Update on meningioma: Clinical-radiological and radio-pathological correlation

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Tras este, muestra paresia facial izquierda y disartria autolimitadas: a) TC con CIV que muestra una masa extraaxial en la convexidad temporal (flecha). Se identifica una zona central con densidad de grasa que corresponde con zona de metaplasia grasa. El resto de la lesión presenta una ávida y homogénea captación de contraste; b) Secuencia sagital T1 de RM. El componente graso observado en la TC presenta una hiperintensidad clara (flecha); c) Imagen obtenida con microscopio de 100 aumentos con tinción de hematoxilina-eosina. Se observan algunas células meningoteliales que contienen vacuolas llenas de grasa que les hacen asemejarse a adipocitos, siendo el diagnóstico de meningioma metaplásico lipomatoso grado 1." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. Navarro-Ballester, M. Aleixandre-Barrachina, S.F. Marco-Doménech" "autores" => array:3 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Navarro-Ballester" ] 1 => array:2 [ "nombre" => "M." 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(A) Orthopantomography: vague lytic lesions in the third quadrant associated with diffuse sclerosis of the neighbouring bone. (B) Computed tomography, axial slice below the alveolar ridge: sclerosis of the left hemimandible can be seen better and a fracture of the vestibular cortex is identified (black arrow). (C) Computed tomography, superior axial slice: in addition to the fracture line mentioned above (black arrow), an area of bone sequestration in the distal sector of the third quadrant (blue arrow) and smooth periosteal reaction (white arrow) can be identified. (D) Computed tomography, axial slice at the alveolar ridge: small gas bubbles are identified in the focus of osteonecrosis, suggesting superinfection (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article)." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "R. Alemán Millares, E. Santos Armentia, S. Del Campo Estepar, M. 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Navarro-Ballester, M. Aleixandre-Barrachina, S.F. Marco-Doménech" "autores" => array:3 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Navarro-Ballester" "email" => array:1 [ 0 => "antonio.navarroball@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M." "apellidos" => "Aleixandre-Barrachina" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "S.F." "apellidos" => "Marco-Doménech" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Radiodiagnóstico, Hospital General Universitario de Castellón, Castellón de la Plana, Castellón, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital General Universitario de Castellón, Castellón de la Plana, Castellón, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Actualización sobre el meningioma: correlación clínico-radiológica y radio-patológica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1971 "Ancho" => 650 "Tamanyo" => 270501 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0350" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Incidental finding in a 63-year-old woman who had MRI for migraine headache: a) Sagittal T2-weighted MRI. Note the lesion in the cerebellopontine angle (arrow). T2 hypointensity may be evidence of the meningioma histological subtype. The presence of a hyperintense halo on T2 along its border (cleft sign) indicates the extra-axial location of the lesion (arrowhead); b) T1-weighted fat-saturated gadolinium-enhanced sequence showing the lesion with heterogeneous uptake (arrow); c) Microscopic image at 200x magnification with haematoxylin-eosin staining, showing a proliferation of spindle-shaped meningothelial cells with predominantly hyaline stromal cells forming interlacing bundles. Pathology diagnosis of grade 1 fibrous meningioma." ] ] ] "textoCompleto" => "IntroductionMeningiomas arise from arachnoid cap cells embedded in the arachnoid villi, most commonly found in the skullcap and base of the skull, although they can also be found in the spinal cord. Not only are meningiomas the most common meningeal tumour, they are also the most common non-glial tumours of the central nervous system.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>The word “meningioma”, comes from the Ancient Greek “mēninx”, meaning membrane, “angeion”, meaning blood vessel and “-oma”, which translates as mass, biological structure or tumour. Although the first monographic scientific publication on these tumours is attributed to the French military surgeon Antoine Louis in the later years of the French Enlightenment (18th century), it was not until the Cavendish Conference in 1922 that Harvey Cushing gave birth to the term “meningioma”.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>The incidence of meningioma peaks at 22.2 per 100,000 population in the age range 75–89.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> Diagnosis is three times more common in women than in men, with this difference particularly pronounced in the 30–59 age range, in tumour grade I and when located in the spine.<a class="elsevierStyleCrossRef" href="#bib0020">4</a>There are many reasons, beyond the high incidence, to support the need for further studies on meningiomas. Firstly, the fact that they are mostly clinically silent makes it more difficult to obtain reliable data on epidemiology or clinical features. Not surprisingly then, some 80% of these tumours are considered low-grade in the World Health Organisation (WHO) classification.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> Secondly, meningiomas have a high recurrence rate after surgery, as well as a not-insignificant potential to be fatal, both of which are related to histological grade.<a class="elsevierStyleCrossRef" href="#bib0025">5</a>The aim of this study was to analyse the most common locations for meningiomas and radiological behaviour based on their histological nature.Syndromes associated with meningiomaIn people under the age of 40, a finding of meningiomas raises the suspicion of neurofibromatosis type 2, with intracranial meningiomas being an independent factor for poor prognosis associated with a two- to five-fold increase in the mortality rate for the neurofibromatosis.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> Other diseases which increase the risk of meningiomas are multiple endocrine neoplasia type 1, Cowden syndrome, Werner syndrome, nevoid basal cell carcinoma syndrome, Rubinstein-Taybi syndrome, BAP1 tumour predisposition syndrome and familial meningiomatosis, which is caused by germline mutations in SMARCB1 and SMARCE1 genes.<a class="elsevierStyleCrossRef" href="#bib0035">7</a>Symptoms of meningioma: clinical-radiological correlationMost meningiomas are asymptomatic and detected incidentally.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> In those that do cause symptoms, the specific dural, intracranial or spinal location enables us to estimate the clinical presentation to expect:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">•Cerebral convexity: is the most common location. Approximately one in four meningiomas occupy this position.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> In symptomatic patients, the most common neurological manifestations detected are headache (43.4%), motor disturbances (34.4%) and seizures (32.8).<a class="elsevierStyleCrossRef" href="#bib0045">9</a> Among the locations in convexity, the most common is frontal (53%), followed by parietal (20%), temporal (18%), occipital (7%) and pterional (2%).<a class="elsevierStyleCrossRef" href="#bib0050">10</a> It is important to be aware that meningiomas of the frontal convexity can cause psychological and neurocognitive disorders, a less common presentation which may delay diagnosis.<a class="elsevierStyleCrossRef" href="#bib0055">11</a></li><li class="elsevierStyleListItem" id="lsti0010">•Skull base: according to some of the series with the largest number of cases analysed, the location at the skull base as a whole (anterior, middle or posterior cranial fossa) would be the most common of all, even above that of convexity, with a prevalence of 47%–58.5%.<a class="elsevierStyleCrossRefs" href="#bib0020">4,12</a> Within the skull base, the middle cranial fossa is the most common location, followed by the anterior and posterior respectively.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> When meningiomas in this location cause symptoms, headache is the most common (52.1%), slightly more so than in convexity tumours. In second place are visual disturbances (46.5%), typical of anterior fossa meningiomas. Clinical manifestations related to alterations in the cerebellum are found in 31.7% of cases, usually in posterior fossa tumours, where hydrocephalus and cranial nerve-related abnormalities are also more common.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> Hearing loss can occur, in most cases after invasion of the internal auditory canal by cerebellopontine angle meningiomas<a class="elsevierStyleCrossRef" href="#bib0065">13</a> (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Anosmia can also occur, being about three times more common in skull base than in convexity meningiomas.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> We should particularly mention meningiomas located in the vicinity of the greater wing of the sphenoid bone, which are divided into lateral, medial and intermediate, depending on their position. Those located lateral to the greater wing of the sphenoid bone tend to cause epilepsy and/or speech disturbances if located on the left-hand side. Those medial to the greater wing can cause unilateral loss of vision; if affecting the cavernous sinus, they may be associated with other symptoms, usually starting with oculomotor deficits (paresis, ophthalmoplegia, ptosis, diplopia and anisocoria) and progressing to facial hypoaesthesia or hyperaesthesia due to trigeminal nerve involvement.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> Meningiomas of the middle cranial fossa, in addition to the potential symptoms mentioned, may also cause clinical manifestations due to cerebral ischaemia resulting from compression of the arteries that make up the circle of Willis, and even alterations in pituitary function due to the mass effect of the tumour on the gland.<elsevierMultimedia ident="fig0005"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0015">•Parasagittal: defined as meningiomas which grow on at least one wall of the superior sagittal sinus.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> Some 10%–20% of all meningiomas are found in this location,<a class="elsevierStyleCrossRefs" href="#bib0020">4,9</a> although differentiating between parasagittal meningiomas and those located in the high convexity is not always simple; those considered to be convexity meningiomas can even have small points of attachment to the dura mater of the superior sagittal sinus (SSS). The clinical presentation of the two differs very little and will depend on their specific position. However, it should be remembered that parasagittal meningiomas sometimes invade the SSS, and this significantly affects the neurosurgical strategy.<a class="elsevierStyleCrossRef" href="#bib0080">16</a></li><li class="elsevierStyleListItem" id="lsti0020">•Falx cerebri: about 8% of meningiomas occupy this site<a class="elsevierStyleCrossRefs" href="#bib0020">4,16</a> (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). In this case, the tumour arises from the falx cerebri, but differs from the parasagittal tumour in that it is completely covered by the overlying cerebral cortex and does not affect the superior sagittal sinus.<a class="elsevierStyleCrossRef" href="#bib0085">17</a> In the surgical series of Sung et al., patients with falcine meningioma had symptoms such as headache (30%), unilateral motor deficits (16%), seizures (7%) and personality disorders (7%), with 6% being asymptomatic.<a class="elsevierStyleCrossRef" href="#bib0090">18</a> It has been found that, at the same histological grade, parasagittal and falcine meningiomas are more likely to recur, possibly because of the greater difficulty in achieving complete resection in these locations.<a class="elsevierStyleCrossRef" href="#bib0080">16</a><elsevierMultimedia ident="fig0010"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0025">•Intraventricular: 0.5%–3% of meningiomas<a class="elsevierStyleCrossRef" href="#bib0095">19</a> (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). When located in the lateral ventricles, it is more common for the left side to be affected; this is also the case with other intracranial meningiomas, but it is not understood why.<a class="elsevierStyleCrossRef" href="#bib0100">20</a> Unlike other types of meningioma, it tends to be silent and cause mild, long-lasting symptoms such as headache or visual disturbances. This means the tumour volume is usually large at the time of diagnosis.<a class="elsevierStyleCrossRef" href="#bib0105">21</a> Intraventricular meningioma is associated more often than other tumours with postoperative meningitis, a potentially serious complication.