Ischaemic stroke with partial haemorrhagic transformation related to a small-sized tuberculum sellae meningioma

Excerpt

Intracranial tumours compress and dislocate surrounding blood vessels, which leads to reduced cerebral blood flow. These compressions of the vasculature can become symptomatic through an ischaemic stroke. In patients with benign meningioma, an ischaemic lesion can also occur suddenly [1]. A previously healthy, 48-year-old, right-handed woman experienced the sudden onset of headache, vomiting, impairment of consciousness, and right upper extremity numbness.  On hospital admission, a computed tomography scan revealed a suprasellar lesion and a haemorrhagic area in the region of the left recurrent artery of Heubner. Brain magnetic resonance imaging (MRI) revealed an ischaemic stroke on the frontal left cortex in the region of the A2 segment of the anterior cerebral artery (the orbitofrontal, frontopolar, and anterior internal frontal arteries), as well an ischaemic and haemorrhagic lesion in the region of the recurrent Heubner’s artery (Fig. 1). A 2.8 cm × 2 cm suprasellar lesion appeared to originate from the tuberculum sellae. On the angiographic sequences, the anterior communicating artery and the left posterior communicating artery were not represented. After the improvement of consciousness, an ophthalmological examination revealed a slight reduction of visual acuity in the right eye (20/40 vision), but no campimetric deficits. No abnormalities in the haematological screening were detected. Eight days later, the patient underwent complete tumour resection through a bifrontal approach. Histological examination confirmed the diagnosis of meningioma (WHO I). During the next 3 weeks, she recovered from right-sided numbness and visual impairment. The control MRI indicated no residual tumour at the previous site (Fig. 2). Although small-sized tuberculum sellae meningiomas (2–3 cm in diameter) can be slow-growing lesions without symptoms, a linear growth rate >10 % per year is at risk of developing symptoms [2]. Stretched vessels induce the abnormal impairment of perilesional cerebral blood flow, which should be considered a risk factor in asymptomatic patients. Cerebral ischaemia secondary to a meningioma has been considered a very rare event, averaging 0.19 % of cases [3]. The stroke in our patient, without specific risk factors, suggests that the meningioma, a reasonably fast-growing lesion, might have a pathogenic role. To our knowledge, no previous reports have described an acute ischaemic stroke and partial reperfusion haemorrhage in a single region, both related to a small-sized tuberculum sellae meningioma. In this patient, slow stretching of the left anterior cerebral artery (not encased by the small meningioma) produced an ischaemic event in three branches, the A2 region and an ischaemic–haemorrhagic event in another branch (the Heubner’s artery). The recurrent artery of Heubner arises from the proximal A2 segment of the anterior cerebral artery (64 % of total) [4]. The haemorrhage in the region of the left recurrent Heubner’s artery, by a possible secondary reperfusion mechanism, suggests the temporary impairment of cerebral blood flow, followed by subsequent compensatory collateral blood flow from the perforating arteries originating from the middle cerebral artery [5]. Meningiomas that average 2 cm in diameter and do not grow are rarely symptomatic, and observation should be considered. During the decision-making process, an angiographic MRI should determine the degree to which the meningioma impinges on the surrounding vessels, as well as the presence of the communicating arteries, to inform an asymptomatic patient that an acute ischaemic attack may occur. Factors such as age, occupation, and comorbidities should counterbalance the risks of surgery on an individual basis. Patients with even a small intracranial meningioma resting on stretched vessels should undergo MRI angiographic studies to evaluate the degree of vascular peritumoural contact and the presence of communicating arteries that would be able to support collateral compensatory blood flow.

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