Meningiomas: Overview and New Directions in Therapy

Nancy Wang, MD; Matthias Osswald, MD


Semin Neurol. 2018;38(1):112-120. 

In This Article

Presentation and Diagnosis

Presenting symptoms of meningiomas are often nonspecific and dependent on tumor location. Compression of adjacent brain and vascular structures can lead to focal neurologic deficits (including cranial nerve deficits) as well as nonspecific symptoms such as headache and seizures.

Often incidentally noted on brain imaging obtained for other reasons, meningiomas typically appear hyperdense on computed tomography (CT), hypo- to isointense on T1-weighted magnetic resonance imaging (MRI) sequences, iso- to hyperintense on T2-weighted MRI sequences, and homogeneously contrast-enhancing. The extradural nature can be suggested by imaging features such as (1) the presence of a dural tail, (2) well-circumscribed margins, (3) an inward displacement of cortical gray matter, and (4) the presence of a cerebrospinal fluid cleft between the lesion and the adjacent brain.[28,66,67] [Figure 1] demonstrates classic imaging features of meningiomas. Meningiomas are highly vascular tumors that demonstrate intratumoral blush on conventional cerebral angiography, and elevated relative cerebral blood volume and cerebral blood flow on MR perfusion.[68] Hyperostosis in the adjacent skull and intratumoral calcification may be present and are best visualized on CT. The role of positron emission tomography (PET) in meningioma diagnosis is not yet standardized but is increasing.[69] PET ligands for somatostatin receptors may help clarify the diagnosis, delineate the extent of tumor, and distinguish between tumor progression and treatment effect.

Figure 1.

Panels A to C demonstrate an anterior temporal lobe meningioma on axial (A) and coronal (B) gadolinium-enhanced T1-weighted magnetic resonance imaging (MRI) sequences. There is significant edema surrounding the lesion seen on the T2/FLAIR (fluid attenuation inversion recovery) sequence (C) and a dural tail present (B, arrow). Panels D and E show a sphenoid wing meningioma on axial (D) and coronal (E) gadolinium-enhanced T1-weighted sequences with encasement of the right cavernous carotid artery and involvement of the cavernous sinus as well as cranial nerves II, III, and V. Panel F shows a parasagittal meningioma on a coronal gadolinium-enhanced T1-weighted sequence with invasion of the superior sagittal sinus.

The presence of atypical imaging features such as marked T2 hypo- or hyperintensity, osseous destruction, leptomeningeal extension, and lack of a dural tail should raise concern for an alternative diagnosis such as lymphoma, solitary fibrous tumor/hemangiopericytoma, pleomorphic xanthoastrocytoma, glioma, hemangioblastoma, dural metastasis, hemangioma, or chondrosarcoma.[70] Differential diagnoses also depend on location, such as optic glioma or neuritis for optic nerve sheath lesions, or infectious or granulomatous diseases for cavernous sinus lesions.[71] Octreotide scintigraphy can be helpful in the setting of an otherwise undiagnostic MRI.[72]