<a class="elsevierStyleCrossRef" href="#bib0110">22</a><elsevierMultimedia ident="fig0015"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0030">•Optic nerve: like intraventricular and pineal region meningiomas, those affecting the optic nerve are part of the intradural meningioma family. They account for 2% of all orbital tumours and 1% of all meningiomas. They are usually intraorbital and unilateral (92% and 95% respectively) and their most common form is secondary, in other words caused by the extension of an intracranial meningioma into the orbit.<a class="elsevierStyleCrossRef" href="#bib0115">23</a></li><li class="elsevierStyleListItem" id="lsti0035">•Spinal: account for about 1.2% of all meningiomas.<a class="elsevierStyleCrossRef" href="#bib0120">24</a> Most are located in the intradural compartment, sparing the pial layer of the spinal cord, and account for 25%–45% of all intradural spinal tumours.<a class="elsevierStyleCrossRef" href="#bib0125">25</a> They are usually located in the thoracic spine (78%), being less common in the cervical (19%) and lumbar (3%) areas. In the axial plane, they are most commonly lateral (55%) or ventral (29%).<a class="elsevierStyleCrossRefs" href="#bib0110">22,24</a> They are more common in the older adult population and, if diagnosed in young patients, a genetic disorder such as neurofibromatosis type 2 or an aggressive histological subtype of the tumour should be suspected.<a class="elsevierStyleCrossRef" href="#bib0130">26</a> The most common symptoms related to spinal meningioma are motor or sensory deficits (84%), gait disturbances (52%–83%) and pain (33%–47%)<a class="elsevierStyleCrossRefs" href="#bib0115">23,24</a> (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).<elsevierMultimedia ident="fig0020"></elsevierMultimedia></li></ul>Radiological features of meningioma<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0040">•Plain X-ray: not a useful technique for the study of meningiomas. In a very small number of cases, intratumour calcifications, the effect of meningiomas on the skullcap (hyperostosis or bone resorption) or enlargement of the meningeal artery grooves can be seen on skull X-rays.<a class="elsevierStyleCrossRef" href="#bib0135">27</a></li><li class="elsevierStyleListItem" id="lsti0045">•Computed tomography<a class="elsevierStyleCrossRef" href="#bib0140">28</a>:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0050">oCalcification: 25%</li><li class="elsevierStyleListItem" id="lsti0055">oPerilesional oedema: 60%–67% of meningiomas, but more easily identifiable by MRI.<a class="elsevierStyleCrossRefs" href="#bib0135">27,29</a></li><li class="elsevierStyleListItem" id="lsti0060">oHyperostosis of adjacent bone: 20% (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>).<elsevierMultimedia ident="fig0025"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0065">oOsteolysis of adjacent bone: rare finding and seen in intraosseous or locally invasive meningiomas.</li><li class="elsevierStyleListItem" id="lsti0070">oHyperdense relative to the rest of the brain in non-contrast study: 60%.</li><li class="elsevierStyleListItem" id="lsti0075">oHomogeneous and intense contrast enhancement: 72%.</li></ul></li><li class="elsevierStyleListItem" id="lsti0080">•Magnetic resonance imaging (MRI): the technique of choice.</li></ul>It typically presents as an extra-axial mass with well-defined margins:<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0085">•T1: isointense with respect to the grey matter.</li><li class="elsevierStyleListItem" id="lsti0090">•T2: isointense or slightly hyperintense.</li><li class="elsevierStyleListItem" id="lsti0095">•Magnetic susceptibility sequences: areas of signal loss coinciding with calcifications.</li><li class="elsevierStyleListItem" id="lsti0100">•T1 with gadolinium: intense and homogeneous enhancement. Occasionally, there may be areas of calcification and/or necrosis which do not enhance.</li><li class="elsevierStyleListItem" id="lsti0105">•Diffusion: grade 2 or 3 tumours may have restricted diffusion (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>) but this is not a reliable predictor of histological grade, due to its low negative predictive value.<a class="elsevierStyleCrossRef" href="#bib0150">30</a><elsevierMultimedia ident="fig0030"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0110">•“Dural tail sign”: defined as thickening and enhancement of the dura mater adjacent to the tumour on contrast studies and seen in up to 72% of cases.<a class="elsevierStyleCrossRef" href="#bib0135">27</a> The presence of this sign may be useful for differentiating meningioma of the cerebellopontine angle from schwannoma, for example, as a dural tail is not usually associated with schwannoma. However, it is not a pathognomonic sign and can be identified in other types of cancer such as glial tumours, lymphomas and even metastases.<a class="elsevierStyleCrossRef" href="#bib0005">1</a></li><li class="elsevierStyleListItem" id="lsti0115">•Cerebrospinal fluid “cleft sign”: consists of a cleft of cerebrospinal fluid between the tumour and the underlying cortex and suggests the extra-axial origin of the lesion (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). This sign may not be found in grade 3 meningiomas, due to their aggressive local behaviour.</li><li class="elsevierStyleListItem" id="lsti0120">•“Tram-track sign” (optic nerve meningioma): intense gadolinium enhancement of the optic nerve sheath surrounding the nerve, producing an image resembling tram tracks. It is important to remember that, although this sign differentiates meningioma from glioma, it can be found in other diseases (for example, orbital pseudotumour, optic perineuritis, orbital sarcoidosis, lymphoma and metastasis).</li><li class="elsevierStyleListItem" id="lsti0125">•MRI spectroscopy: in meningiomas, it is common to find increased alanine, choline and glutamine/glutamate, with reduced or absent N-acetylaspartate (NAA) and creatine.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Although elevated alanine has traditionally been considered characteristic of meningioma,<a class="elsevierStyleCrossRef" href="#bib0155">31</a> it is not detected in all meningiomas and it may correlate inversely with the degree of tumour necrosis.<a class="elsevierStyleCrossRef" href="#bib0160">32</a> One publication suggests that an increased choline/NAA ratio >2.409 may be indicative of a high tumour grade, with a specificity of 86.36%, although further studies are needed to validate the results.<a class="elsevierStyleCrossRef" href="#bib0165">33</a> Increases in lactate or lipids have also been suggested in the past as indicators of high tumour grade; unfortunately, they have proven to not always be reliable parameters.<a class="elsevierStyleCrossRefs" href="#bib0005">1,34</a></li><li class="elsevierStyleListItem" id="lsti0130">•Perfusion MRI: meningiomas are hypervascular lesions and are therefore highly perfused in perfusion studies. Relative cerebral blood volume (rCBV) will be increased, with reported values of between 6 and 9ml/100g.<a class="elsevierStyleCrossRef" href="#bib0150">30</a> However, a histological subtype such as angiomatous meningioma may have slightly higher figures, due to its larger vascular component. In contrast, fibrous meningioma will show somewhat lower perfusion values due to the presence of hypovascular fibrous tissue.<a class="elsevierStyleCrossRefs" href="#bib0175">35,36</a></li></ul>Histological subtypes: radiological-pathological correlationMeningioma has a separate category in the 2021 fifth edition of the World Health Organisation Classification of Tumours of the Central Nervous System.<a class="elsevierStyleCrossRef" href="#bib0185">37</a> This classification system establishes 15 histological subtypes of meningioma, emphasising that the criteria defining atypical or anaplastic meningioma (current grades 2 and 3 respectively) should be applied regardless of the underlying subtype. However, there are some subtypes which, due to their high recurrence rates or aggressive behaviour, are assigned a grade higher than 1. It should be noted that some molecular biomarkers can also demonstrate the assigned classification and grade.<a class="elsevierStyleCrossRef" href="#bib0190">38</a>Histopathological criteria for differentiating grade 2 and 3 meningiomas<a class="elsevierStyleCrossRef" href="#bib0195">39</a>:<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0135">•Grade 2 (atypical): brain invasion, between 4 and 19 mitoses in 10 consecutive high power fields (HPF) or the presence of three or more of the minor criteria (increased cellularity, small cells with a high nuclear/cytoplasmic ratio, prominent nucleoli, foci of geographic or spontaneous necrosis and sheeting) are the main diagnostic criteria for atypical meningiomas. Chordoid and clear cell subtypes are directly categorised as atypical (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).</li><li class="elsevierStyleListItem" id="lsti0140">•Grade 3 (anaplastic): suggested by increased mitotic count of ≥20 in 10 consecutive HPF, homozygous deletion of CDKN2A/B, areas of sarcoma-, carcinoma- or melanoma-like appearance, TERT promoter mutation (<a class="elsevierStyleCrossRefs" href="#fig0015">Figs. 3 and 6</a>).<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0145">-Angiomatous: 1.5%–2.1% of meningiomas.<a class="elsevierStyleCrossRefs" href="#bib0200">40,41</a> As the name suggests, they are tumours with abundant blood vessels (more than 50% of the total tumour volume) combined with areas of classic meningothelial differentiation. Characteristically, they have a slightly higher rCBV on perfusion MRI than other subtypes. Differentiation of this subtype from the microcystic subtype is particularly difficult, as both have similar findings in relation to their apparent diffusion coefficient (ADC) and perfusion, and it is not uncommon for the angiomatous subtype to show areas of cystic degeneration.<a class="elsevierStyleCrossRef" href="#bib0205">41</a> A differential feature between the two subtypes could be peritumoural oedema (seen in 100% of pure angiomatous versus 66.7% of pure microcystic)<a class="elsevierStyleCrossRef" href="#bib0210">42</a> or the higher likelihood of a dural tail (66.7%).<a class="elsevierStyleCrossRef" href="#bib0180">36</a> Despite being a histopathologically distinct entity, it is not always easy to differentiate between angiomatous meningioma and solitary fibrous tumour of the meninges (SFTM), formerly known as haemangiopericytoma<a class="elsevierStyleCrossRef" href="#bib0185">37</a> (<a class="elsevierStyleCrossRef" href="#fig0035">Fig. 7</a>). Unlike the angiomatous subtype of meningioma, SFTM are more common in males (75%) and affect younger patients (mean age 41.4 compared to 48.2 for meningioma).<a class="elsevierStyleCrossRef" href="#bib0215">43</a> Radiologically, the SFTM is isointense with respect to the grey matter in T1 and T2 and, in general, more often shows aggressive behaviour. Also, necrosis is more common, with heterogeneous contrast uptake more likely than in meningioma. In perfusion studies the rCBV of SFTM is even higher than that of angiomatous meningioma.<a class="elsevierStyleCrossRef" href="#bib0215">43</a> On spectroscopy, SFTM usually show a marked increase in choline with a lipid/L-lactate peak, increased glutamate/glutamine, increased myo-inositol, decreased creatinine and no NAA.<a class="elsevierStyleCrossRef" href="#bib0220">44</a> According to Ohba et al., the combination of the criteria age <45 years and myo-inositol >6.347 distinguishes SFTM from meningioma, with a sensitivity of 100% and a specificity of 97.8%.<a class="elsevierStyleCrossRef" href="#bib0220">44</a><elsevierMultimedia ident="fig0035"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0150">-Atypical: is a WHO grade 2 tumour, alongside chordoid meningioma and clear cell meningioma. This histological grade has shown an increased relative incidence in recent years, accounting for 22.7%–24.5% of all cases.<a class="elsevierStyleCrossRefs" href="#bib0225">45,46</a> It is foreseeably more aggressive, fast-growing and prone to recurrence than grade 1.<a class="elsevierStyleCrossRef" href="#bib0235">47</a> However, radiologically it is indistinguishable from grade 1 or 3 meningiomas.</li><li class="elsevierStyleListItem" id="lsti0155">-Anaplastic: 1%–3% of meningiomas.<a class="elsevierStyleCrossRef" href="#bib0240">48</a> This is the most aggressive form of the tumour and is classified as WHO grade 3. Studies suggest that a higher degree of cellularity and intratumour necrosis correlate statistically significantly with low ADC,<a class="elsevierStyleCrossRefs" href="#bib0180">36,47</a> and a significant correlation was also found between low ADC and high tumour cell proliferation rates in high-grade meningiomas.<a class="elsevierStyleCrossRef" href="#bib0245">49</a></li><li class="elsevierStyleListItem" id="lsti0160">-Chordoid: 1%–4.1%.<a class="elsevierStyleCrossRef" href="#bib0250">50</a> Classified as a WHO grade 2 tumour. The most characteristic imaging features are hyperintensity on T2 (probably due to its richness in mucoid matrix), but above all, hyperintensity on ADC.