PMC9282788_01
Parasagittal meningioma. Axial (a) and coronal (b) T1-weighted magnetic resonance images showing an enhanced tumor in the right parasagittal region that extends toward the superior sagittal sinus (SSS) (white arrow). (c) Lateral right internal carotid angiogram, arterial phase, showing a tumor blush supplied by the anterior cerebral artery (ACA). (d) Lateral right internal carotid angiogram, capillary phase, showing stasis of tumor blood flow. (e) Lateral right external carotid angiogram showing that both the middle meningeal artery (MMA) and superficial temporal artery (STA) supply the dural arteriovenous fistula (dAVF). (f) Lateral left external carotid angiogram showing that both the MMA and STA supply the dAVF.
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F1
T1-weighted magnetic resonance (MR) imaging showed prominent enhancement with dural tail sign after gadolinium-diethylenetriaminepenta-acid acid administration, suggestive of meningioma [Figures 1a and b]. Simultaneous congestion findings suggested impaired drainage to the SSS [Figures 1c and d]. Bilateral external carotid angiography showed shunt blood flow from the bilateral MMAs, superficial temporal artery (STA), and occipital artery (OA) to the SSS colocated with the tumor invasion site [Figures 1e and f].
(a) Computed tomography scan showing left frontal subcortical hemorrhage. Axial (b) and coronal (c) T1-weighted magnetic resonance images showing a homogeneous enhanced growing tumor in the right parasagittal region that extends toward the superior sagittal sinus (SSS) (white arrow). (d) Lateral right internal carotid angiogram, arterial phase, showing a pial AVF fed by the ACA (white dotted arrow). (e) Lateral right internal carotid angiogram, capillary phase, showing retrograde blood flow anteriorly in the SSS (white arrowhead). (f) Anteroposterior right internal carotid angiogram showing cortical venous reflux in the left frontal cortex (white asterisk). Lateral right (g) and left (h) external carotid angiograms showing that the MMA, STA, and occipital artery supply the dAVF and stenosis of the posterior third of the SSS (white arrowhead).
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F2
On admission, CT showed small subcortical hemorrhage in the left frontal lobe [Figure 2a]. MR imaging showed that the tumor had increased to 4 cm in size compared to 4 years ago [Figures 2b and c]. Carotid angiography showed a pial shunt from the ACA PIFA to the SSS and slight tumor staining [Figure 2d]. The findings of stagnant perfusion from the ACA were improved compared to the initial carotid angiography taken 4 years before [Figure 2e]. The stenosis of the posterior third of the SSS and the development of dAVF seemed to have caused retrograde blood flow anteriorly in the SSS, indicating left frontal cortical venous regurgitation [Figures 2e and f]. External carotid angiography showed an increased shunt from the bilateral STAs, OAs, and MMAs to the SSS similar to the tumor invasion [Figures 2g and h].
Tumor removal through right frontal craniotomy. The PIFA (white arrow) of the ACA was incised into the tumor (white asterisk) and a shunt vessel (white dotted arrow) was found on the anterior surface of the tumor.
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F3
Ten days after the embolization, tumor removal and shunt dissection were performed [Figure 3].
Postoperative axial (a) and coronal (b) T1-weighted magnetic resonance images confirming gross total resection of the tumor except for the superior sagittal sinus (SSS) invasion (white arrow). (c) Postoperative lateral right internal carotid angiogram, arterial phase, demonstrating disappearance of a pial AVF fed by the ACA. (d) Lateral right internal carotid angiogram, venous phase, showing antegrade flow of the SSS. Lateral right (e) and left (f) external carotid angiograms demonstrating disappearance of the dAVF.
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F4
Postoperative MR imaging showed partial removal of the tumor except for the part inside the SSS [Figures 4a and b]. Postoperative carotid angiography showed disappearance of tumor staining and shunt blood flow from the ACA, and disappearance of shunt blood flow from the bilateral OAs, STAs, and MMAs to the lesion [Figures 4c-4f].