Figure 1
Magnetic resonance venography (MRV)
Clinical History
A 30-year-old female patient presented with worsening headaches for the last three years.
Imaging Findings
A large lesion from the falcotentorial junction along the straight sinus (Fig. 1). There is displacement of the Galenic venous system contralaterally (Fig. 2, 3). Angiogram showing artery of Barniskoni which is pathognomonic for falcotentorial meningioma (Fig. 4).
Imaging features representing Type IV falcotentorial meningioma.
Imaging features representing Type IV falcotentorial meningioma.
Discussion
Background: Falcotentorial meningiomas are the tumours arising at the junction of dural folds in which straight sinus and both torcular and arachnoid granulations are embedded [1], projecting either anteriorly, inferiorly or posteriorly [2, 3, 4]. They are more common in women, regarded as a subgroup of tentorial meningiomas and extremely rare, constituting only 0.3% to 1.1% of all intracranial meningiomas [5, 6]. Further classified by neurosurgeons based on the surgical approach and vascular encasement and displacement by the tumour. Usually classified as:
Type I: Arises above the junction of the vein of Galen with the straight sinus, displaces the great vein of Galen and the internal cerebral veins inferiorly.
Type II: Arises from the undersurface of tentorium near the junction of the vein of Galen with the straight sinus, results in superior displacement of the Galenic venous system.
Type III: It is lateralised as it arises from the paramedian tentorial incisura. The great vein of Galen lies medial to the tumour.
Type IV: Arises from the FT junction along the straight sinus, causes contralateral displacement of the vein of Galen [7, 8].
MRI characteristics are the same as those of other meningiomas. Cerebral angiograms show they usually derive supply from internal carotid artery including the mengio-hypophyseal branch [9].
Clinical Perspective: Insidious onset of symptoms. The patient commonly presents with headache, papilloedema, gait disturbances and altered mental status. The pathophysiology is raised intracranial pressure and hydrocephalus [10].
Imaging Perspective: Imaging is needed to localise the origin of the lesion to convey the relationship of the lesion to the vein of Galen to the surgeons so it can guide them regarding the approach. Apart from conventional imaging features of meningioma, angiogram is essential to help localise the lesion, such as in our case, where its supply was from the artery of Barniskoni.
Outcome: Complete resection is the mainstay of therapy. Subtotal resection may be considered when the tumour invades or adheres to adjacent structures. Subtotal resection requires a close follow up. Reoperation may be required if the residual tumour regrows [11].
Thorough preoperative neuroimaging and knowledge of the nuances of the surgical technique are the key to an excellent outcome [12].
Our patient’s tumour was resected completely.
Take Home Message, Teaching Points:
Localisation is important as it helps the neurosurgeon with determining the appropriate approach.
Type I: Arises above the junction of the vein of Galen with the straight sinus, displaces the great vein of Galen and the internal cerebral veins inferiorly.
Type II: Arises from the undersurface of tentorium near the junction of the vein of Galen with the straight sinus, results in superior displacement of the Galenic venous system.
Type III: It is lateralised as it arises from the paramedian tentorial incisura. The great vein of Galen lies medial to the tumour.
Type IV: Arises from the FT junction along the straight sinus, causes contralateral displacement of the vein of Galen [7, 8].
MRI characteristics are the same as those of other meningiomas. Cerebral angiograms show they usually derive supply from internal carotid artery including the mengio-hypophyseal branch [9].
Clinical Perspective: Insidious onset of symptoms. The patient commonly presents with headache, papilloedema, gait disturbances and altered mental status. The pathophysiology is raised intracranial pressure and hydrocephalus [10].
Imaging Perspective: Imaging is needed to localise the origin of the lesion to convey the relationship of the lesion to the vein of Galen to the surgeons so it can guide them regarding the approach. Apart from conventional imaging features of meningioma, angiogram is essential to help localise the lesion, such as in our case, where its supply was from the artery of Barniskoni.
Outcome: Complete resection is the mainstay of therapy. Subtotal resection may be considered when the tumour invades or adheres to adjacent structures. Subtotal resection requires a close follow up. Reoperation may be required if the residual tumour regrows [11].
Thorough preoperative neuroimaging and knowledge of the nuances of the surgical technique are the key to an excellent outcome [12].
Our patient’s tumour was resected completely.
Take Home Message, Teaching Points:
Localisation is important as it helps the neurosurgeon with determining the appropriate approach.