<a class="elsevierStyleCrossRef" href="#bib0255">51</a> Cut-off values of ADC≥1.33×10−3mm2/s and normalised ADC (NADC) ≥1.63 enable differentiation of chordoid meningioma from grade 1, non-chordoid or focal chordoid grade 2 meningiomas (<50%) and grade 3 meningiomas on preoperative imaging with considerable diagnostic accuracy, as all of the above usually show a more pronounced diffusion restriction with a low ADC (800×10−6mm2/s).<a class="elsevierStyleCrossRef" href="#bib0260">52</a></li><li class="elsevierStyleListItem" id="lsti0165">-Clear cells: 0.2%–1%.<a class="elsevierStyleCrossRefs" href="#bib0265">53,54</a> Usually located in the cerebellopontine angle and in the spine, especially in the cauda equina.<a class="elsevierStyleCrossRef" href="#bib0270">54</a> They are classified as grade 2 and on imaging have the typical meningioma appearance, with no differentiating features (<a class="elsevierStyleCrossRefs" href="#fig0020">Figs. 4 and 5</a>). However, they appear to show a very distinctive epigenetic signature, with frequent mutations in the SMARCE1 gene and/or loss of expression of the SMARCE protein.<a class="elsevierStyleCrossRef" href="#bib0275">55</a></li><li class="elsevierStyleListItem" id="lsti0170">-Fibrous or fibroblastic: considered one of the most common subtypes, accounting for 7.1%–10.2% of the total in its isolated form.<a class="elsevierStyleCrossRefs" href="#bib0215">43,56</a> As it is more common in its combined form (transitional meningioma), it is often not possible to differentiate it from the meningothelial subtype. However, in pure fibrous meningiomas, a loss of signal on T2 can be identified due to their high collagen content, a finding that distinguishes them from other subtypes of meningioma, opening up the differential diagnosis towards other types of disease such as solitary fibrous tumour of the dura or histiocytosis (Erdheim-Chester disease). Another way to differentiate this subtype of meningioma is by detecting a mutation in the NF2 tumour suppressor gene, which occurs in most neurofibromatosis type 2 and in 40%–60% of sporadic meningiomas, especially in the fibrous and transitional subtypes and when located in the convexity and posterior fossa (skull base)<a class="elsevierStyleCrossRef" href="#bib0285">57</a> (<a class="elsevierStyleCrossRef" href="#fig0040">Fig. 8</a>).<elsevierMultimedia ident="fig0040"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0175">-Lymphoplasmacytic: 0.5%.<a class="elsevierStyleCrossRef" href="#bib0265">53</a> The longest review to date is of 164 cases, in which the authors note that this meningioma does not have a characteristic radiological appearance and cannot be differentiated from other subtypes.<a class="elsevierStyleCrossRef" href="#bib0290">58</a></li><li class="elsevierStyleListItem" id="lsti0180">-Meningothelial: the most common subtype (17%), second only to transitional meningioma.<a class="elsevierStyleCrossRef" href="#bib0265">53</a> Usually shows the general radiological characteristics of meningioma (see section “Radiological features of meningioma”), with no distinct imaging features to differentiate it from other subtypes.</li><li class="elsevierStyleListItem" id="lsti0185">-Metaplastic: 0.04%−0.21%.<a class="elsevierStyleCrossRef" href="#bib0295">59</a> In this case, the tumour cells of the meningioma (usually of the meningothelial, fibrous or transitional subtypes) differentiate to adopt the tissue characteristics of other parts of the body.<a class="elsevierStyleCrossRef" href="#bib0300">60</a> Therefore, the radiological appearance will depend on the type of tissue being expressed.</li></ul></li><li class="elsevierStyleListItem" id="lsti0190">•Cartilaginous: no more than 10 cases have been reported in the scientific literature.<a class="elsevierStyleCrossRef" href="#bib0305">61</a> As the name suggests, the meningioma takes on a cartilaginous appearance. It may be difficult to distinguish from chondroblastoma or chondrosarcoma, especially when located in the spine.</li><li class="elsevierStyleListItem" id="lsti0195">•Lipomatous: the meningothelial cells take on an appearance resembling adipocytes (<a class="elsevierStyleCrossRef" href="#fig0045">Fig. 9</a>). Some studies have suggested that the accumulation of lipids in these cells is due to altered metabolism rather than true metaplasia.<a class="elsevierStyleCrossRef" href="#bib0300">60</a> If there is a sufficient amount of fatty tissue, they will be hypointense on CT and hyperintense on MRI on T1-weighted sequences, with loss of signal after fat suppression.<elsevierMultimedia ident="fig0045"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0200">•Melanotic: if there is a sufficient amount of melanin, it will be hyperintense on T1, with variable behaviour in T2 (the presence of haemorrhage can cause hypointensity) and homogeneous contrast uptake. This differs from melanomas and meningeal melanocytosis in that they tend to have a more heterogeneous uptake pattern. However, it is not uncommon for them to be confused on imaging.<a class="elsevierStyleCrossRef" href="#bib0310">62</a></li><li class="elsevierStyleListItem" id="lsti0205">•Myxoid: myxoid transformation involves the presence of endothelial cells, pericytes and stromal cells. This type has the general appearance of any meningioma, with no distinctive imaging features. Immunohistochemistry plays an important role in differentiating myxoid from other meningiomas which also have a stromal matrix, such as chordoid meningioma.</li><li class="elsevierStyleListItem" id="lsti0210">•Bone: similar characteristics to other meningiomas. Their bone differentiation makes it virtually impossible to differentiate them from meningiomas with a tendency to calcify (psammomatous) and intraosseous meningiomas.</li><li class="elsevierStyleListItem" id="lsti0215">•Xanthomatous: imaging characteristics are very similar to the lipomatous variant of meningioma, and can only be differentiated on histological examination.<a class="elsevierStyleCrossRef" href="#bib0315">63</a><ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0220">-Microcystic: 1%–1.6%.<a class="elsevierStyleCrossRef" href="#bib0315">63</a> Radiological features suggestive of this subtype include hypointensity on T1-weighted images and irregular peripheral gadolinium uptake. However, although this uptake pattern is very specific (94%), it is not very sensitive (27%).<a class="elsevierStyleCrossRef" href="#bib0320">64</a> Another typical feature is that, compared to other subtypes of the same grade, it tends to have a larger volume of peritumoural oedema, which seems to be due to a higher vascular permeability factor/vascular endothelial growth factor ratio<a class="elsevierStyleCrossRef" href="#bib0320">64</a> (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>B).</li><li class="elsevierStyleListItem" id="lsti0225">-Papillary: 1%–2.5%.<a class="elsevierStyleCrossRef" href="#bib0325">65</a> Papillary meningiomas are characterised by their aggressive behaviour, with a greater tendency towards recurrence and even metastasis,<a class="elsevierStyleCrossRef" href="#bib0330">66</a> but they are no longer classified as grade 3, as in the previous WHO classification.<a class="elsevierStyleCrossRef" href="#bib0335">67</a></li><li class="elsevierStyleListItem" id="lsti0230">-Psammomatous: 0.5%.<a class="elsevierStyleCrossRef" href="#bib0265">53</a> We have to differentiate between the terms “calcification” and “ossification”. “Calcification” is a radiological concept which usually refers to the accumulation of psammoma bodies and is therefore common in psammomatous meningioma. Ossification in meningioma manifests as the presence of mature or immature bone tissue within the tumour and is a much rarer phenomenon histologically.<a class="elsevierStyleCrossRef" href="#bib0340">68</a> On CT it appears as a calcified lesion, although when the psammoma bodies are more dispersed, it shows as a hyperdense mass without clear calcifications. On MRI, it may show hypointensity on T2-weighted images and loss of signal on magnetic susceptibility sequences (<a class="elsevierStyleCrossRef" href="#fig0050">Fig. 10</a>).<elsevierMultimedia ident="fig0050"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0235">-Rabdoid: 0.004%.<a class="elsevierStyleCrossRef" href="#bib0345">69</a> The term rhabdoid refers to the characteristic resemblance of the cells to a rhabdomyoblast without true musculoskeletal differentiation. This histological type usually means a poor prognosis and a tendency for recurrence. They can have a cystic component (38%) and marked peritumoural oedema.<a class="elsevierStyleCrossRef" href="#bib0350">70</a> There may be associated bone changes, ranging from hyperostosis (60%) to bone destruction (33.33%).<a class="elsevierStyleCrossRef" href="#bib0350">70</a></li><li class="elsevierStyleListItem" id="lsti0240">-Secretory: 0.5%.<a class="elsevierStyleCrossRef" href="#bib0265">53</a> They tend to be located at the base of the skull.<a class="elsevierStyleCrossRef" href="#bib0345">69</a> Radiological features are indistinguishable from other meningiomas, although they are more likely to show hyperintensity on T2-weighted images (95.6%).<a class="elsevierStyleCrossRef" href="#bib0355">71</a></li><li class="elsevierStyleListItem" id="lsti0245">-Transitional: the most common subtype (39.8%).<a class="elsevierStyleCrossRef" href="#bib0265">53</a> Combined form of meningothelial and fibroblastic meningioma; imaging features will depend on which component is predominant.</li></ul></li></ul>ConclusionsImaging techniques and particularly MRI can be a useful tool to guide the diagnosis of meningioma, ruling out alternative diagnoses with different management, and sometimes helping us make a preliminary estimation of the potential histological subtype and grade. Findings such as the presence of a cerebrospinal fluid cleft around the lesion may demonstrate its extra-axial nature, while low ADC values may point to a high tumour grade, to cite a few examples. However, based on current scientific evidence, it is not yet possible to establish a sufficiently consistent radiological-pathological correlation, so the radiologist has to delegate the definitive diagnosis of the disease to the pathologist. Future development of imaging techniques based on genomics and proteomics could be the key to a more accurate correlation between imaging and histological subtype.FundingThis study received no specific grants from public agencies, the commercial sector or non-profit organisations.Authorship<ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0250">1Responsible for the integrity of the study: ANB, MAB and SMD.</li><li class="elsevierStyleListItem" id="lsti0255">2Study conception: ANB, MAB and SMD.</li><li class="elsevierStyleListItem" id="lsti0260">3Study design: ANB, MAB and SMD.</li><li class="elsevierStyleListItem" id="lsti0265">4Data collection: ANB, MAB and SMD.</li><li class="elsevierStyleListItem" id="lsti0270">5Data analysis and interpretation: ANB, MAB and SMD.</li><li class="elsevierStyleListItem" id="lsti0275">6Literature search: ANB, MAB and SMD.</li><li class="elsevierStyleListItem" id="lsti0280">7Drafting of the article: ANB, MAB and SMD.</li><li class="elsevierStyleListItem" id="lsti0285">8Critical review of the manuscript with intellectually relevant contributions: ANB, MAB and SMD.</li><li class="elsevierStyleListItem" id="lsti0290">9Approval of the final version: ANB, MAB and SMD.</li></ul>Conflicts of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:3 [ "identificador" => "xres1975838" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1699477" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1975839" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1699476" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Syndromes associated with meningioma" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Symptoms of meningioma: clinical-radiological correlation" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Radiological features of meningioma" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Histological subtypes: radiological-pathological correlation" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conclusions" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Funding" ] 11 => array:2 [ "identificador" => "sec0040" "titulo" => "Authorship" ] 12 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of interest" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2022-12-27" "fechaAceptado" => "2023-02-07" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1699477" "palabras" => array:10 [ 0 => "Meningioma" 1 => "Anaplasia" 2 => "Radiology" 3 => "Diagnostic imaging" 4 => "Brain neoplasm" 5 => "Pathology" 6 => "Magnetic resonance spectroscopy" 7 => "Magnetic resonance imaging" 8 => "Diffusion magnetic resonance imaging" 9 => "Multidetector computed tomography" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1699476" "palabras" => array:10 [ 0 => "Meningioma" 1 => "Anaplasia" 2 => "Radiología" 3 => "Diagnóstico por imagen" 4 => "Neoplasia cerebral" 5 => "Patología" 6 => "Espectroscopia de resonancia magnética" 7 => "Imagen de resonancia magnética" 8 => "Difusión de imágenes por resonancia magnética" 9 => "Tomografía computarizada multidetector" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Meningiomas are tumors that originate in the arachnoid villi and are the most common non-glial neoplasm in the central nervous system. The clinical manifestations associated with meningioma depend, fundamentally, on its location. The location in the cerebral convexity is the most frequent, especially in the frontal lobes, manifesting with headache, motor disturbances, seizures and even neurocognitive disorders. There are 15 histologic subtypes of meningioma and three histologic grades. Within these, grades two and three have a worse prognosis and a higher rate of recurrence, as well as a radiological behavior that is generally more aggressive. Although there are some imaging features that can suggest a specific subtype, the definitive diagnosis will always require histological/molecular confirmation." