Spontaneous Intraventricular Hemorrhage Caused

by Lateral Ventricular Meningioma

-Case Report-

Yasuo MURAI, Daizo YOSHIDA, Yukio IKEDA, Akira TERAMOTO,

Toyoyuki KOJIMA, and Kyoko IKAKURA*

Departments of Neurosurgery, Nippon Medical

Critical School,
Care Medicine,
Tokyo*Departments
Nippon ofMedical School, Tokyo

Abstract

A 39-year-old female presented with acute intraventricular hemorrhage manifesting as sudden onset of
headache associated with gradually progressing somnolence and left oculomotor nerve paresis. Intra
ventricular hemorrhage occurred from a meningioma of the lateral ventricle. Computed tomography
and magnetic resonance (MR) imaging revealed intraventricular hemorrhage and a mass in the right
trigone. The tumor was totally removed. Her postoperative course was uneventful except for left
homonymous hemianopia. The histological diagnosis was fibroblastic meningioma. The MR imaging
was highly suggestive of hemorrhage from the tumor periphery.

Key words: intraventricular hemorrhage, lateral ventricle, magnetic resonance imaging,

meningioma

Introduction homonymous hemianopia, and left oculomotor

nerve paresis with intact pupillary reflex.
Certain malignant brain tumors, such as glioblasto Skull roentgenography showed an abnormal,
mas,11,17>metastatic carcinomas, 8,15,17and choroid round calcification, approximately 2.5 cm in di
plexus papillomas,13,17) are recognized as common ameter, located in the right trigone (Fig. 1). Comput
tumor sources of intracranial hemorrhage. The natu ed tomography revealed an intraventricular hemor
ral history of meningiomas is well known, but me rhage and a high-density mass in the right trigone.
ningiomas which present with intracranial hemor
rhage, such as acute intraventricular hemorrhage in
patients with lateral ventricular meningiomas, is
considered exceedingly rare.
We describe a patient with trigone meningioma
who presented with lateral ventricular hemorrhage.

