1977, British Journal of Radiology, 50, 15-22

JANUARY

1977

The radiological diagnosis of meningiomas, the impact of EMI scanning* scanning

By L E. Claveria, L.M.S., D. Sutton, M.D., F.R.C.P., F.R.C.R., and B. M. Tress, F.R.C.R. Radiological Departments, The National Hospitals for Nervous Diseases, Queen Square, London, W.C.1 and Maida Vale, W.9
{Received July, 1976)
ABSTRACT

A review of the impact of computerized axial tomography on the radiological diagnosis of meningiomas is presented. Seventy-one intracranial and eight orbital cases have been examined by this new method using the 160 X 160 matrix. The diagnostic accuracy of the method is compared with established neuroradiological methods of examination (plain X rays, angiography, pneumography and isotope scanning). The new non-invasive method is undoubtedly the most accurate diagnostic tool yet available. It provided a specific diagnosis of meningioma in 77% of the intracranial cases without contrast enhancement and diagnosed the presence of tumour in a further 19% giving an overall tumour diagnosis of 96%. There were three false negatives (4%). After intravenous injection of contrast medium specific diagnosis of meningioma was made in a further six cases raising the specific diagnostic rate to 86%. Specific identification of intra-orbital meningiomas is more difficult though the presence of retro-orbital tumour was correctly diagnosed in all eight cases examined (100%). In none of our cases was a false positive diagnosis of tumour made. However, there are areas where a specific diagnosis of meningioma can only be made as part of a wider differential diagnosis. Apart from the orbit these include the suprasellar area, the cerebello-pontine angle, and the intraventricular regions. Occasionally also supratentorial gliomas or secondaries can simulate meningiomas.

Appleby, 1969; Butchel et al, 1971), while the presence of tumour should be diagnosed in over 90% (Jacobson et al, 1959). Pneumography will similarly localize 95% of meningiomas (Wickbom and Statin, 1958). Both these methods are invasive; they may require general anaesthetic and present some risk to the patient. Brain scanning will diagnose a tumour in 70-90% of meningiomas and the pattern of uptake will suggest the pathology in a high proportion of these (Schunk et al, 1964; Witcofski et al, 1967; duBoulay and McAllister, 1970; Sauer et al, 1971; Sheldon et al, 1973). Material: 71 intracranial meningiomas have been investigated by computerized axial tomography (CAT) with the high resolution matrix (160x160) and by various other methods. The comparative value of these is discussed below. Eight orbital cases have been separately assessed. Findings Plain X ray. The diagnosis of cerebral tumour was made in 39 out of 57 cases where plain X rays were available for review (72%): specific diagnosis of meningioma was made in 25 of these cases (46%). Specific diagnosis is based on the presence of such features as characteristic meningeal calcification, bony hyperostosis in a typical meningioma site and locally increased meningeal markings leading to a meningioma. Angiography: Arteriography was performed in 45 cases. It was diagnostic of tumour in 42 cases (93%) and diagnostic of meningioma in 33 cases (73%). It was considered normal in three cases (6%). Angiography was frequently undertaken in cases where the diagnosis of meningioma was already certain on other grounds. The reason for this is that many neurosurgeons wish to define the exact relationship of the tumour to veins and arteries and to determine the exact blood supply of the tumour before operation. Meningiomas can infiltrate around arteries and can also invade veins. This can be particularly important with sphenoidal ridge meningiomas invading the middle cerebral or anterior cerebral artery. It is

Meningiomas are one of the commonest intracranial tumours. The diagnosis is frequently suspected on clinical grounds but definitive diagnosis has up to now depended on radiological methods and, in more recent years, gamma scanning of the brain. The accuracy of these methods has been the subject of several reviews. For the last two years EMI scanning has been available at the National Hospital, Queen Square, and this has given us the opportunity to analyse a large series of meningiomas and assess the place of this new technique. It is generally accepted that plain X rays will diagnose 30-63% of intracranial meningiomas, though it may raise suspicion of the presence of an intracranial tumour in 73-78% of cases (Jacobson et al, 1959; Traub, 1961; Schunk et al, 1964; Gold etal, 1969). Angiography enables a definitive diagnosis to be made in a higher proportion of cases which in skilled hands should reach close to 70% (Wickbom and Statin, 1958; Schunk et al, 1964; Banna and
Requests for reprints to D. Sutton, St. Mary's Hospital, Praed Street, London, W.2.