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "Los meningiomas son tumores que se originan en las vellosidades aracnoideas y que constituyen la neoplasia no glial más común en el sistema nervioso central. Las manifestaciones clínicas asociadas al meningioma dependen, fundamentalmente, de su localización. La ubicación en la convexidad cerebral es las más frecuente, especialmente en lóbulos frontales, manifestándose con cefalea, alteraciones motoras, convulsiones e, incluso, con trastornos neurocognitivos. Existen 15 subtipos histológicos de meningioma y tres grados histológicos. Dentro de estos, los grados dos y tres tienen un peor pronóstico y una mayor tasa de recurrencia, así como un comportamiento radiológico, por lo general, más agresivo. Aunque existen algunas características de imagen que pueden permitir sugerir un subtipo concreto, el diagnóstico definitivo siempre requerirá la confirmación histológica/molecular." ] ] "multimedia" => array:10 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1971 "Ancho" => 650 "Tamanyo" => 270501 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0350" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Incidental finding in a 63-year-old woman who had MRI for migraine headache: a) Sagittal T2-weighted MRI. Note the lesion in the cerebellopontine angle (arrow). T2 hypointensity may be evidence of the meningioma histological subtype. The presence of a hyperintense halo on T2 along its border (cleft sign) indicates the extra-axial location of the lesion (arrowhead); b) T1-weighted fat-saturated gadolinium-enhanced sequence showing the lesion with heterogeneous uptake (arrow); c) Microscopic image at 200x magnification with haematoxylin-eosin staining, showing a proliferation of spindle-shaped meningothelial cells with predominantly hyaline stromal cells forming interlacing bundles. Pathology diagnosis of grade 1 fibrous meningioma." ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2695 "Ancho" => 874 "Tamanyo" => 380965 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0355" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "72-year-old female patient, being investigated by her neurologist for vertigo: a) Sagittal FLAIR MRI showing a meningioma of the frontal falx cerebri, isointense with respect to the grey matter and no discernible oedema in the adjacent brain parenchyma; b) Sagittal T1-weighted fat-saturated gadolinium-enhanced MRI. Homogeneous contrast uptake can be seen; c) Macroscopic appearance of the tumour after resection, showing a multilobulated nodular formation with a smooth external surface and whitish colouring; d) Microscopic image of the lesion at 100x magnification and haematoxylin-eosin staining, showing spindle cells arranged in parallel fascicles with collagenised stroma. Pathology diagnosis of grade 1 fibrous meningioma." ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2600 "Ancho" => 636 "Tamanyo" => 338910 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0360" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "71-year-old female patient with progressive neurological deterioration in the previous two months, with bradypsychia, motor incoordination and motor disorientation: a) Axial T2-weighted MRI. Lesion inside the left ventricle, hypointense and multi-lobulated; b) Axial T1-weighted fat-saturated gadolinium-enhanced MRI of the same patient. Shows contrast uptake, with areas of central necrosis; (c) Microscope image at 200x magnification, with haematoxylin-eosin staining. Neoplastic cellularity is evident with moderate nuclear pleomorphism and foci of necrosis; d) Microscope image at 400x magnification and haematoxylin-eosin staining. Mitotic figures (circles) can be seen in a lesion with a high proliferative index. Pathology diagnosis of grade 3 anaplastic meningioma." ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 2505 "Ancho" => 586 "Tamanyo" => 318619 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0365" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "34-year-old female patient with a month-long history of paraesthesia in hands and feet: a) Axial T2-weighted MRI. Heterogeneous predominantly hyperintense mass (arrow), displacing the medulla towards the posterior and left lateral region (arrowhead), causing slightly abnormal signal intensity, related to compressive myelopathy; b) fat-suppressed T2-weighted sagittal MRI showing the same lesion (arrow); c) and d) Microscopic images at 100× and 200× magnification respectively, with haematoxylin-eosin staining, showing a proliferation of clusters and sheets of clear cells delimited by hyalinised collagen septa. Higher magnification (×200) shows clusters of polygonal meningothelial cells with clear granular cytoplasm. Pathology diagnosis of clear cell meningioma with areas of grade 2 chordoid meningioma." ] ] 4 => array:8 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 2078 "Ancho" => 2007 "Tamanyo" => 674785 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0370" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "a) 65-year-old male patient with behavioural disturbance and temporospatial disorientation. T2-weighted axial MRI. Note the large number of cystic areas inside the lesion and the large amount of adjacent vasogenic oedema. On the right of the image is a 400× magnification microscope image with haematoxylin-eosin staining, showing a sheet-like proliferation of polygonal cells with homogeneous nuclei and large, clear cytoplasm. Pathology diagnosis of grade 2 clear cell meningioma; b) 64 year old woman who went to her doctor with a more than 10-year history of a left frontal tumour. She had no neurological symptoms. Axial T2-weighted MRI shows an extra-axial mass in the left frontal convexity, predominantly hyperintense on T2, associated with hyperostosis of the adjacent skullcap and an increase in soft tissue on the scalp. On the right of the image is the appearance of the lesion under 200× magnification microscopy with haematoxylin-eosin staining, showing meningothelial cell proliferation with intranuclear inclusions (circle) associated with micro (*) and macro (#) cysts. They are true cysts without epithelial lining as a result of degenerative change. As can be seen in this figure, several subtypes of meningioma can show a macroscopic cystic component." ] ] 5 => array:8 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 1334 "Ancho" => 2007 "Tamanyo" => 626545 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0375" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "a) 63 year old woman with an episode of partial seizures. Axial ADC map in MRI. Extra-axial mass in the right frontal convexity (arrow), with invasion and destruction of the adjacent skullcap. Note the clear hypointensity in ADC suggesting high histological grade. On the right is the macroscopic specimen of the surgical resection, consisting of a multi-lobulated nodular formation with a smooth external surface and a brownish colour. Light microscopy at 200x magnification and haematoxylin-eosin staining shows a hypercellular lesion with increased nuclear variability. The definitive diagnosis was grade 3 anaplastic meningioma; b) Incidental finding in a 59-year-old woman having MRI for mild cognitive impairment. Axial ADC map. Left parasagittal extra-axial mass, isointense with respect to the grey matter, suggesting low histological grade. On the right is a light microscope image of the same lesion at 100x magnification with haematoxylin-eosin staining, showing a mesenchymal-like neoplasm with a storiform growth pattern; at higher magnification the lesion consists of spindle-shaped meningothelial cells without atypia, with collagenised stromal areas. The final histological diagnosis was grade 1 fibrous meningioma." ] ] 6 => array:8 [ "identificador" => "fig0035" "etiqueta" => "Figure 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr7.jpeg" "Alto" => 1976 "Ancho" => 2007 "Tamanyo" => 566489 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0380" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "a) 65-year-old male who attended the emergency department due to epileptic seizures. Axial T2-weighted MRI showing an extra-axial mass in the left frontal convexity (arrow), with cystic areas inside and marked oedema. On the right is a specimen of the tumour (haematoxylin-eosin stain, ×100 magnification under the microscope) with a proliferation of meningothelial cells associated with calcifications and vascular proliferation with vessels of different calibre, all suggestive of the haemangiomatous subtype of grade 1 meningioma; (b) 47-year-old woman having a brain CT scan for migraine-type headache. Axial T2 MRI showing a bilobulated extra-axial mass in the right frontal convexity (black arrow), cystic areas inside, moderate oedema and mass effect, with displacement of the interhemispheric fissure to the left. On the right is a 100× magnification microscopy image showing diffuse nuclear staining and STAT6 characteristic of haemangiopericytoma. Although their radiological appearance can be confused, as a general rule, angiomatous meningioma and haemangiopericytoma can be differentiated on pathology examination." ] ] 7 => array:8 [ "identificador" => "fig0040" "etiqueta" => "Figure 8" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr8.jpeg" "Alto" => 2639 "Ancho" => 2007 "Tamanyo" => 614032 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0385" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "62-year-old female patient with a history of neurofibromatosis type 2, with left-dominant homonymous haemianopia: a) Non-contrast CT scan. Multiple calcified extra-axial lesions identified (arrow), compatible with meningioma; b) Fat-saturated T1-weighted MRI with gadolinium injection. Homogeneous contrast uptake is observed in most lesions (arrow); c) Microscopy image at 100x magnification with haematoxylin-eosin staining showing a fasciculated spindle cell neoplasm with cellular predominance; d) Progesterone receptor immunohistochemistry at 100x magnification; diffuse nuclear staining. Pathology diagnosis was grade 1 fibrous meningioma." ] ] 8 => array:8 [ "identificador" => "fig0045" "etiqueta" => "Figure 9" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr9.jpeg" "Alto" => 2408 "Ancho" => 874 "Tamanyo" => 314448 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0390" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "74-year-old female patient with 5–10min episode of loss of consciousness. Following this, she had self-limiting left facial paresis and dysarthria: a) CT with intravenous contrast showing an extra-axial mass in the temporal convexity (arrow). There is a central region with fat density which corresponds to an area of fat metaplasia. The rest of the lesion showed intense, homogeneous uptake of contrast; b) Sagittal T1-weighted MRI sequence. The fatty component seen on CT shows clear hyperintensity (arrow); (c) Image obtained with 100x magnification microscopy with haematoxylin-eosin staining. Some meningothelial cells can be seen containing fat-filled vacuoles which make them resemble adipocytes; the diagnosis is grade 1 metaplastic lipomatous meningioma." ] ] 9 => array:8 [ "identificador" => "fig0050" "etiqueta" => "Figure 10" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr10.jpeg" "Alto" => 2266 "Ancho" => 2007 "Tamanyo" => 718986 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0395" "detalle" => "Figure 1" "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "62-year-old female patient with worsening paraparesis, increased spasticity and abolished reflexes: (a) Axial T2-weighted MRI of the spine. Intradural extramedullary lesion (arrow) causing hydrosyringomyelia (arrowhead); (b) T1-weighted MRI with gadolinium. There is homogeneous contrast uptake, with lesion enclosing nerve roots (arrow); (c) 40× magnification microscopy image with haematoxylin-eosin staining showing cell proliferation interspersed with abundant psammoma bodies; (d) Higher magnification image (×100) of psammoma bodies. Pathology diagnosis of grade 1 psammomatous meningioma." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:71 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Magnetic resonance imaging of meningiomas: a pictorial review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J. Watts" 1 => "G. Box" 2 => "A. Galvin" 3 => "P. Brotchie" 4 => "N. Trost" 5 => "T. 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Actualización sobre el meningioma: correlación clínico-radiológica y radio-patológica

A. Navarro-Ballestera,

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antonio.navarroball@gmail.com

Corresponding author.