Case Report

A 39-year-old female was admitted to our hospital

on October 25, 1994, after suffering sudden onset of
severe headache and vomiting followed by loss of
consciousness. Her family and medical history were
noncontributory. At admission, she was assessed as
Glasgow Coma Scale 15, but was confused. Her
blood pressure was 128/80 mmHg. Neurological
evaluation disclosed meningismus, complete left Fig. 1 Skull radiographs on admission disclosing an
abnormal, round, calcified mass located in the
Received August 16, 1995; Accepted March 6, 1996 right trigone.
 Fig. 2 Axial T,-weighted MR images revealing a large
mass in the right lateral ventricle appearing as a
moderately low-intensity area in the right
trigone, surrounded by a thin ring of high-inten
sity hematoma (left), and with homogeneous
enhancement after Gd-DTPA administration
(right). Hemorrhage from the tumor periphery
is suggested. Fig. 3 Right carotid (upper row) and left vertebral
(lower row) angiograms showing enlarged feed
ing arteries from the right anterior choroidal ar
T, and proton-weighted magnetic resonance (MR) tery and the right lateral posterior choroidal ar
imaging 4 days later showed a mass in the lateral ven tery. The venous phase shows tumor staining
tricle as a moderately low-intensity area, with in the region of the right trigone.
homogeneous enhancement after the administration
of gadolinium-diethylenetriaminepenta-acetic acid
(Gd-DTPA) (Fig. 2). T2-weighted MR imaging
showed the lesion as a high-intensity area adjacent
to the hematoma within the right lateral ventricle.
Both T1 and T2-weighted imaging showed low
intensity areas within the tumor consistent with
calcification. The periphery of the tumor was high in
tensity on T,-weighted images and low intensity on
T2-weighted images, suggesting the presence of deoxy
hemoglobin in the hematoma. These findings suggest
ed that the tumor had hemorrhaged from the periph
ery into the lateral ventricle. Cerebral angiography
failed to disclose any vascular malformation. Right
carotid and left vertebral injections showed the
Fig. 4 Photomicrograph showing the tumor specimen
tumor fed primarily by the right anterior choroidal
composed of psammoma bodies and whorl for
artery and the right lateral posterior choroidal ar
mations. The tumor cells appear flattened and
tery. Tumor staining was seen in the venous phase spindle-shaped, and the nuclei are narrow and
(Fig. 3). These neuroimaging examinations were high elongated in a storiform pattern. No cell atypia
ly suggestive of a right trigone meningioma which or mitotic figures are visible. These findings are
had spontaneously hemorrhaged from its periphery consisted with fibroblastic meningioma. HE
into the lateral ventricle. stain, x 100
On November 4, 1994, the tumor was totally re
moved from the right lateral ventricle using a middle
temporal gyrus approach through a right lateral tem ing arteries were carefully coagulated.
poroparietal craniotomy. The tumor was embedded Histological examination of the tumor specimen
in the clot, and was relatively soft and well-demarcat showed psammoma bodies and whorl formations.
ed with solid calcification on its rostral side. The feed The tumor cells were flattened and spindle-shaped,
and the nuclei were narrow and elongated. No cell
atypia or mitotic figures were observed (Fig. 4). The
histological diagnosis was fibroblastic meningioma.
Her postoperative recovery was uneventful, and
no residual intraventricular mass was found on fol
low-up examination. She was discharged on Novem
ber 30, 1994 with persistent left homonymous
hemianopia.
Discussion
Meningiomas causing intracranial hemorrhage are in
frequent,',") and hemorrhage from a lateral ventricu
lar meningioma seems to be even rarer. Only five
previous cases of a lateral ventricular meningioma
presenting with hemorrhage have been described (Ta
ble 1). 1,5,9,16)All six tumors were located in the
trigone, and only one associated with expansive in
tracranial hematoma.5) The hemorrhage affected fe
males more than males (male:female 2:4), which is a
similar predominance to that found in meningioma
in other locations.') These patients were also younger
(range 14-64 years old, mean 41 years old) than most
patients with meningiomas. Four of the tumors occu
pied the left trigone for unexplained reasons, like
nonhemorrhagic intraventricular meningiomas .3,7,9,16)
Fibroblastic meningioma is the most frequent histolo
gy seen in lateral ventricle meningiomas,') and four
of these six cases were also fibroblastic meningiomas,
whereas the others were endotheliomatous meningio
mas. Analysis of possible hemorrhagic ventricular
meningiomas with diagnosis based on hemorrhagic
or xanthochromic cerebrospinal fluid (CSF) or
meningeal signs observed following an apoplectic at
tack suggests that the frequency of bleeding from
lateral ventricular meningiomas may be greater than
previously considered.16>
The mechanism of hemorrhage associated with a
clinically silent meningioma of the lateral ventricle