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50, No. 589 L. E. Claveria, D. Sutton and B. M. Tress In the literature the percentage of accuracy of | scanning in diagnosing meningiomas is given vari-! ously as 71% and 95% (Sheldon et al, 1973; Witcofski et al., 1967). EMI scanning: A review of our material shows that the overall accuracy of this new method in making a specific diagnosis of meningioma is as high or higher than any of the other methods, including the invasive ones. The difficult areas where a specific diagnosis cannot readily be made though a tumour may be identified, include the orbits, the suprasellar area and occasionally the parasagittal region when dealing with small lesions. It is important to stress that careful evaluation of the clinical history and signs is necessary before scanning to assess the appropriate areas for tomography, since a small lesion can easily be missed if the appropriate area is not included. Two small tuberculum sellae meningiomas in our series were missed but both were less than 1 cm in size. In one case the cuts performed did not have the correct angulation to visualize the region accurately. In the second case a small lesion was missed though review showed that it was visible on the Polaroid print. One small parasagittal recurrence (under 1 cm) was also missed, but in that case there was a large amount of interference artefact from residual clips. All tumours more than 1 cm in size and localized over the convexity, parasagitally or in the sphenoidal ridge area were adequately demonstrated as were such tumours in the posterior fossa, including the

also of great importance where the tumour is parasagittal or adjacent to the lateral sinus. In such cases the sinus may be invaded and obstructed. Pneumography: This was only undertaken in six cases. In four intracranial cases the presence of tumour was confirmed but in two cases the findings were normal. Both of these were extracerebral tumours in the orbit, where it was desired to exclude intracranial spread. There were usually special indications for air studies. Thus with a tumour in a difficult site such as near the petrous apex or with a small suprasellar tumour the full extent of the tumour might be better shown by air studies than by angiography. It may also help in deciding whether a tumour is intra- or extracerebral. Brain scanning: 40 of our intracranial cases were investigated. Tumour was diagnosed in 36 cases (90%), and a specific diagnosis of meningioma was suggested in 23 cases (58%). The specific features suggesting meningioma were fairly heavy uptake by the tumour in a circumscribed or rounded lesion which was sited in a typical meningioma position, e.g. parasagitally, adjacent to the sphenoidal ridge, or adjacent to the olfactory groove. On the other hand we have several times suggested a diagnosis of meningioma with tumours of this type and have been proved wrong when the lesion was found to be a superficial glioma or metastasis. It has been claimed that serial scanning can suggest a diagnosis of meningioma rather than glioma because of the differential rate of uptake of the isotope (Sheldon et ah, 1973). However, this is not a procedure which we have used, nor is it one readily available in most routine departments.

TABLE I EMI features Localization Convexity Frontal Parietal Temporal Occipital Parasagittal Subfrontal Tuberculum sellae Sphenoidal ridge Cerebello-pontine angle Cerebellar tentorium Cerebellar convexity Intraventricular Total No. of patients 9 4 7 1 19 2 10 10 4 1 3 1
71

Diagnostic 8 (89%) -|

Tumour non-specific 1 (11%) 1 (25%)* 2 (29%) 4 (22%)** 2 (25%) 1 (25%)* 2 (67%)** 13 (19%)

Normal

14 (78%) 2 (100%) 6 (75%) 10 (100%) 3 (75%) 1 (100%) 1 (33%) 1 (100%) 55 (77%)

3(75%) L lM/o o/ 5(71%) f 1 (100%)J

1 (5%) 2 (20%)

3 (4%)

In six cases (one parietal convexity, two parasagittal, one cerebello-pontine angle, two cerebellar convexity*) the scan became diagnostic of meningioma after intravenous injection of contrast medium giving an overall figure of 61 (86%) diagnostic of meningioma scans.

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JANUARY 1977

The radiological diagnosis of meningiomas, the impact of EMI scanning cerebello-pontine angle. Orbital lesions were also readily identified but the differential diagnosis from other extrinsic lesions presented special difficulties in this area. These will be discussed below. The localization of meningiomas in our series is shown in Table I. Among the 71 cases listed there were four cases with multiple meningiomas and eight cases with recurrence. The unenhanced scans of meningiomas have characteristic features (Table II). The tumours appear as homogeneous high density areas with well defined round borders. Figures 1-11 illustrate tumours in varying sites showing the classical appearances. Their density averages 20-35 Hounsfield EMI units if uncalcified, but the density range extends as high as 270 or 300 if calcified. The density of normal brain tissue is 16-20 units.