, M. Aleixandre-Barrachinab, S.F. Marco-Doménecha

a Servicio de Radiodiagnóstico, Hospital General Universitario de Castellón, Castellón de la Plana, Castellón, Spain

b Servicio de Anatomía Patológica, Hospital General Universitario de Castellón, Castellón de la Plana, Castellón, Spain

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beyond the high incidence&#44; to support the need for further studies on meningiomas&#46; Firstly&#44; the fact that they are mostly clinically silent makes it more difficult to obtain reliable data on epidemiology or clinical features&#46; Not surprisingly then&#44; some 80&#37; of these tumours are considered low-grade in the World Health Organisation &#40;WHO&#41; classification&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Secondly&#44; meningiomas have a high recurrence rate after surgery&#44; as well as a not-insignificant potential to be fatal&#44; both of which are related to histological grade&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The aim of this study was to analyse the most common locations for meningiomas and radiological behaviour based on their histological nature&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Syndromes associated with meningioma</span><p id="par0030" class="elsevierStylePara elsevierViewall">In people under the age of 40&#44; a finding of meningiomas raises the suspicion of neurofibromatosis type 2&#44; with intracranial meningiomas being an independent factor for poor prognosis associated with a two- to five-fold increase in the mortality rate for the neurofibromatosis&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Other diseases which increase the risk of meningiomas are multiple endocrine neoplasia type 1&#44; Cowden syndrome&#44; Werner syndrome&#44; nevoid basal cell carcinoma syndrome&#44; Rubinstein-Taybi syndrome&#44; BAP1 tumour predisposition syndrome and familial meningiomatosis&#44; which is caused by germline mutations in SMARCB1 and SMARCE1 genes&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Symptoms of meningioma&#58; clinical-radiological correlation</span><p id="par0035" class="elsevierStylePara elsevierViewall">Most meningiomas are asymptomatic and detected incidentally&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> In those that do cause symptoms&#44; the specific dural&#44; intracranial or spinal location enables us to estimate the clinical presentation to expect&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Cerebral convexity&#58;</span> is the most common location&#46; Approximately one in four meningiomas occupy this position&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In symptomatic patients&#44; the most common neurological manifestations detected are headache &#40;43&#46;4&#37;&#41;&#44; motor disturbances &#40;34&#46;4&#37;&#41; and seizures &#40;32&#46;8&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Among the locations in convexity&#44; the most common is frontal &#40;53&#37;&#41;&#44; followed by parietal &#40;20&#37;&#41;&#44; temporal &#40;18&#37;&#41;&#44; occipital &#40;7&#37;&#41; and pterional &#40;2&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> It is important to be aware that meningiomas of the frontal convexity can cause psychological and neurocognitive disorders&#44; a less common presentation which may delay diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Skull base&#58;</span> according to some of the series with the largest number of cases analysed&#44; the location at the skull base as a whole &#40;anterior&#44; middle or posterior cranial fossa&#41; would be the most common of all&#44; even above that of convexity&#44; with a prevalence of 47&#37;&#8211;58&#46;5&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;12</span></a> Within the skull base&#44; the middle cranial fossa is the most common location&#44; followed by the anterior and posterior respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> When meningiomas in this location cause symptoms&#44; headache is the most common &#40;52&#46;1&#37;&#41;&#44; slightly more so than in convexity tumours&#46; In second place are visual disturbances &#40;46&#46;5&#37;&#41;&#44; typical of anterior fossa meningiomas&#46; Clinical manifestations related to alterations in the cerebellum are found in 31&#46;7&#37; of cases&#44; usually in posterior fossa tumours&#44; where hydrocephalus and cranial nerve-related abnormalities are also more common&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Hearing loss can occur&#44; in most cases after invasion of the internal auditory canal by cerebellopontine angle meningiomas<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Anosmia can also occur&#44; being about three times more common in skull base than in convexity meningiomas&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> We should particularly mention meningiomas located in the vicinity of the greater wing of the sphenoid bone&#44; which are divided into lateral&#44; medial and intermediate&#44; depending on their position&#46; Those located lateral to the greater wing of the sphenoid bone tend to cause epilepsy and&#47;or speech disturbances if located on the left-hand side&#46; Those medial to the greater wing can cause unilateral loss of vision&#59; if affecting the cavernous sinus&#44; they may be associated with other symptoms&#44; usually starting with oculomotor deficits &#40;paresis&#44; ophthalmoplegia&#44; ptosis&#44; diplopia and anisocoria&#41; and progressing to facial hypoaesthesia or hyperaesthesia due to trigeminal nerve involvement&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Meningiomas of the middle cranial fossa&#44; in addition to the potential symptoms mentioned&#44; may also cause clinical manifestations due to cerebral ischaemia resulting from compression of the arteries that make up the circle of Willis&#44; and even alterations in pituitary function due to the mass effect of the tumour on the gland&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Parasagittal&#58;</span> defined as meningiomas which grow on at least one wall of the superior sagittal sinus&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Some 10&#37;&#8211;20&#37; of all meningiomas are found in this location&#44;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;9</span></a> although differentiating between parasagittal meningiomas and those located in the high convexity is not always simple&#59; those considered to be convexity meningiomas can even have small points of attachment to the dura mater of the superior sagittal sinus &#40;SSS&#41;&#46; The clinical presentation of the two differs very little and will depend on their specific position&#46; However&#44; it should be remembered that parasagittal meningiomas sometimes invade the SSS&#44; and this significantly affects the neurosurgical strategy&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Falx cerebri&#58;</span> about 8&#37; of meningiomas occupy this site<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;16</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; In this case&#44; the tumour arises from the falx cerebri&#44; but differs from the parasagittal tumour in that it is completely covered by the overlying cerebral cortex and does not affect the superior sagittal sinus&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> In the surgical series of Sung et al&#46;&#44; patients with falcine meningioma had symptoms such as headache &#40;30&#37;&#41;&#44; unilateral motor deficits &#40;16&#37;&#41;&#44; seizures &#40;7&#37;&#41; and personality disorders &#40;7&#37;&#41;&#44; with 6&#37; being asymptomatic&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> It has been found that&#44; at the same histological grade&#44; parasagittal and falcine meningiomas are more likely to recur&#44; possibly because of the greater difficulty in achieving complete resection in these locations&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0060" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Intraventricular&#58;</span> 0&#46;5&#37;&#8211;3&#37; of meningiomas<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; When located in the lateral ventricles&#44; it is more common for the left side to be affected&#59; this is also the case with other intracranial meningiomas&#44; but it is not understood why&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> Unlike other types of meningioma&#44; it tends to be silent and cause mild&#44; long-lasting symptoms such as headache or visual disturbances&#46; This means the tumour volume is usually large at the time of diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Intraventricular meningioma is associated more often than other tumours with postoperative meningitis&#44; a potentially serious complication&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Optic nerve&#58;</span> like intraventricular and pineal region meningiomas&#44; those affecting the optic nerve are part of the intradural meningioma family&#46; They account for 2&#37; of all orbital tumours and 1&#37; of all meningiomas&#46; They are usually intraorbital and unilateral &#40;92&#37; and 95&#37; respectively&#41; and their most common form is secondary&#44; in other words caused by the extension of an intracranial meningioma into the orbit&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Spinal&#58;</span> account for about 1&#46;2&#37; of all meningiomas&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> Most are located in the intradural compartment&#44; sparing the pial layer of the spinal cord&#44; and account for 25&#37;&#8211;45&#37; of all intradural spinal tumours&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> They are usually located in the thoracic spine &#40;78&#37;&#41;&#44; being less common in the cervical &#40;19&#37;&#41; and lumbar &#40;3&#37;&#41; areas&#46; In the axial plane&#44; they are most commonly lateral &#40;55&#37;&#41; or ventral &#40;29&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#44;24</span></a> They are more common in the older adult population and&#44; if diagnosed in young patients&#44; a genetic disorder such as neurofibromatosis type 2 or an aggressive histological subtype of the tumour should be suspected&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> The most common symptoms related to spinal meningioma are motor or sensory deficits &#40;84&#37;&#41;&#44; gait disturbances &#40;52&#37;&#8211;83&#37;&#41; and pain &#40;33&#37;&#8211;47&#37;&#41;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;24</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></li></ul></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Radiological features of meningioma</span><p id="par0360" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Plain X-ray&#58;</span> not a useful technique for the study of meningiomas&#46; In a very small number of cases&#44; intratumour calcifications&#44; the effect of meningiomas on the skullcap &#40;hyperostosis or bone resorption&#41; or enlargement of the meningeal artery grooves can be seen on skull X-rays&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Computed tomography</span><a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a>&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">o</span><p id="par0085" class="elsevierStylePara elsevierViewall">Calcification&#58; 25&#37;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">o</span><p id="par0090" class="elsevierStylePara elsevierViewall">Perilesional oedema&#58; 60&#37;&#8211;67&#37; of meningiomas&#44; but more easily identifiable by MRI&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;29</span></a></p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">o</span><p id="par0095" class="elsevierStylePara elsevierViewall">Hyperostosis of adjacent bone&#58; 20&#37; &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">o</span><p id="par0100" class="elsevierStylePara elsevierViewall">Osteolysis of adjacent bone&#58; rare finding and seen in intraosseous or locally invasive meningiomas&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">o</span><p id="par0105" class="elsevierStylePara elsevierViewall">Hyperdense relative to the rest of the brain in non-contrast study&#58; 60&#37;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">o</span><p id="par0110" class="elsevierStylePara elsevierViewall">Homogeneous and intense contrast enhancement&#58; 72&#37;&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">&#8226;</span><p id="par0115" class="elsevierStylePara elsevierViewall">Magnetic resonance imaging &#40;MRI&#41;&#58; the technique of choice&#46;</p></li></ul></p><p id="par0120" class="elsevierStylePara elsevierViewall">It typically presents as an extra-axial mass with well-defined margins&#58;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">&#8226;</span><p id="par0125" class="elsevierStylePara elsevierViewall">T1&#58; isointense with respect to the grey matter&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">&#8226;</span><p id="par0130" class="elsevierStylePara elsevierViewall">T2&#58; isointense or slightly hyperintense&#46;</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">&#8226;</span><p id="par0135" class="elsevierStylePara elsevierViewall">Magnetic susceptibility sequences&#58; areas of signal loss coinciding with calcifications&#46;</p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">&#8226;</span><p id="par0140" class="elsevierStylePara elsevierViewall">T1 with gadolinium&#58; intense and homogeneous enhancement&#46; Occasionally&#44; there may be areas of calcification and&#47;or necrosis which do not enhance&#46;</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">&#8226;</span><p id="par0145" class="elsevierStylePara elsevierViewall">Diffusion&#58; grade 2 or 3 tumours may have restricted diffusion &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41; but this is not a reliable predictor of histological grade&#44; due to its low negative predictive value&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p><elsevierMultimedia ident="fig0030"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">&#8226;</span><p id="par0150" class="elsevierStylePara elsevierViewall">&#8220;<span class="elsevierStyleItalic">Dural tail