Journal of Islamabad Medical & Dental College (JIMDC); 2015:4(4):176-177 Case Report Unusual Clinical Presentation of Cervical Extradural Meningioma Muhammad Khalid 1 , Khaleeq uz Zaman 2 and Muhammad Tahir 3 1 Post graduate Resident, Pathology Department, Federal Government Polyclinic Hospital, Islamabad 2 Professor/HOD Neurosurgery Department, Pakistan Institute of Medical Sciences, Islamabad 3 Consultant Pathologist/HOD Pathology Department, Federal Government Polyclinic Hospital, Islamabad Abstract Case Report The Extradural Meningiomas are rare and those in A 20 year-young girl presented with history of cervical region are extremely rare. 1 Mostly they neckache and brachalgia. Examination revealed present with quadriparesis. 2 We report an unusual diminished pinprick in C4 C5 dermatomes. clinical presentation of cervical region extradural meningioma in a 20-year old young girl who presented with severe pain in neck and brachalgia. As per our literature search this ours will be the first case report with such unusual presentation. Keywords: Cervical Spine Meningioma, Epidural Tumors, Extradural Meningiomas . Introduction Meningiomas arise from the covering of the spinal cord and are the second most common intradural extramedullary spinal tumors representing 25 % of all such tumors. 1 They are small in size but due to confines to the spinal canal they can cause significant neurological dysfunction and usually present with Figure 1: MRI cervical spine with contrast (Gadolinium) myelopathy. 2 The spinal meningiomas have a peak incidence in the fifth and sixth decades. Females are ten times more commonly affected than males. In children, male to female ratio is the same. 3 There is an increased incidence of spinal meningiomas in patients. 4 neurofibromatosis type 2 Extradural Meningiomas of the Cervical Spine are rare. 5 Usually they present with progressive quadriparesis. 6 We report a case of unusual clinical presentation of Cervical Extradural Meningioma who presented with neck pain and brachalgia. Corresponding Author: Dr. Muhammad Khalid E mail: drkhalid86@yahoo.com Received: Dec 21 st 2015; Accepted: Jan 18 th 2016 Figure 2: MRI cervical spine with contrast (Gadolinium) 176
Journal of Islamabad Medical & Dental College (JIMDC); 2015:4(4):176-177 present. 13 There was no power deficit. Rest of the neurological meningiomas were Usually these examination was normal. MRI Cervical Spine showed meningiomas present with progressive quadriparesis hyperintense lesion at level of C3, 4, 5, 6 on T1 image and no case of cervical extradural meningioma and homogenously enhancing with gadolinium presenting with neck-ache and brachalgia has been reported. 6 contrast as shown in Figure.1. The Patient was operated. The tumor was adherent but was separable Conclusion from the dura and total excision was obtained. Histology showed meningioma with EMA positive on Cervical extradural meningioma can present in unusual Immunohistochemistry. Axial cuts with contrast pattern both clinically and radiologically. It should be showed extradural contrast enhancing lesion extending kept in mind in patients presenting with neck-ache and into C4/5 neural foramen along the nerve root as brachalgia. shown in Figure 2. References Discussion 1. Osborn AG. Diagnostic neuroradiology. Mosby Among the intraspinal tumors, meningiomas are the Inc.1994; ISBN:0801674867. 2. Soderlund KA, Smith AB, Rushing EJ et-ai. Radiologic- second most common tumors. It is four times more pathologic correlation of pediatric and adolescent common in women than men and usually occurs in the spinal neoplasms: part 2, intradural extramedullary fifth to sixth decades of life. Almost 80% of these spinal neoplasms. AJR Am J Roentgenol.2012;198(1): tumors arise from the thoracic spine. 7 These spinal 44-51 3. Buetow MP, Buetow PC, Smirniotopoulos JG. Typical, meningiomas are intradural extramedullary lesions and Atypical, and misleading features in meningioma. are mostly ventrally or ventro-laterally placed. 8 There Radiographics 1991;11(6):1086-1106. is an extradural component in almost 10% of the cases 4. Abul-kasim K, thurnher MM, Mckeever P et-al. but it is rare to have an exclusively extradural Intradural spinal tumors: current classification and meningioma. 9 It is still unclear how meningiomas arise MRI features. Neuroradiology.2008;50(4):301-14. 5. Brian L Frank, James S Harrop, Amgad Hanna, John from extradural site and one of the possibility is due to Ratliff. Cervical Extradural Meningioma: Case Report abnormally located meningothelial cells in this and Literature Review. J Spinal Cord Med 2008;31(3): region. 10 Mostly extradural spinal lesions are 302–305. metastatic neoplasms and can also be due to 6. Takeuchi H, Kubota T, Sato K, Hirose S. Cervical lymphomas and therefore it is essential to make a extradural meningioma with rapidly progressive myelopathy. Journal of Clinical Neuroscience April correct diagnosis and to exclude these extradural 2006;13(3): 397–400. lesions to have a proper treatment plan accordingly. 11 7. Tuli J, Drzymalski DM, Lidov H, Tuli S. Extradural In patients having a younger age group and in whom en ‑ plaque spinal meningioma with intraneural there is a negative metastatic evaluation, other invasion. World Neurosurg 2012; 77:202.e5 ‑ 13. possibilities should be considered such as 8. Santiago BM, Rodeia P, Cunha E Sa M. Extradural meningiomas, neurofibromas, schwannomas, thoracic spinal meningioma. Neurol India 2009; chordomas, infectious lesions or synovial cysts. 12 57:98. 9. Zevgaridis D, Thomé C. Purely epidural spinal In the literature reviewed there were 17 case reports of meningioma mimicking metastatic tumor: Case report extradural meningioma found. Most of the patients and review of literature. Spine (Phila Pa 1976) presenting with extradural meningioma were of 14 to 2002;27:E403 ‑ 5. 75 years age group, and among these 47% of the 10. Vargas M, Abu Eid M, Bogorin A et al., patients were younger than 30 years of age. In most of “Lesm´eningiomes rachidiens extraduraux: donn´ees IRM ´a propos de deux observations,” Journal of the cases the affected individuals were females Neuroradiology, vol. 31, no. 3, pp. 214–219, 2004. (64.7%) similar results were seen in our case. Among 11. Savardekar A, Chatterjee D, Chatterjee D, Dhandapani the female patients 75% of cases were younger than 30 S, Mohindra S, Salunke P. Totally extradural spinal en years of age. This predilection of age along with plaque meningiomas - Diagnostic dilemmas and gender may be due to association of hormonal effects treatment strategies. Surg Neurol Int 2014;5: S291-4. 12. Ross J, Brant-Zawadzki M, Chen M, Moore K, Salzman on the growth and development of meningioma. K. Diagnostic Imaging: Spine. 1st ed. Salt Lake City, Among various studies, in 52.9% of cases reviewed, UT: Amirsys; 2004. Meningioma; IV1–78-IV1-81. the most common site involved was thoracic region and in 41.2% of the cases cervical extradural 177
Journal of Islamabad Medical & Dental College (JIMDC); 2015:4(4):176-177 13. Frank BL, Harrop JS, Hanna A, Ratliff J. Cervical Review. J Spinal Cord Med. 2008; 31(3): 302–305 . Extradural Meningioma: Case Report and Literature 178
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