has not yet been clarified, but may be similar to that
of hemorrhagic malignant neoplasms,8"5") in which
endothelial obliteration leads to necrosis, and patho
logical vascular proliferation results in newly
formed, thin-walled vessels which easily rupture.
Pituitary apoplexy occurs when the pituitary adeno
ma becomes ischemic because it has outgrown its
blood supply or compressed its own feeding vessels,
which results in necrosis and hemorrhage. The events
leading to or contributing to hemorrhage of menin
giomas may be as follows: 1) sudden disruption of
congested, tortuous vessels surrounding the menin
gioma which are less resistant to blood pressure
changes, 14)2) rupture of new vessels with softened
and thin vascular walls located in the peritumoral
Table 1 Patients presenting with he morrhage due to
a lateral ventricular meningioma
GR: good recovery, PND: persistent neurological deficit.
zone, 2,5,6,14)
3) bleeding from enlarged and weakened
feeding arteries which corresponds to demand for in
creased blood supply, 1,14)and 4) anticoagulation ther
apy or systemic disorders such as hypertension or
atherosclerosis.4,1o) The intraventricular location of
these pathological vessels presumably favors apoplec
tic rupture. A slow-growing meningioma in the ven
tricular space may be clinically silent for a longer
period than meningiomas in other regions, which
may account for the increased occurrence of apoplec
tic hemorrhage in such meningiomas as neovasculari
zation or compression of tortuous blood vessels has
more time to develop. Close histological examina
tion of specimens and neuroimaging studies can
confirm the presence of hypervascularization.
Preoperative MR imaging suggested that hemor
rhage from the tumor periphery depended on the
mechanisms described above.2)
None of the patients in Table 1 required decom
pression such as ventricular drainage or shunt em
placement for obstructive hydrocephalus, although
the hemorrhage did involve the ventricular space.
This suggests that these hemorrhages may be of
venous origin that would be insufficient to obstruct
the CSF flow. Surgical resection resulted in the death
of two patients in the 1960s.' Since then, patients
with intraventricular meningiomas treated surgically
have achieved a good recovery. Hemorrhage from a
clinically silent meningioma can influence the progno
sis of the patient, so surgical treatment appears to be
the optimal treatment for this rare disease.
References
1) Askenasy HM, Behmoaram AD: Subarachnoid
hemorrhage in meningiomas of the lateral ventricle.
Neurology 10: 484-489, 1960
 2) Budney JL, Glassaure FE, Sil R: Rapid recurrence of gery 8: 96-101, 1981
meningioma causing intracerebral hemorrhage. Surg 11) Little JR Jr, Blomquist GA, Ethier R: Intraventricu
Neurol 8: 323-325, 1977 lar hemorrhage in adults. Surg Neurol 8: 143-149,
3) Cushing H, Eisenhardt L: Meningiomas: Their Clas 1977
sification, Regional Behavior, Life History, and 12) Martinez-Lage JF, Poza M, Martinez M, Esteban
Surgical End Results. Springfield, Ill, Charles C JA, Antunez MC, Sola J: Meningiomas with hemor
Thomas, 1938, 785 pp rhagic onset. Acta Neurochir (Wien) 110: 129-132,
4) Everett BA, Kusske JA, Pribram HW: An 1991
ticoagulants and intracerebral hemorrhage from an 13) Piguet V, Tribolet ND: Choroid plexus papilloma of
unsuspected meningioma. Surg Neurol 11: 233-235, the cerebellopontine angle presenting as
1979 subarachnoid hemorrhage: Case report. Neurosur
5) Goran A, Ciminello VJ, Fisher RG: Hemorrhage gery 15: 114-116, 1984
into meningioma. Arch Neurol 13: 65-69, 1965 14) Plucino F, Lodorini S, Savoisardo M: Subarachnoid
6) Helle TL, Conley FK: Hemorrhage associated with haemorrhage and meningiomas: Report of two cases.
meningioma: A case report and review of the litera Acta Neurochir (Wien) 68: 45-53, 1983
ture. J Neurol Neurosurg Psychiatry 43: 725-729, 15) Scott M: Spontaneous intracranial hematoma caused
1980 by cerebral neoplasms: Report of eight verified cases.
7) Kobayashi S, Okazaki H, MacCarty CS: Intraven J Neurosurg 42: 338-342, 1975
tricular meningiomas. Mayo Clin Proc 46: 735-741, 16) Smith VR, Stein PS, MacCarty CS: Subarachnoid
1971 hemorrhage due to lateral ventricular meningioma.
8) Kondziolka D, Bernstein M, Resch L, Tator CH, Surg Neurol 4: 241-243, 1975
Fleming JFR, Vanderlinden RG, Schutz H: Sig 17) Wakai S, Yamakawa K, Manaka S, Takakura K:
nificance of hemorrhage into brain tumors: Spontaneous intracranial hemorrhage caused by
Clinicopathological study. J Neurosurg 67: 852-857, brain tumor: Its incidence and clinical significance.
1987 Neurosurgery 10: 437-444, 1982
9) Lang I, Jackson A, Strang FA: Intraventricular
hemorrhage caused by intraventricular meningioma:
CT appearance. AJNR Am J Neuroradiol 16: 1378
1381, 1995 - Address reprint requests to: Y. Murai, M.D., Department
10) Lazaro RP, Messer HD, Brinker RA: Intracranial of Neurosurgery, Nippon Medical School, 1-1-5
hemorrhage associated with meningioma. Neurosur Sendagi, Bunkyo-ku, Tokyo 113, Japan.