Giant Meningioma Fed by the Anterior Choroidal Artery: Successful Removal Following Embolization —

Hirofumi Takehisa

Case Report—

OYAMA,

Satoshi

KINOMOTO*,

NODA*,

Shigeru

and

Makoto

MIYACHI,

Yasukazu

NEGORO,

Naoto

KUWAYAMA

KAJITA

Department of Neurosurgery, Nagoya University School of Medicine, Nagoya; *Department

of Neurosurgery

, Nishio City Hospital,

Nishio, Aichi

Abstract A 53-year-old

female

hemianopsia,

and dressing

huge

mass

markedly

vascularity bolized

was admitted enhanced

of the tumor with

was totally

was discharged Key words:

left sensory

Computed

tomography

in and around

mainly

microfibrillar removed

with apathy,

apraxia.

the right

fed by the right after

superselective

with low blood

loss.

The histological

without

neurological

meningioma,

deficit,

trigone,

except

embolization,

Introduction Meningioma may occur in the lateral ven tricles. '°Z,s°6,s,"°'2)Large, richly vascular meningioma, in particular, are frequently complicated by postoperative hemorrhage. Here, we report a case of a huge, richly vascular meningioma in the right trigone which was easily removed after preoperative embolization.

Case

Report

A 53-year-old female presented with general fatigue and left hemihypesthesia. On admission, she was apathetic with minimum left hemiparesis, left homonymous hemianopsia, and dressing apraxia, but no signs of increased intracranial pressure. Com puted tomographic (CT) scans showed a large high density mass markedly enhanced postcontrast in and around the right trigone. Magnetic resonance (MR) Received Authors'

October present

11, 1991; addresses:

anterior

collagen

Accepted H. Oyama, S. Miyachi, Aichi,

Japan.

M.D., M.D.,

May

and motor

disturbance,

and magnetic trigone.

Cerebral

choroidal

artery.

catheterization. diagnosis

choroidal

left homonymous imaging

angiography The

feeding

Seven

days

was fibroblastic

for left homonymous anterior

resonance

showed

revealed

a

rich

vessel was em later,

the tumor

meningioma.

She

hemianopsia. artery

imaging showed this mass as a low-intensity area on the T,-weighted image and a high-intensity area on the T2-weighted image, markedly enhanced with gadolinium-diethylenetriaminepenta-acetic acid (Gd DTPA) (Fig. 1). Cerebral angiograms revealed the vascular-rich tumor mainly fed by the right anterior choroidal artery and partially by the right thalamoperforating and right posterior choroidal arteries (Fig. 2). A tracker catheter (proximal 3.0 F, distal 2.7 F; Target Co.; San Jose, Cal., U.S.A.) was introduced superselectively into the right anterior choroidal ar tery (Fig. 3). A provocative test with amobarbital was performed after advancing the microcatheter beyond the choroidal branches. This test was nega tive, so the feeder was embolized with 50 mg micro fibrillar collagen (Avitene). This achieved consider able devascularization of the mass without neuro logical deterioration. A right frontoparietotemporal craniotomy was per

7, 1992

Department Department

of Neurosurgery, of Neurosurgery,

Komaki City Hospital, Toyohashi Municipal

Komaki, Aichi, Japan; Hospital, Toyohashi,

formed 7 days after embolization. The brain was bulging and the gyri were flat. A 3.5 cm corticotomy was performed on the right superior temporal gyrus, where the tumor was nearest to the cortex. The yellow, elastic tumor was exposed at a depth of 5 mm and totally removed after enucleation with an ultrasonic aspirator with total blood loss 300 ml. The right anterior choroidal artery, right posterior choroidal artery, and a draining vein to the internal cerebral vein were found in the trigone and severed after coagulation. The operation took 8 hours.

Fig. 1 Axial (left) and lateral (right) T,-weighted MR images after Gd-DTPA enhancement, showing a well-enhanced mass lesion and some necrotic parts of low-signal intensity.

Histological examination revealed interlacing bundles of elongated spindle-shaped tumor cells. The diagnosis was fibroblastic meningioma (Fig. 4). Despite the marked angiographic devascularization, the tumor showed no obvious histological change caused by embolization, such as necrosis or obstruc

Fig. 2

left: Right carotid angiogram, arterial phase, showing the right anterior choroidal artery to be the main feeder. center: Right carotid angiogram, venous phase, showing the rich vascularity of the tumor. right: Left vertebral angiogram, arterial phase, showing some additional supply from the right thalamoperforating and right posterior choroidal arteries.

