Cavernous Angioma of the Dural Convexity Mimicking a Meningioma

Case Report

Austin Neurosurg Open Access. 2014;1(4): 1019.

Cavernous Angioma of the Dural Convexity Mimicking a Meningioma

Kashlan ON1, Sack JA2 and Ramnath S1*

1Department of Neurosurgery, University of Michigan, USA

2Department of Neurosurgery, University of California-San Diego, USA

*Corresponding author: Ramnath S, Department of Neurosurgery, University of Michigan, 1500 E. Medical Center Dr., Room 3552 TC, Ann Arbor, MI 48109-5338, USA

Received: May 29, 2014; Accepted: August 08, 2014; Published: August 12, 2014

Abstract

Background: Dural-based cavernous angiomas represent a small proportion of all intracranial cavernous angiomas. Moreover even though these lesions have a similar histological appearance as their intra-axial counterparts, they have different imaging characteristics. This fact leads to frequent misdiagnosis via imaging. We present a case of a dural-based occipital convexity cavernous angioma thought to be a meningioma preoperatively followed by a review of the recent literature.

Case Presentation: A 56-year-old man with a known left occipital mass presented with a recent history of visual scintillations. Imaging showed an enhancing mass felt to represent a meningioma. At the time of his operation, a red to purple appearing extra cerebral mass was removed, and its histology was consistent with cavernous angioma.

Conclusions: It is difficult to distinguish an isolated dural based convexity cavernous angioma from a meningioma based on radiology. This case report highlights the importance of keeping both etiologies in the differential diagnosis of a dural-based lesion.

Keywords: Cavernous angioma; Cavernoma; Cavernous malformation; Meningioma mimicker

Abbreviations

CT: Computed Tomography; MRI: Magnetic Resonance Imaging

Case Presentation

A 56-year-old man presented with a 6-month history of episodic visual scintillations of bright lights in the right visual field. His neurologic findings were normal, with no visual field deficits. A left occipital mass had been found incidentally seven years earlier on a CT scan performed at an outside hospital following a closed head injury. Repeat CT and MRI scans showed an enhancing mass in the left occipital convexity measuring 2.5 cm X 3.2 cm X 3cm as shown in Figures 1 & 2. His non-contrast CT scan report from seven years earlier described a 1.8cm X 2cm mass. Preoperatively, this mass was thought to be an enlarging meningioma. At craniotomy, it was noted that there was no erosion or hyperostosis of the overlying skull. After incising the dura, a dense, red mass was easily dissected off the cortical surface with no invasion of the brain. The mass histologically showed numerous vascular channels divided by various thicknesses of connective tissue septae typical of cavernous angiomas as shown in Figure 3. The patient's postoperative course was uneventful and his imaging demonstrated a gross total resection. At his 1 year postoperative visit, the patient had no evidence of recurrence or development of other lesions.

Figure 1: Non-contrast head CT demonstrating left parieto-occipital lesion.






Figure 1: Non-contrast head CT demonstrating left parieto-occipital lesion.

Figure 2: Pre-operative brain MRI with (a) pre-contrast T1, (b) post-contrast T1, (c) FLAIR, and (d) diffusion-weighted axial images.






Figure 2:  Pre-operative brain MRI with (a) pre-contrast T1, (b) post-contrast T1, (c) FLAIR, and (d) diffusion-weighted axial images.

Figure 3: Pathology of lesion demonstrating a findings characteristic of a cavernous angioma.






Figure 3:   Pathology of lesion demonstrating a findings characteristic of a cavernous angioma.

Discussion/Conclusion

Cavernous angiomas are vascular malformations composed of enlarged sinusoidal vessels arranged in clusters, enclosed by a thin endothelial wall without interposed tissue within. They lack smooth muscle, an elastic lamina, and are sometimes calcified or ossified. The lumina can be thrombosed and show attempts at re-canalization. The term "cavernous angioma" has been used interchangeably with "cavernous hemangioma," "cavernous malformation," or "cavernoma". These lesions are accepted as vascular abnormalities rather than as neoplastic processes [1]. Their origin remains obscure [2].

Cavernous angiomas are most commonly seen within the brain parenchyma. However, they are also found intraspinally, or arising from the dura as illustrated by this case report. Extra-axial dural-based cavernous angiomas are extremely rare when compared to their intra-axial counterparts [3]. Published data from Lewis et al. identified two types of dural cavernous angiomas [2]. The first, which is more common, includes ones that present in the dura of the middle fossa usually in vicinity of the cavernous sinus. The second type consists of dural-based lesions elsewhere such as the convexity, cerebral and cerebellar falx, the tentorium, posterior fossa, and the floor of the anterior fossa [2,4]. The separation of the two types is important due to the differences in the patient population affected and the more aggressive clinical course of dural-based cavernous angiomas in the middle fossa [2].