sign</span>&#8221;&#58; defined as thickening and enhancement of the dura mater adjacent to the tumour on contrast studies and seen in up to 72&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> The presence of this sign may be useful for differentiating meningioma of the cerebellopontine angle from schwannoma&#44; for example&#44; as a dural tail is not usually associated with schwannoma&#46; However&#44; it is not a pathognomonic sign and can be identified in other types of cancer such as glial tumours&#44; lymphomas and even metastases&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">&#8226;</span><p id="par0155" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Cerebrospinal fluid</span> &#8220;<span class="elsevierStyleItalic">cleft sign</span>&#8221;&#58; consists of a cleft of cerebrospinal fluid between the tumour and the underlying cortex and suggests the extra-axial origin of the lesion &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; This sign may not be found in grade 3 meningiomas&#44; due to their aggressive local behaviour&#46;</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">&#8226;</span><p id="par0160" class="elsevierStylePara elsevierViewall">&#8220;<span class="elsevierStyleItalic">Tram-track sign</span>&#8221; <span class="elsevierStyleItalic">&#40;optic nerve meningioma&#41;</span>&#58; intense gadolinium enhancement of the optic nerve sheath surrounding the nerve&#44; producing an image resembling tram tracks&#46; It is important to remember that&#44; although this sign differentiates meningioma from glioma&#44; it can be found in other diseases &#40;for example&#44; orbital pseudotumour&#44; optic perineuritis&#44; orbital sarcoidosis&#44; lymphoma and metastasis&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">&#8226;</span><p id="par0165" class="elsevierStylePara elsevierViewall">MRI spectroscopy&#58; in meningiomas&#44; it is common to find increased alanine&#44; choline and glutamine&#47;glutamate&#44; with reduced or absent N-acetylaspartate &#40;NAA&#41; and creatine&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Although elevated alanine has traditionally been considered characteristic of meningioma&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> it is not detected in all meningiomas and it may correlate inversely with the degree of tumour necrosis&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> One publication suggests that an increased choline&#47;NAA ratio &#62;2&#46;409 may be indicative of a high tumour grade&#44; with a specificity of 86&#46;36&#37;&#44; although further studies are needed to validate the results&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> Increases in lactate or lipids have also been suggested in the past as indicators of high tumour grade&#59; unfortunately&#44; they have proven to not always be reliable parameters&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;34</span></a></p></li><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">&#8226;</span><p id="par0170" class="elsevierStylePara elsevierViewall">Perfusion MRI&#58; meningiomas are hypervascular lesions and are therefore highly perfused in perfusion studies&#46; Relative cerebral blood volume &#40;rCBV&#41; will be increased&#44; with reported values of between 6 and 9<span class="elsevierStyleHsp" style=""></span>ml&#47;100<span class="elsevierStyleHsp" style=""></span>g&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> However&#44; a histological subtype such as angiomatous meningioma may have slightly higher figures&#44; due to its larger vascular component&#46; In contrast&#44; fibrous meningioma will show somewhat lower perfusion values due to the presence of hypovascular fibrous tissue&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35&#44;36</span></a></p></li></ul></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Histological subtypes&#58; radiological-pathological correlation</span><p id="par0175" class="elsevierStylePara elsevierViewall">Meningioma has a separate category in the 2021 fifth edition of the World Health Organisation Classification of Tumours of the Central Nervous System&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> This classification system establishes 15 histological subtypes of meningioma&#44; emphasising that the criteria defining atypical or anaplastic meningioma &#40;current grades 2 and 3 respectively&#41; should be applied regardless of the underlying subtype&#46; However&#44; there are some subtypes which&#44; due to their high recurrence rates or aggressive behaviour&#44; are assigned a grade higher than 1&#46; It should be noted that some molecular biomarkers can also demonstrate the assigned classification and grade&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">Histopathological criteria for differentiating grade 2 and 3 meningiomas<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a>&#58;<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">&#8226;</span><p id="par0185" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Grade 2 &#40;atypical&#41;&#58;</span> brain invasion&#44; between 4 and 19 mitoses in 10 consecutive high power fields &#40;HPF&#41; or the presence of three or more of the minor criteria &#40;increased cellularity&#44; small cells with a high nuclear&#47;cytoplasmic ratio&#44; prominent nucleoli&#44; foci of geographic or spontaneous necrosis and sheeting&#41; are the main diagnostic criteria for atypical meningiomas&#46; Chordoid and clear cell subtypes are directly categorised as atypical &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">&#8226;</span><p id="par0190" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Grade 3 &#40;anaplastic&#41;&#58;</span> suggested by increased mitotic count of &#8805;20 in 10 consecutive HPF&#44; homozygous deletion of CDKN2A&#47;B&#44; areas of sarcoma-&#44; carcinoma- or melanoma-like appearance&#44; TERT promoter mutation &#40;<a class="elsevierStyleCrossRefs" href="#fig0015">Figs&#46; 3 and 6</a>&#41;&#46;<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">-</span><p id="par0195" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Angiomatous&#58;</span> 1&#46;5&#37;&#8211;2&#46;1&#37; of meningiomas&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">40&#44;41</span></a> As the name suggests&#44; they are tumours with abundant blood vessels &#40;more than 50&#37; of the total tumour volume&#41; combined with areas of classic meningothelial differentiation&#46; Characteristically&#44; they have a slightly higher rCBV on perfusion MRI than other subtypes&#46; Differentiation of this subtype from the microcystic subtype is particularly difficult&#44; as both have similar findings in relation to their apparent diffusion coefficient &#40;ADC&#41; and perfusion&#44; and it is not uncommon for the angiomatous subtype to show areas of cystic degeneration&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> A differential feature between the two subtypes could be peritumoural oedema &#40;seen in 100&#37; of pure angiomatous versus 66&#46;7&#37; of pure microcystic<span class="elsevierStyleSup">&#41;</span><a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> or the higher likelihood of a dural tail &#40;66&#46;7&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> Despite being a histopathologically distinct entity&#44; it is not always easy to differentiate between angiomatous meningioma and solitary fibrous tumour of the meninges &#40;SFTM&#41;&#44; formerly known as haemangiopericytoma<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>&#41;&#46; Unlike the angiomatous subtype of meningioma&#44; SFTM are more common in males &#40;75&#37;&#41; and affect younger patients &#40;mean age 41&#46;4 compared to 48&#46;2 for meningioma&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> Radiologically&#44; the SFTM is isointense with respect to the grey matter in T1 and T2 and&#44; in general&#44; more often shows aggressive behaviour&#46; Also&#44; necrosis is more common&#44; with heterogeneous contrast uptake more likely than in meningioma&#46; In perfusion studies the rCBV of SFTM is even higher than that of angiomatous meningioma&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> On spectroscopy&#44; SFTM usually show a marked increase in choline with a lipid&#47;L-lactate peak&#44; increased glutamate&#47;glutamine&#44; increased myo-inositol&#44; decreased creatinine and no NAA&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> According to Ohba et al&#46;&#44; the combination of the criteria age &#60;45 years and myo-inositol &#62;6&#46;347 distinguishes SFTM from meningioma&#44; with a sensitivity of 100&#37; and a specificity of 97&#46;8&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a></p><elsevierMultimedia ident="fig0035"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">-</span><p id="par0200" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Atypical&#58;</span> is a WHO grade 2 tumour&#44; alongside chordoid meningioma and clear cell meningioma&#46; This histological grade has shown an increased relative incidence in recent years&#44; accounting for 22&#46;7&#37;&#8211;24&#46;5&#37; of all cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">45&#44;46</span></a> It is foreseeably more aggressive&#44; fast-growing and prone to recurrence than grade 1&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> However&#44; radiologically it is indistinguishable from grade 1 or 3 meningiomas&#46;</p></li><li class="elsevierStyleListItem" id="lsti0155"><span class="elsevierStyleLabel">-</span><p id="par0205" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Anaplastic&#58;</span> 1&#37;&#8211;3&#37; of meningiomas&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> This is the most aggressive form of the tumour and is classified as WHO grade 3&#46; Studies suggest that a higher degree of cellularity and intratumour necrosis correlate statistically significantly with low ADC&#44;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">36&#44;47</span></a> and a significant correlation was also found between low ADC and high tumour cell proliferation rates in high-grade meningiomas&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a></p></li><li class="elsevierStyleListItem" id="lsti0160"><span class="elsevierStyleLabel">-</span><p id="par0210" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Chordoid&#58;</span> 1&#37;&#8211;4&#46;1&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> Classified as a WHO grade 2 tumour&#46; The most characteristic imaging features are hyperintensity on T2 &#40;probably due to its richness in mucoid matrix&#41;&#44; but above all&#44; hyperintensity on ADC&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a> Cut-off values of ADC<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>1&#46;33<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">&#8722;3</span><span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span>&#47;s and normalised ADC &#40;NADC&#41; &#8805;1&#46;63 enable differentiation of chordoid meningioma from grade 1&#44; non-chordoid or focal chordoid grade 2 meningiomas &#40;&#60;50&#37;&#41; and grade 3 meningiomas on preoperative imaging with considerable diagnostic accuracy&#44; as all of the above usually show a more pronounced diffusion restriction with a low ADC &#40;800<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">&#8722;6</span><span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span>&#47;s&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a></p></li><li class="elsevierStyleListItem" id="lsti0165"><span class="elsevierStyleLabel">-</span><p id="par0215" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Clear cells&#58;</span> 0&#46;2&#37;&#8211;1&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">53&#44;54</span></a> Usually located in the cerebellopontine angle and in the spine&#44; especially in the cauda equina&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">54</span></a> They are classified as grade 2 and on imaging have the typical meningioma appearance&#44; with no differentiating features &#40;<a class="elsevierStyleCrossRefs" href="#fig0020">Figs&#46; 4 and 5</a>&#41;&#46; However&#44; they appear to show a very distinctive epigenetic signature&#44; with frequent mutations in the SMARCE1 gene and&#47;or loss of expression of the SMARCE protein&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a></p></li><li class="elsevierStyleListItem" id="lsti0170"><span class="elsevierStyleLabel">-</span><p id="par0220" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Fibrous or fibroblastic&#58;</span> considered one of the most common subtypes&#44; accounting for 7&#46;1&#37;&#8211;10&#46;2&#37; of the total in its isolated form&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">43&#44;56</span></a> As it is more common in its combined form &#40;transitional meningioma&#41;&#44; it is often not possible to differentiate it from the meningothelial subtype&#46; However&#44; in pure fibrous meningiomas&#44; a loss of signal on T2 can be identified due to their high collagen content&#44; a finding that distinguishes them from other subtypes of meningioma&#44; opening up the differential diagnosis towards other types of disease such as solitary fibrous tumour of the dura or histiocytosis &#40;Erdheim-Chester disease&#41;&#46; Another way to differentiate this subtype of meningioma is by detecting a mutation in the NF2 tumour suppressor gene&#44; which occurs in most neurofibromatosis type 2 and in 40&#37;&#8211;60&#37; of sporadic meningiomas&#44; especially in the fibrous and transitional subtypes and when located in the convexity and posterior fossa &#40;skull base&#41;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">57</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0040">Fig&#46; 8</a>&#41;&#46;</p><elsevierMultimedia ident="fig0040"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0175"><span class="elsevierStyleLabel">-</span><p id="par0225" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Lymphoplasmacytic&#58;</span> 0&#46;5&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a> The longest review to date is of 164 cases&#44; in which the authors note that this meningioma does not have a characteristic radiological