FIG. 1. Olfactory groove meningioma showing typical meningioma features. (A, B) Increased density of circular mid-line subfrontal lesion. Slight surrounding oedema, (c, D) Enhancement of tumour after Conray.

FIG. 2. Parasagittal frontal meningioma. (A) Slightly increased density of the lesion. (B) Enhancement of lesion by Conray.

FIG. 3. Sphenoidal ridge meningioma showing classic features. (A, B) Rounded tumour of increased density. (c, D) Marked enhancement after Conray.

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50, No. 589 L. E. Claveria, D. Sutton and B. M. Tress TABLE II

E M I FEATURES (71 INTRACRANIAL CASES)

Hyperostosis Bone destruction Mass effect Oedema

Multiple Recurrence Calcification Cystic component

4 cases marked 8 cases slight 3 cases 5 cases marked 37 cases slight 13 cases minimal 2 cases very severe 6 cases moderately severe 40 cases minimal and adjacent to the tumour only 4 cases 8 cases 14 cases 3 of which only detected with the digital printout 3 major cystic component 3 minor cystic component

FIG. 5. High occipito-parietal convexity meningioma showing characteristic features. Note mass effect displacing the ventricles and right choroid plexus. (A) Before Conray. (B) After Conray showing marked enhancement.

FIG. 6. Supra-sellar meningioma. (A) Slightly increased density before Conray. (B) Marked enhancement after Conray.

FIG. 4. Bilateral mid-line falx meningioma at tentorial apex. (A, C) Increased density lesion. (B, D) Marked enhancement after Conray.

FIG. 7. Parasagittal meningioma showing increased density of tumour, and nodular, and peripheral calcification.

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JANUARY 1977

The radiological diagnosis of meningiomas, the impact of EMI scanning

8. Intraventricular meningioma before and after Conray.

FIG.

FIG. 10. Posterior fossa meningioma arising from the occipital region over the cerebellar convexity. (A) Before. (B) After Conray enhancement.

Other features shown by simple X-ray which assist in the diagnosis of meningioma such as hyperstosis were rarely visualized on the EMI scan. However, four cases did demonstrate clearly the hyperostosis and in another eight cases there was a suggestion of its presence. It was very well shown in one of the orbital cases (Fig. 14). Bone destruction is a relatively rare radiological manifestation. It was however identified in three cases by EMI scan (Fig. 12), as well as on simple X rays. FIG. 9. Calcification within the tumour was identified as a Mainly low density lesion in the right frontal region. Shows density greater than 45 Hounsfield EMI units. This a cystic area following Conray injection and marked oedema. Pathologytuberculoma adjacent to a small falx meningi- was present in 14 cases and varied from global calcification of the tumour to irregular and scanty calcification within it (Fig. 7). In three cases this was only identified in numerical printouts. The presence of oedema surrounding the tumour Cystic components are rare in meningioma but are was seen in 48 out of 71 proven intracranial cases. occasionally seen, and three of our cases showed The oedema tended to be minimal and circumthese. One was misdiagnosed as a glioma because of scribed around the lesion (Figs. 2 and 4). Only occaits unusual appearance (Fig. 9). However, the path- sionally does it appear extensive and with the ology of this case was unique in that the meningioma characteristic digital elongation of more malignant was associated with an adjacent tuberculoma, a tumours (see Fig. 9). Oedema was not noted at all in double pathology which puzzled the pathologists. A tumours localized to the orbits, or in the majority of second case was also most unusual and atypical. A subfrontal, suprasellar, cerebello-pontine angle and low density area lateral to the tumour was ringed by cerebello-tentorial regions. enhanced tumour after Conray. Operation confirmed Except for the very small suprasellar and paraa "cystic" meningioma. In the third case a diagnosis sagittal tumours, most of the tumours produced was readily made of cystic areas within a classical some mass effects (Fig. 3), distorting the mid-line meningioma. structures and/or obliterating CSF pathways. 19

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50, No. 589 L. E. Claveria, D. Sutton and B. M. Tress

FIG.11.

Meningioma straddling the petrous apex, after Conray enhancement.

Retro-orbital tumour. (A) Before. (B) After Conray enhancement.

FIG. 12. Bone destruction shown on EMI scan in a case of posterior fossa meningioma.