To better understand these rare lesions, a literature review was performed searching for case reports published after 1992 dealing with dural-based cavernous angiomas occurring outside the middle cranial fossa [1,4,6-9,11-25]. These results were compared to published data from the Lewis et al manuscript, which included a review of the literature published prior to 1992 [2]. A summary of the cases found is shown in Table I. As was noted by Lewis et al, headache was the most common chief complaint in our review, occurring in 12 of the 22 patients; however, this prevalence is lower than the 75% (9 of 12 patients) seen in their paper [2]. Moreover, the cerebral convexities continue to be the most common area affected by dural-based cavernous angiomas outside the middle cranial fossa occurring in 10 out of 22 patients (45.5%). Even though noted in the literature to have no gender preference, our review indicated that there may be a male predominance with 16 of the 22 cases affecting males; this is in contrast to Lewis et al where only 10 out of 18 of patients affected were male [2]. If the data are combined, 26 out of the 40 total cases evaluated (65%) occurred in males, which strengthen the idea of a possible male predominance in patients affected with dural-based cavernous angiomas occurring outside the middle fossa. With regards to prognosis, these lesions are amenable to gross total resection and do not have a propensity to recur [4].

Table 1: Summary of 22 Cases of Dural-Based Cavernous Angiomas outside the Middle Fossa since 1992.




  

    
Case

    
Chief Complaint

    
Age

    
Sex

    
Location

    
MRI T1 Appearance

    
MRI T2 Appearance

    
MRI Enhancement

    
CT Appearance

    
CT Enhancement

    
Angiogram

  

  

    
Tsutsumi S, et al.4 

      
 

    
Headache 

    
43 

    
M 

    
Cerebellar 

    
Hypointense 

    
Mixed 

    
Yes 

    
Isodense 

    
----- 

    
----- 

  

  

    
Zeng,    X et al.13 

      
 

    
Seizures 

    
37 

    
F 

    
Falx 

    
----- 

    
Hyperintense 

    
Yes 

    
----- 

    
----- 

    
----- 

  

  

    
Melone    AG et al.14 

      
 

    
Episode of confusion 

    
58 

    
M 

    
Cerebellar falx 

    
Isointense 

    
Hyperintense 

    
Yes 

    
Hyperdense 

    
----- 

    
----- 

  

  

    
Sakakibara    Y et al.15 

      
 

    
Left face and upper extremity numbness 

      
 

    
59 

    
M 

    
Convexity 

    
Isointense 

    
----- 

    
Yes 

    
----- 

    
----- 

    
Pooling of medium in late venous phase 

  

  

    
Gutiérrez-González    R et al.16 

      
 

    
Anosmia 

    
47 

    
F 

    
Anterior cranial fossa floor 

    
Hypointense 

    
Hyperintense 

    
Yes 

    
----- 

    
----- 

    
----- 

  

  

    
Ito M et al.17 

      
 

    
Incidental finding 

    
47 

    
M 

    
Cerebellar falx 

    
Isointense 

    
Hyperintense 

    
Yes 

    
Hyperdense 

    
----- 

    
----- 

  

  

    
Joshi V et al.11 

      
 

    
Headache 

    
15 

    
M 

    
Convexity 

    
Hypointense 

    
Mixed 

    
Yes 

    
Hyperdense 

    
Yes 

    
----- 

  

  

    
Mori H et al.18 

      
 

    
Occipital headache, intermittent left field scintillations 

      
 

    
15 

    
M 

    
Tentorium 

    
Mixed 

    
Mixed 

    
Yes 

    
----- 

    
----- 

    
Hypervascular with pooling of contrast medium in late venous phase 

  

  

    
Hwang SW et al.9 

    
Vertigo, headaches 

      
 

      
 

    
61 

    
M 

    
Convexity 

    
Isointense 

    
Hyperintense 

    
Yes 

    
----- 

    
----- 

    
----- 

  

  

    
Boockvar JA et al.19 

      
 

    
Headaches, decreasing visual acuity 

    
31 

    
M 

    
Superior sagittal sinus (superior to torcula) 

      
 

    
----- 

    
----- 

    
Yes 

    
----- 

    
----- 

    
Avascular mass 

  

  

    
Biondi    A et al.1 

      
 

    
Ophthalmic migraine 

    
63 

    
F 

    
Falx 

    
Hypointense 

    
Hyperintense 

    
Yes 

    
----- 

    
Yes 

    
----- 

  