appearance and cannot be differentiated from other subtypes&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">58</span></a></p></li><li class="elsevierStyleListItem" id="lsti0180"><span class="elsevierStyleLabel">-</span><p id="par0230" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Meningothelial&#58;</span> the most common subtype &#40;17&#37;&#41;&#44; second only to transitional meningioma&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a> Usually shows the general radiological characteristics of meningioma &#40;see section &#8220;Radiological features of meningioma&#8221;&#41;&#44; with no distinct imaging features to differentiate it from other subtypes&#46;</p></li><li class="elsevierStyleListItem" id="lsti0185"><span class="elsevierStyleLabel">-</span><p id="par0235" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Metaplastic&#58;</span> 0&#46;04&#37;&#8722;0&#46;21&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">59</span></a> In this case&#44; the tumour cells of the meningioma &#40;usually of the meningothelial&#44; fibrous or transitional subtypes&#41; differentiate to adopt the tissue characteristics of other parts of the body&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">60</span></a> Therefore&#44; the radiological appearance will depend on the type of tissue being expressed&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0190"><span class="elsevierStyleLabel">&#8226;</span><p id="par0240" class="elsevierStylePara elsevierViewall">Cartilaginous&#58; no more than 10 cases have been reported in the scientific literature&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">61</span></a> As the name suggests&#44; the meningioma takes on a cartilaginous appearance&#46; It may be difficult to distinguish from chondroblastoma or chondrosarcoma&#44; especially when located in the spine&#46;</p></li><li class="elsevierStyleListItem" id="lsti0195"><span class="elsevierStyleLabel">&#8226;</span><p id="par0245" class="elsevierStylePara elsevierViewall">Lipomatous&#58; the meningothelial cells take on an appearance resembling adipocytes &#40;<a class="elsevierStyleCrossRef" href="#fig0045">Fig&#46; 9</a>&#41;&#46; Some studies have suggested that the accumulation of lipids in these cells is due to altered metabolism rather than true metaplasia&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">60</span></a> If there is a sufficient amount of fatty tissue&#44; they will be hypointense on CT and hyperintense on MRI on T1-weighted sequences&#44; with loss of signal after fat suppression&#46;</p><elsevierMultimedia ident="fig0045"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0200"><span class="elsevierStyleLabel">&#8226;</span><p id="par0250" class="elsevierStylePara elsevierViewall">Melanotic&#58; if there is a sufficient amount of melanin&#44; it will be hyperintense on T1&#44; with variable behaviour in T2 &#40;the presence of haemorrhage can cause hypointensity&#41; and homogeneous contrast uptake&#46; This differs from melanomas and meningeal melanocytosis in that they tend to have a more heterogeneous uptake pattern&#46; However&#44; it is not uncommon for them to be confused on imaging&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">62</span></a></p></li><li class="elsevierStyleListItem" id="lsti0205"><span class="elsevierStyleLabel">&#8226;</span><p id="par0255" class="elsevierStylePara elsevierViewall">Myxoid&#58; myxoid transformation involves the presence of endothelial cells&#44; pericytes and stromal cells&#46; This type has the general appearance of any meningioma&#44; with no distinctive imaging features&#46; Immunohistochemistry plays an important role in differentiating myxoid from other meningiomas which also have a stromal matrix&#44; such as chordoid meningioma&#46;</p></li><li class="elsevierStyleListItem" id="lsti0210"><span class="elsevierStyleLabel">&#8226;</span><p id="par0260" class="elsevierStylePara elsevierViewall">Bone&#58; similar characteristics to other meningiomas&#46; Their bone differentiation makes it virtually impossible to differentiate them from meningiomas with a tendency to calcify &#40;psammomatous&#41; and intraosseous meningiomas&#46;</p></li><li class="elsevierStyleListItem" id="lsti0215"><span class="elsevierStyleLabel">&#8226;</span><p id="par0265" class="elsevierStylePara elsevierViewall">Xanthomatous&#58; imaging characteristics are very similar to the lipomatous variant of meningioma&#44; and can only be differentiated on histological examination&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">63</span></a><ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0220"><span class="elsevierStyleLabel">-</span><p id="par0270" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Microcystic&#58;</span> 1&#37;&#8211;1&#46;6&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">63</span></a> Radiological features suggestive of this subtype include hypointensity on T1-weighted images and irregular peripheral gadolinium uptake&#46; However&#44; although this uptake pattern is very specific &#40;94&#37;&#41;&#44; it is not very sensitive &#40;27&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">64</span></a> Another typical feature is that&#44; compared to other subtypes of the same grade&#44; it tends to have a larger volume of peritumoural oedema&#44; which seems to be due to a higher vascular permeability factor&#47;vascular endothelial growth factor ratio<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">64</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>B&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0225"><span class="elsevierStyleLabel">-</span><p id="par0275" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Papillary&#58;</span> 1&#37;&#8211;2&#46;5&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">65</span></a> Papillary meningiomas are characterised by their aggressive behaviour&#44; with a greater tendency towards recurrence and even metastasis&#44;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">66</span></a> but they are no longer classified as grade 3&#44; as in the previous WHO classification&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">67</span></a></p></li><li class="elsevierStyleListItem" id="lsti0230"><span class="elsevierStyleLabel">-</span><p id="par0280" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Psammomatous&#58;</span> 0&#46;5&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a> We have to differentiate between the terms &#8220;<span class="elsevierStyleItalic">calcification</span>&#8221; and &#8220;<span class="elsevierStyleItalic">ossification</span>&#8221;&#46; &#8220;<span class="elsevierStyleItalic">Calcification</span>&#8221; is a radiological concept which usually refers to the accumulation of psammoma bodies and is therefore common in psammomatous meningioma&#46; Ossification in meningioma manifests as the presence of mature or immature bone tissue within the tumour and is a much rarer phenomenon histologically&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">68</span></a> On CT it appears as a calcified lesion&#44; although when the psammoma bodies are more dispersed&#44; it shows as a hyperdense mass without clear calcifications&#46; On MRI&#44; it may show hypointensity on T2-weighted images and loss of signal on magnetic susceptibility sequences &#40;<a class="elsevierStyleCrossRef" href="#fig0050">Fig&#46; 10</a>&#41;&#46;</p><elsevierMultimedia ident="fig0050"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0235"><span class="elsevierStyleLabel">-</span><p id="par0285" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rabdoid&#58;</span> 0&#46;004&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">69</span></a> The term rhabdoid refers to the characteristic resemblance of the cells to a rhabdomyoblast without true musculoskeletal differentiation&#46; This histological type usually means a poor prognosis and a tendency for recurrence&#46; They can have a cystic component &#40;38&#37;&#41; and marked peritumoural oedema&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">70</span></a> There may be associated bone changes&#44; ranging from hyperostosis &#40;60&#37;&#41; to bone destruction &#40;33&#46;33&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">70</span></a></p></li><li class="elsevierStyleListItem" id="lsti0240"><span class="elsevierStyleLabel">-</span><p id="par0290" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Secretory&#58;</span> 0&#46;5&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a> They tend to be located at the base of the skull&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">69</span></a> Radiological features are indistinguishable from other meningiomas&#44; although they are more likely to show hyperintensity on T2-weighted images &#40;95&#46;6&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">71</span></a></p></li><li class="elsevierStyleListItem" id="lsti0245"><span class="elsevierStyleLabel">-</span><p id="par0295" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Transitional&#58;</span> the most common subtype &#40;39&#46;8&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a> Combined form of meningothelial and fibroblastic meningioma&#59; imaging features will depend on which component is predominant&#46;</p></li></ul></p></li></ul></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="par0300" class="elsevierStylePara elsevierViewall">Imaging techniques and particularly MRI can be a useful tool to guide the diagnosis of meningioma&#44; ruling out alternative diagnoses with different management&#44; and sometimes helping us make a preliminary estimation of the potential histological subtype and grade&#46; Findings such as the presence of a cerebrospinal fluid cleft around the lesion may demonstrate its extra-axial nature&#44; while low ADC values may point to a high tumour grade&#44; to cite a few examples&#46; However&#44; based on current scientific evidence&#44; it is not yet possible to establish a sufficiently consistent radiological-pathological correlation&#44; so the radiologist has to delegate the definitive diagnosis of the disease to the pathologist&#46; Future development of imaging techniques based on genomics and proteomics could be the key to a more accurate correlation between imaging and histological subtype&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Funding</span><p id="par0305" class="elsevierStylePara elsevierViewall">This study received no specific grants from public agencies&#44; the commercial sector or non-profit organisations&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Authorship</span><p id="par0365" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0250"><span class="elsevierStyleLabel">1</span><p id="par0310" class="elsevierStylePara elsevierViewall">Responsible for the integrity of the study&#58; ANB&#44; MAB and SMD&#46;</p></li><li class="elsevierStyleListItem" id="lsti0255"><span class="elsevierStyleLabel">2</span><p id="par0315" class="elsevierStylePara elsevierViewall">Study conception&#58; ANB&#44; MAB and SMD&#46;</p></li><li class="elsevierStyleListItem" id="lsti0260"><span class="elsevierStyleLabel">3</span><p id="par0320" class="elsevierStylePara elsevierViewall">Study design&#58; ANB&#44; MAB and SMD&#46;</p></li><li class="elsevierStyleListItem" id="lsti0265"><span class="elsevierStyleLabel">4</span><p id="par0325" class="elsevierStylePara elsevierViewall">Data collection&#58; ANB&#44; MAB and SMD&#46;</p></li><li class="elsevierStyleListItem" id="lsti0270"><span class="elsevierStyleLabel">5</span><p id="par0330" class="elsevierStylePara elsevierViewall">Data analysis and interpretation&#58; ANB&#44; MAB and SMD&#46;</p></li><li class="elsevierStyleListItem" id="lsti0275"><span class="elsevierStyleLabel">6</span><p id="par0335" class="elsevierStylePara elsevierViewall">Literature search&#58; ANB&#44; MAB and SMD&#46;</p></li><li class="elsevierStyleListItem" id="lsti0280"><span class="elsevierStyleLabel">7</span><p id="par0340" class="elsevierStylePara elsevierViewall">Drafting of the article&#58; ANB&#44; MAB and SMD&#46;</p></li><li class="elsevierStyleListItem" id="lsti0285"><span class="elsevierStyleLabel">8</span><p id="par0345" class="elsevierStylePara elsevierViewall">Critical review of the manuscript with intellectually relevant contributions&#58; ANB&#44; MAB and SMD&#46;</p></li><li class="elsevierStyleListItem" id="lsti0290"><span class="elsevierStyleLabel">9</span><p id="par0350" class="elsevierStylePara elsevierViewall">Approval of the final version&#58; ANB&#44; MAB and SMD&#46;</p></li></ul></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of interest</span><p id="par0355" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Meningiomas are tumors that originate in the arachnoid villi and are the most common non-glial neoplasm in the central nervous system&#46; The clinical manifestations associated with meningioma depend&#44; fundamentally&#44; on its location&#46; The location in the cerebral convexity is the most frequent&#44; especially in the frontal lobes&#44; manifesting with headache&#44; motor disturbances&#44; seizures and even neurocognitive disorders&#46; There are 15 histologic subtypes of meningioma and three histologic grades&#46; Within these&#44; grades two and three have a worse prognosis and a higher rate of recurrence&#44; as well as a radiological behavior that is generally more aggressive&#46; Although there are some imaging features that can suggest a specific subtype&#44; the definitive diagnosis will always require histological&#47;molecular confirmation&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Los meningiomas son tumores que se originan en las vellosidades aracnoideas y que constituyen la neoplasia no glial m&#225;s com&#250;n en el sistema nervioso central&#46; Las manifestaciones cl&#237;nicas asociadas al meningioma dependen&#44; fundamentalmente&#44; de su localizaci&#243;n&#46; La ubicaci&#243;n en la convexidad cerebral es las m&#225;s frecuente&#44; especialmente en l&#243;bulos frontales&#44; manifest&#225;ndose con cefalea&#44; alteraciones motoras&#44; convulsiones e&#44; incluso&#44; con trastornos neurocognitivos&#46; Existen 15 subtipos histol&#243;gicos de meningioma y tres grados histol&#243;gicos&#46; Dentro de estos&#44; los grados dos y tres tienen un peor pron&#243;stico y una mayor tasa de recurrencia&#44; as&#237; como un comportamiento radiol&#243;gico&#44; por lo general&#44; m&#225;s agresivo&#46; Aunque existen algunas caracter&#237;sticas de imagen que pueden permitir sugerir un subtipo concreto&#44; el diagn&#243;stico definitivo siempre requerir&#225; la confirmaci&#243;n histol&#243;gica&#47;molecular&#46;</p></span>"
