF/NFD is a debilitating and sometimes fatal disease. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin;yellowspots on the whites of the eyes; joint stiffness with trouble moving or straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness. For more information, see the FDA Public Health Advisory or Medscape.
Degree of Confidence
In general, the sensitivity and specificity of MRI are high in the diagnosis of meningiomas. MRI has proved to be superior in delineation of the tumor and its relation with surrounding structures. MRI is unreliable for recognition of tumor calcification. Acute hemorrhage is often difficult to image on MRI.
False Positives/Negatives
False-negative findings of tumor calcium must be considered. Delineation of acute hemorrhage into tumor with conventional sequences is a disadvantage of MRI and may generate false findings.
Ultrasonography
Findings
The location of intratumoral hemorrhage, cystic changes inside or outside of the tumor mass, calcifications, invasion of the parenchyma by malignant meningiomas, and lobulated or multilobulated masses is demonstrable only with intraoperative ultrasonography.
Angiography
Findings
Although magnetic resonance angiography (MRA and MRV) have decreased the role of classical angiography, the latter remains a powerful tool for embolization and planning surgery. Angiography is still indispensable if embolization of the tumor is deemed necessary.
Meningiomas are supplied by meningeal branches of the internal and external carotid artery. Basal meningiomas of the anterior and middle cranial fossa and meningiomas of the wings of the sphenoid bone commonly are supplied by the internal carotid artery. Other supratentorial meningiomas are supplied by the internal and external carotid arteries.
Tumors that arise along the falx, the sphenoidal ridge, and the convexity are supplied by the middle meningeal artery. Falcine meningiomas can be supplied additionally by the anterior meningeal artery. Parasellar and tentorium tumors are supplied by the hypophyseal meningeal artery. Direct meningeal arteries from the cavernous sinus can supply meningiomas of the middle cranial fossa. Intraventricular tumors are supplied by anterior and posterior choroidal arteries.
External carotid and vertebral branches supply tumors of the posterior fossa. Large meningiomas can be supplied by pia vessels around the tumor.
Meningeal arteries penetrate to a meningioma through its dural attachment with inside branches radially distributed like sunrays. Homogeneous sharp tumor staining is seen early and remains late. Usually, meningiomas do not exhibit drainage veins, but angioblastic types can display it.
In summary, angiography is useful in delineating the blood supply of the external versus internal carotid arteries and can show encasement of intracranial vessels. Angiography demonstrates an arterial map for preoperative embolization (see Image 14).
Recently, as an alternative to traditional catheter angiography, 3-dimensional CT angiography may depict the relationship between skull base meningiomas and neighboring bony and vascular structures clearly, quickly, and with minimal risk to the patient.
Degree of Confidence
Angiography has a high degree of confidence in recognizing the arterial source of the meningioma. Tumor feeding can be identified with a low rate of false-positive and/or false-negative findings.
False Positives/Negatives
Arterial findings have a high sensitivity and specificity in the diagnosis of meningiomas. Angiography shows an arterial map for preoperative embolization with a low false-finding rate.
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Further Reading
Keywords
meningothelioma, leptomeningioma, mesothelioma of the dura mater