Fig. 3

Superselective angiograms. left: Before embolization, showing very rich vascularity of the tu mor. center: During embolization, showing the catheter advanced close to the plexal segment and decreased vascularity of the tumor. right: After embolization, showing obliteration of almost all tumor vessels from the right anterior choroidal artery.

embolization. cellently and

We found recommend

this procedure it.

to work

ex

References 1)

2)

Fig.

4

Photomicrograph

of

the

tumor,

showing

in

terlacing bundles of elongated spindle-shaped tumor cells. HE stain, x 200.

tion of tumor vessels, probably because the proximal side of the tumor vessels were predominantly obstructed by embolization. After 1 month, she was discharged without neuro logical deficits except for the left homonymous he mianopsia.

Discussion Large, richly vascular meningiomas in the lateral ven tricle are difficult to treat surgically. Since feeders such as anterior and posterior choroidal arteries are frequently located medial to the tumor, 2,3,7,9)control of bleeding is usually impossible until the tumor is removed. Obliteration of the feeders before surgery would reduce hemorrhage and facilitate surgery. Preoperative embolization of meningioma in other sites is common, 11,13)but preoperative embolization through the anterior choroidal artery has not previously been reported. The main reason is that the anterior choroidal artery feeds very important brain areas, 4) so migration of embolic agents or oblitera tion of this artery might cause serious neurological deficits. This artery consists of cisternal and plexal segments. The point of entry into the choroidal plexus is known as the plexal point.') Successful em bolization requires the catheter to enter the plexal seg ment beyond the plexal point. In this case, we injected the embolic agent after confirming that no neurological deterioration occur red with amobarbital infusion. During injection, we took care to prevent reverse flow of embolic agent which might lead to obliteration of normal vessels. This achieved successful embolization of the tumor vessels without neurological complications. The tumor removal was facilitated by the preoperative

Andoh T, Shinoda J, Miya Y, Hirata T, Sakai N, Yamada H, Shimokawa K: Tumors at the trigone of the lateral ventricle. Clinical analysis of eight cases. Neurol Med Chir (Tokyo) 30: 676-684, 1990 Fornari M, Savoiardo M, Morello G, Solero CL: Meningiomas of the lateral ventricles. J Neurosurg 54: 64-74, 1981

3) Goldberg HI: The anterior choroidal Newton TH, Potts DG (eds): Radiology and Brain, vol II, book 2. St Louis, 1974, pp 1650-1651 4) Goldberg HI: The anterior choroidal Newton TH, Potts DG (eds): Radiology and Brain, vol II, book 2. St Louis, 1974, pp 1629-1639

artery, in of the Skull CV Mosby, artery, in of the Skull CV Mosby,

5)

Guidetti B, Delfini R, Gagliardi FM, Vagnozzi R: Meningiomas of the lateral ventricles. Surg Neurol 24: 364-370, 1985 6) Guthrie BL, Ebersold MJ, Scheithaner BW: Neoplasms of the intracranial meninges, in Youmans JR (ed): Neurological Surgery, vol 5. Philadelphia, WB Saunders, 1990, pp 3285-3286 7) Handa H, Nagasawa S: Surgery of trigonal tumor. No Shinkei Geka 12: 901-912, 1984 (in Japanese) 8) Lapras C, Peruty R, Bret P: Tumors of the lateral ventricles, in Symon L (ed): Advances and Technical Standards in Neurosurgery, vol 11. Wien, Springer Verlag, 1984, pp 103-167 9) Mani RL, Hedgcock MW, Mass SI, Gilmor RL, Enzmann DR, Eisenberg RL: Radiographic diag nosis of meningioma of the lateral ventricle. J Neurosurg 49: 249-255, 1978 10) Richter HP, Schachenmayr W: Preoperative em bolization of intracranial meningiomas. Neurosur gery 13: 261-268, 1983 11) Spencer DD, Collins WF: Surgical management of lateral intraventricular tumors, in Schmidek HH, Sweet WH (eds): Operative Neurosurgical Tech niques, vol 1. New York, Grune & Stratton, 1982, pp 561-574 12) Sugita K: Intraventricular meningioma, in: Microneurosurgical Atlas. Berlin, Springer-Verlag, 1985, pp 206-207 13) Teasdale E, Patterson J, McLellan D, Macpherson P: Subselective preoperative embolization for menin gioma. J Neurosurg 60: 506-511, 1984

Address ment

reprint

requests

of Neurosurgery,

Tsunebushin,

Komaki,

to:

H.

Oyama,

Komaki Aichi

M.D.,

City 485,

Hospital,

Japan.

Depart 1-20