      ]
    ]
    "multimedia" => array:10 [
      0 => array:8 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
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        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
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        "detalles" => array:1 [
          0 => array:3 [
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Incidental finding in a 63-year-old woman who had MRI for migraine headache&#58; a&#41; Sagittal T2-weighted MRI&#46; Note the lesion in the cerebellopontine angle &#40;arrow&#41;&#46; T2 hypointensity may be evidence of the meningioma histological subtype&#46; The presence of a hyperintense halo on T2 along its border &#40;cleft sign&#41; indicates the extra-axial location of the lesion &#40;arrowhead&#41;&#59; b&#41; T1-weighted fat-saturated gadolinium-enhanced sequence showing the lesion with heterogeneous uptake &#40;arrow&#41;&#59; c&#41; Microscopic image at 200x magnification with haematoxylin-eosin staining&#44; showing a proliferation of spindle-shaped meningothelial cells with predominantly hyaline stromal cells forming interlacing bundles&#46; Pathology diagnosis of grade 1 fibrous meningioma&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
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        "detalles" => array:1 [
          0 => array:3 [
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">72-year-old female patient&#44; being investigated by her neurologist for vertigo&#58; a&#41; Sagittal FLAIR MRI showing a meningioma of the frontal falx cerebri&#44; isointense with respect to the grey matter and no discernible oedema in the adjacent brain parenchyma&#59; b&#41; Sagittal T1-weighted fat-saturated gadolinium-enhanced MRI&#46; Homogeneous contrast uptake can be seen&#59; c&#41; Macroscopic appearance of the tumour after resection&#44; showing a multilobulated nodular formation with a smooth external surface and whitish colouring&#59; d&#41; Microscopic image of the lesion at 100x magnification and haematoxylin-eosin staining&#44; showing spindle cells arranged in parallel fascicles with collagenised stroma&#46; Pathology diagnosis of grade 1 fibrous meningioma&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 2600
            "Ancho" => 636
            "Tamanyo" => 338910
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        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0360"
            "detalle" => "Figure "
            "rol" => "short"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">71-year-old female patient with progressive neurological deterioration in the previous two months&#44; with bradypsychia&#44; motor incoordination and motor disorientation&#58; a&#41; Axial T2-weighted MRI&#46; Lesion inside the left ventricle&#44; hypointense and multi-lobulated&#59; b&#41; Axial T1-weighted fat-saturated gadolinium-enhanced MRI of the same patient&#46; Shows contrast uptake&#44; with areas of central necrosis&#59; &#40;c&#41; Microscope image at 200x magnification&#44; with haematoxylin-eosin staining&#46; Neoplastic cellularity is evident with moderate nuclear pleomorphism and foci of necrosis&#59; d&#41; Microscope image at 400x magnification and haematoxylin-eosin staining&#46; Mitotic figures &#40;circles&#41; can be seen in a lesion with a high proliferative index&#46; Pathology diagnosis of grade 3 anaplastic meningioma&#46;</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "fig0020"
        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr4.jpeg"
            "Alto" => 2505
            "Ancho" => 586
            "Tamanyo" => 318619
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0365"
            "detalle" => "Figure "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">34-year-old female patient with a month-long history of paraesthesia in hands and feet&#58; a&#41; Axial T2-weighted MRI&#46; Heterogeneous predominantly hyperintense mass &#40;arrow&#41;&#44; displacing the medulla towards the posterior and left lateral region &#40;arrowhead&#41;&#44; causing slightly abnormal signal intensity&#44; related to compressive myelopathy&#59; b&#41; fat-suppressed T2-weighted sagittal MRI showing the same lesion &#40;arrow&#41;&#59; c&#41; and d&#41; Microscopic images at 100&#215; and 200&#215; magnification respectively&#44; with haematoxylin-eosin staining&#44; showing a proliferation of clusters and sheets of clear cells delimited by hyalinised collagen septa&#46; Higher magnification &#40;&#215;200&#41; shows clusters of polygonal meningothelial cells with clear granular cytoplasm&#46; Pathology diagnosis of clear cell meningioma with areas of grade 2 chordoid meningioma&#46;</p>"
        ]
      ]
      4 => array:8 [
        "identificador" => "fig0025"
        "etiqueta" => "Figure 5"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr5.jpeg"
            "Alto" => 2078
            "Ancho" => 2007
            "Tamanyo" => 674785
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0370"
            "detalle" => "Figure "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">a&#41; 65-year-old male patient with behavioural disturbance and temporospatial disorientation&#46; T2-weighted axial MRI&#46; Note the large number of cystic areas inside the lesion and the large amount of adjacent vasogenic oedema&#46; On the right of the image is a 400&#215; magnification microscope image with haematoxylin-eosin staining&#44; showing a sheet-like proliferation of polygonal cells with homogeneous nuclei and large&#44; clear cytoplasm&#46; Pathology diagnosis of grade 2 clear cell meningioma&#59; b&#41; 64 year old woman who went to her doctor with a more than 10-year history of a left frontal tumour&#46; She had no neurological symptoms&#46; Axial T2-weighted MRI shows an extra-axial mass in the left frontal convexity&#44; predominantly hyperintense on T2&#44; associated with hyperostosis of the adjacent skullcap and an increase in soft tissue on the scalp&#46; On the right of the image is the appearance of the lesion under 200&#215; magnification microscopy with haematoxylin-eosin staining&#44; showing meningothelial cell proliferation with intranuclear inclusions &#40;circle&#41; associated with micro &#40;&#42;&#41; and macro &#40;&#35;&#41; cysts&#46; They are true cysts without epithelial lining as a result of degenerative change&#46; As can be seen in this figure&#44; several subtypes of meningioma can show a macroscopic cystic component&#46;</p>"
        ]
      ]
      5 => array:8 [
        "identificador" => "fig0030"
        "etiqueta" => "Figure 6"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr6.jpeg"
            "Alto" => 1334
            "Ancho" => 2007
            "Tamanyo" => 626545
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0375"
            "detalle" => "Figure "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">a&#41; 63 year old woman with an episode of partial seizures&#46; Axial ADC map in MRI&#46; Extra-axial mass in the right frontal convexity &#40;arrow&#41;&#44; with invasion and destruction of the adjacent skullcap&#46; Note the clear hypointensity in ADC suggesting high histological grade&#46; On the right is the macroscopic specimen of the surgical resection&#44; consisting of a multi-lobulated nodular formation with a smooth external surface and a brownish colour&#46; Light microscopy at 200x magnification and haematoxylin-eosin staining shows a hypercellular lesion with increased nuclear variability&#46; The definitive diagnosis was grade 3 anaplastic meningioma&#59; b&#41; Incidental finding in a 59-year-old woman having MRI for mild cognitive impairment&#46; Axial ADC map&#46; Left parasagittal extra-axial mass&#44; isointense with respect to the grey matter&#44; suggesting low histological grade&#46; On the right is a light microscope image of the same lesion at 100x magnification with haematoxylin-eosin staining&#44; showing a mesenchymal-like neoplasm with a storiform growth pattern&#59; at higher magnification the lesion consists of spindle-shaped meningothelial cells without atypia&#44; with collagenised stromal areas&#46; The final histological diagnosis was grade 1 fibrous meningioma&#46;</p>"
        ]
      ]
      6 => array:8 [
        "identificador" => "fig0035"
        "etiqueta" => "Figure 7"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr7.jpeg"
            "Alto" => 1976
            "Ancho" => 2007
            "Tamanyo" => 566489
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0380"
            "detalle" => "Figure "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">a&#41; 65-year-old male who attended the emergency department due to epileptic seizures&#46; Axial T2-weighted MRI showing an extra-axial mass in the left frontal convexity &#40;arrow&#41;&#44; with cystic areas inside and marked oedema&#46; On the right is a specimen of the tumour &#40;haematoxylin-eosin stain&#44; &#215;100 magnification under the microscope&#41; with a proliferation of meningothelial cells associated with calcifications and vascular proliferation with vessels of different calibre&#44; all suggestive of the haemangiomatous subtype of grade 1 meningioma&#59; &#40;b&#41; 47-year-old woman having a brain CT scan for migraine-type headache&#46; Axial T2 MRI showing a bilobulated extra-axial mass in the right frontal convexity &#40;black arrow&#41;&#44; cystic areas inside&#44; moderate oedema and mass effect&#44; with displacement of the interhemispheric fissure to the left&#46; On the right is a 100&#215; magnification microscopy image showing diffuse nuclear staining and STAT6 characteristic of haemangiopericytoma&#46; Although their radiological appearance can be confused&#44; as a general rule&#44; angiomatous meningioma and haemangiopericytoma can be differentiated on pathology examination&#46;</p>"
        ]
      ]
      7 => array:8 [
        "identificador" => "fig0040"
        "etiqueta" => "Figure 8"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr8.jpeg"
            "Alto" => 2639
            "Ancho" => 2007
            "Tamanyo" => 614032
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0385"
            "detalle" => "Figure "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">62-year-old female patient with a history of neurofibromatosis type 2&#44; with left-dominant homonymous haemianopia&#58; a&#41; Non-contrast CT scan&#46; Multiple calcified extra-axial lesions identified &#40;arrow&#41;&#44; compatible with meningioma&#59; b&#41; Fat-saturated T1-weighted MRI with gadolinium injection&#46; Homogeneous contrast uptake is observed in most lesions &#40;arrow&#41;&#59; c&#41; Microscopy image at 100x magnification with haematoxylin-eosin staining showing a fasciculated spindle cell neoplasm with cellular predominance&#59; d&#41; Progesterone receptor immunohistochemistry at 100x magnification&#59; diffuse nuclear staining&#46; Pathology diagnosis was grade 1 fibrous meningioma&#46;</p>"
        ]
      ]
      8 => array:8 [
        "identificador" => "fig0045"
        "etiqueta" => "Figure 9"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr9.jpeg"
            "Alto" => 2408
            "Ancho" => 874
            "Tamanyo" => 314448
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0390"
            "detalle" => "Figure "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">74-year-old female patient with 5&#8211;10<span class="elsevierStyleHsp" style=""></span>min episode of loss of consciousness&#46; Following this&#44; she had self-limiting left facial paresis and dysarthria&#58; a&#41; CT with intravenous contrast showing an extra-axial mass in the temporal convexity &#40;arrow&#41;&#46; There is a central region with fat density which corresponds to an area of fat metaplasia&#46; The rest of the lesion showed intense&#44; homogeneous uptake of contrast&#59; b&#41; Sagittal T1-weighted MRI sequence&#46; The fatty component seen on CT shows clear hyperintensity &#40;arrow&#41;&#59; &#40;c&#41; Image obtained with 100x magnification microscopy with haematoxylin-eosin staining&#46; Some meningothelial cells can be seen containing fat-filled vacuoles which make them resemble adipocytes&#59; the diagnosis is grade 1 metaplastic lipomatous meningioma&#46;</p>"
        ]
      ]
      9 => array:8 [
        "identificador" => "fig0050"
        "etiqueta" => "Figure 10"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr10.jpeg"
            "Alto" => 2266
            "Ancho" => 2007
            "Tamanyo" => 718986
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0395"
            "detalle" => "Figure 1"
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">62-year-old female patient with worsening paraparesis&#44; increased spasticity and abolished reflexes&#58; &#40;a&#41; Axial T2-weighted MRI of the spine&#46; Intradural extramedullary lesion &#40;arrow&#41; causing hydrosyringomyelia &#40;arrowhead&#41;&#59; &#40;b&#41; T1-weighted MRI with gadolinium&#46; There is homogeneous contrast uptake&#44; with lesion enclosing nerve roots &#40;arrow&#41;&#59; &#40;c&#41; 40&#215; magnification microscopy image with haematoxylin-eosin staining showing cell proliferation interspersed with abundant psammoma bodies&#59; &#40;d&#41; Higher magnification image &#40;&#215;100&#41; of psammoma bodies&#46; Pathology diagnosis of grade 1 psammomatous meningioma&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
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                        "tituloSerie" => "Neurochirurgie&#46;"
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                        "paginaFinal" => "79"
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Article information

ISSN: 21735107
Original language: English

DOI:10.1016/j.rxeng.2023.09.002

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