  

    
Shen WC et al.12 

      
 

    
Headaches, facial pain 

    
18 

    
F 

    
Convexity 

    
Isointense 

    
Hyperintense 

    
Yes 

    
----- 

    
----- 

    
Tumor blush 

  

  

    
Hyodo A et al.8 

    
Altered mental status 

      
 

    
77 

    
M 

    
Convexity 

    
Hyperintense 

    
Hypointense 

    
Minimal 

    
----- 

    
----- 

    
----- 

  

  

    
Rushton    AW et al.6 

      
 

    
Headaches, vomiting, blurred vision 

    
5 

    
M 

    
Cerebellar 

    
----- 

    
----- 

    
----- 

    
Mixed 

    
----- 

    
----- 

  

  

    
Lee AG et al.20 

      
 

    
Blurred vision 

    
53 

    
M 

    
Tentorium 

    
Mixed 

    
----- 

    
Yes 

    
----- 

    
----- 

    
Hypervascular 

  

  

    
Hsiang    JN et al.21 

      
 

    
Headaches, vomiting 

    
5 

    
M 

    
Cerebellar 

    
----- 

    
----- 

    
----- 

    
Hyperdense 

    
Yes 

    
----- 

  

  

    
Suzuki    K et al.22 

      
 

    
Headaches, vomiting, loss of consciousness 

      
 

    
78 

    
F 

    
Convexity 

    
----- 

    
----- 

    
----- 

    
Subdural hematoma 

    
----- 

    
----- 

  

  

    
Vogler    R et al.7 

      
 

    
Headaches, seizures, left visual blurring 

      
 

    
35 

    
M 

    
Convexity 

    
Mixed 

    
Mixed 

    
Yes 

    
----- 

    
Minimal 

    
Negative 

  

  

    
Revuelta    R et al.23 

      
 

    
Headaches 

    
66 

    
M 

    
Convexity 

    
Isointense 

    
Hyperintense 

    
----- 

    
----- 

    
Yes 

    
----- 

  

  

    
Goel A et al.24 

      
 

    
Episodic ataxia of left limbs 

      
 

    
60 

    
M 

    
Cerebellar 

    
----- 

    
----- 

    
----- 

    
Hyperdense 

    
Yes 

    
Vascular lesion fed by occipital artery 

  

  

    
Perry    JR et al.25 

      
 

    
Seizures 

    
77 

    
F 

    
Convexity 

    
----- 

    
----- 

    
----- 

    
----- 

    
Yes 

    
----- 

  

  

    
 

    
Right visual scintillations 

    
56 

    
M 

    
Convexity 

    
Hypointense 

    
Hyperintense 

    
Yes 

    
Hyperdense 

    
----- 

    
----- 

  









Table 1:  Summary of 22 Cases of Dural-Based Cavernous Angiomas outside the Middle Fossa since 1992.

Even though histologically similar to intraparenchymal cavernous angiomas, dural-based cavernous angiomas have a completely different appearance on CT, MRI and angiography [5]. This fact makes accurate pre-operative diagnosis very difficult, as imaging findings can be varied and resemble meningiomas. On CT, dural-based cavernous angiomas outside the middle fossa are mostly hyperdense, but could be isodense. At times, they may be calcified [6-8]. They also may cause either bony erosion or hyperostosis of the overlying skull [6,9]. They almost always enhance on CT. On MRI, these lesions are usually either isointense or hypointense on T1 sequences. Much like on CT, they also usually enhance on MRI. Based on our review, dural-based cavernous angiomas outside the middle fossa are hyperintense on T2 sequences 64.3% of the time (9 out of 14 patients) and were not seen to be isointense in any of the cases. This is different from meningiomas, which are isointense almost half the time [10]. However, meningiomas can be hyperintense on T2 sequences as well so having a T2 hyperintense lesion is far from specific for dural-based cavernous angioma outside the middle fossa. Interestingly, these lesions can have dural tails like meningiomas, and may also cause significant perilesional edema [11,12]. Angiography can show a tumor blush, hypervascularity, an avascular mass, can be completely negative, or demonstrate pooling of medium during the late venous phase.

As is apparent, there is no definitive differentiation that can be made between dural cavernous angiomas and meningiomas with regards to imaging. Therefore, it is important for the neurosurgeon to keep this entity among the differentials when planning resection of a lesion that seems to be a meningioma.

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Citation: Kashlan ON, Sack JA and Ramnath S. Cavernous Angioma of the Dural Convexity Mimicking a Meningioma. Austin Neurosurg Open Access. 2014;1(4): 1019.