Differential Diagnosis List
Falcotentorial meningioma
• Pineal gland neoplastic lesion
• Tentorial meningioma
• Velum interpositum meningioma
Final Diagnosis
Falcotentorial meningioma
References
[1] Asari S1, Maeshiro T, Tomita S, Kawauchi M, Yabuno N, Kinugasa K, Ohmoto T (1995) Meningiomas arising from the falcotentorial junction. Clinical features, neuroimaging studies, and surgical treatment. J Neurosurg 82(5):726-38 (PMID: 7714596)
[2] Nowak A, Dziedzic T, Czernicki T, Kunert P, Marchel A. (2014) Falcotentorial and velum interpositum meningiomas: two distinct entities of the pineal region. Neurol Neurochir Pol 48(6):397-402 (PMID: 25482250)
[3] Goto T, Ohata K, Morino M, Takami T, Tsuyuguchi N, Nishio A, Hara M (2006) Falcotentorial meningioma: surgical outcome in 14 patients. Journal of neurosurgery. J Neurosurg 104(1):47-53 (PMID: 16509146)
[4] Papo I, Salvolini U (1974) Meningiomas of the free margin of the tentorium developing in the pineal region. Neuroradiology. Neuroradiology 7(4):237-43 (PMID: 4414635)
[5] Bassiouni H, Asgari S, König HJ, Stolke D (2008) Meningiomas of the falcotentorial junction: selection of the surgical approach according to the tumor type. Surgical neurology. Surg Neurolol 69(4):339-49 (PMID: 17707469)
[6] Bassiouni H, Hunold A, Asgari S, Stolke D (2004) Tentorial meningiomas: clinical results in 81 patients treated microsurgically. Neurosurgery 55(1):108-16 (PMID: 15214979)
[7] Konovalov AN, Spallone A, Pitzkhelauri DI (1996) Meningioma of the pineal region: a surgical series of 10 cases. Journal of neurosurgery. J Neurosurg 85(4):586-90 (PMID: 8814160)
[8] Herrmann HD, Winkler D, Westphal M (1992) Treatment of tumours of the pineal region and posterior part of the third ventricle. Acta Neurochir (Wien) 116(2-4):137-46 (PMID: 1502947)
[9] Asari S, Yabuno N, Ohmoto T (1994) Magnetic resonance characteristics of meningiomas arising from the falcotentorial junction. Comput Med Imaging Graph 18(3):181-5 (PMID: 8025884)
[10] Konovalov AN, Spallone A, Pitzkhelauri DI (1996) Meningioma of the pineal region: a surgical series of 10 cases. J Neurosurg 85(4):586-90 (PMID: 8814160)
[11] de la Lama A, Lobato RD, Gomez PA, Boto GR, Lagares A, Alén JF (2001) Tentorial meningiomas. A study of 14 surgically verified cases. Neurocirugia (Astur) 12(2):133-42 (PMID: 11706442)
[12] Quiñones-Hinojosa A, Chang EF, Chaichana KL, McDermott MW (2009) Surgical considerations in the management of falcotentorial meningiomas: advantages of the bilateral occipital transtentorial/transfalcine craniotomy for large tumors. Neurosurgery 64(5 Suppl 2):260-8 (PMID: 19287325)
Case information
| URL: | https://eurorad.org/case/14971 |
| DOI: | 10.1594/EURORAD/CASE.14971 |
| ISSN: | 1563-4086 |
License
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Figure 2
Sagital T2 weighted images
Figure 3
Sagital T1 weighted images-post intravenous gadolinium injection
Magnetic resonance venography (MRV)
MRV image: Blue arrow indicating Vein of Galen.
yellow arrow indicating straight sinus.
M fatima , A alvi department of rdaiology Aga Khan University hospital karachi
M fatima , A alvi department of rdaiology Aga Khan University hospital karachi
MRV image: Blue arrow indicating Vein of Galen.
yellow arrow indicating straight sinus.
M fatima , A alvi department of rdaiology Aga Khan University hospital karachi
M fatima , A alvi department of rdaiology Aga Khan University hospital karachi
MRV image: Pink arrow indicating internal cerebral vein.
M fatima , A alvi department of rdaiology Aga Khan University hospital karachi
M fatima , A alvi department of rdaiology Aga Khan University hospital karachi
Sagital T2 weighted images
Isointense lesion arising from the pineal region with supra and infratentorial extension.
M Fatima, A Alvi department of radiology Aga Khan University hospital karachi
M Fatima, A Alvi department of radiology Aga Khan University hospital karachi
Isointense lesion arising from the pineal region with supra and infratentorial extension.
M Fatima, A Alvi department of radiology Aga Khan University hospital karachi
M Fatima, A Alvi department of radiology Aga Khan University hospital karachi
Isointense lesion arising from the pineal region with supra and infratentorial extension.
M Fatima, A Alvi department of radiology Aga Khan University hospital karachi
M Fatima, A Alvi department of radiology Aga Khan University hospital karachi
Sagital T1 weighted images-post intravenous gadolinium injection
Sagittal post contrast TIWI showing intensly enhancing mass lesion along the straight sinus.
M Fatima, A Alvi Department of radiolgy Aga Khan University Hospital karachi
M Fatima, A Alvi Department of radiolgy Aga Khan University Hospital karachi
Sagittal post contrast TIWI showing intensly enhancing mass lesion along the straight sinus.
M Fatima, A Alvi Department of radiolgy Aga Khan University Hospital karachi
M Fatima, A Alvi Department of radiolgy Aga Khan University Hospital karachi
Sagittal post contrast TIWI showing intensly enhancing mass lesion along the straight sinus.
M Fatima, A Alvi Department of radiolgy Aga Khan University Hospital karachi
M Fatima, A Alvi Department of radiolgy Aga Khan University Hospital karachi