Contrast enhancement Once the simple scan has been performed the procedure was repeated immediately following intravenous injection of 60 ml of Conray 420 given as a bolus. With this technique meningiomas show contrast enhancement in a striking fashion. The whole tumour increases homogeneously in density both visually and as measured by Hounsfield EMI units. In only two cases was contrast enhancement less obvious. In most cases the tumour edge is well defined by the enhancement pictures and the exact extension of the tumour is clear.

JANUARY 1977

The radiological diagnosis of meningiomas, the impact of EMI scanning Attempting histological diagnosis purely on the EMI appearances is also unwise in dealing with intraorbital and retro-ocular lesions.
ORBITAL MENINGIOMAS

Computed axial tomography has been well established as a diagnostic tool in retro-orbital lesions (Gawler et ah, 1974; Ambrose et ah, 1974) and can be favourably compared with other diagnostic techniques. To attempt a specific diagnosis of the nature of a lesion in the orbital compartment still remains a difficult problem. The diagnoses of meninA B gioma can only be made as part of the differential FIG. 14. diagnosis of other vascular space-occupying lesions (A) Bilateral orbital meningiomas. Large mass in right orbit. There is also a smaller dense mass at the apex of the left (Fig. 13), although additional information such as orbit. hyperostosis or extension into the intracranial cavity (B) Bone picture demonstrating marked hyperostosis at back can be very useful. In our series of eight orbital of left orbit. meningiomas a definitive diagnosis was possible in four cases because of the presence of such features. DIFFERENTIAL DIAGNOSIS In two further cases the lesions demonstrated had no In most of the convexity tumours and in the para- definitive features of meningioma but the diagnosis sagittal lesions there is little problem and the diag- was correctly made as both were tumour recurnosis is clear cut. Nevertheless small lesions can be rences. Only one case was misdiagnosed and passed missed if appropriate high cuts are not taken. Also as normal, although a very minor constriction of his judging from EMI appearances there are certain optic canal could be observed retrospectively and regions which may present diagnostic problems. thickening of the lateral rectus was also noted, a High density tumours in the cerebello-pontine angle feature which has not been seen in other orbital with identical appearances to meningiomas and masses (Moseley, 1976). similar behaviour following contrast enhancement Only two orbital cases had contrast injected intrahave been observed in our series. These include high venously and in both of them the enhancement density acoustic neurinomas. Here differentiation is pattern was similar to that of meningiomas of the only possible by taking into account the clinical data intracranial compartment. Our experience however and the results of more conventional radiological has been that the enhancement patterns of other examination. On the other hand in our material most vascular tumours within the orbit are very similar to acoustic tumours have been of low density and those of meningiomas and a differential diagnosis easily differentiated. We have also seen highly cannot be readily made. vascular metastatic deposits present as high density tumours on EMI scanning which are difficult to differentiate from meningiomas. REFERENCES AMBROSE, J. A. E., LLOYD, G. A. S., and WRIGHT, J. E., In the suprasellar region both pituitary adenomas 1974. Computerized axial tomography in orbital space occupying lesions. British Journal of Radiology, 47, 747and craniopharyngiomas can present a similar pic751. ture to a meningioma showing increased density on BANNA, M., and APPLEBY, A., 1969. Some observations on simple EMI scans and contrast enhancement followthe angiography of supratentorial meningiomas. Clinical Radiology, 20, 375-386. ing Conray injection. Differentiation again will B. C , JOHNSON, D. E. Jun., and SAAL, B. M., depend on the clinical presentation and other radio- BUTCHTEL, 1971. Radiographic diagnosis of meningiomas. Southern logical procedures. Pineal tumours can also resemble Medical Journal, 64, 973-977. DUBOULAY, G. H., and MCALLISTER, V. L., 1970. The meningiomas. choice between carotid angiography and brain scanning in Only one intraventricular meningioma was seen in the investigation of tumour suspects. Proceedings of the Royal Society of Medicine, 63, 46-50. this series and this was readily identified (Fig. 8). We J., SANDERS, M. D., BULL, J. W. D., DUBOULAY, have encountered an intraventricular glioma which GAWLER, G. H., and MARSHALL, J., 1974. Computer assisted tomshowed similar features but extended through the ography in orbital disease. British Journal of Ophthalmology, 58, 571-587. septum into both lateral ventricles. Intraventricular L. H., KIEFFER, S. A., and PETERSON, H. O., 1969. ependymomas or papillomas may also show similar GOLD, Intracranial meningiomas: a retrospective analysis of the features. diagnostic value of plain skull films. Neurology, 19, 873.
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SHELDON, J. J., SMOAK, W., GARGANO, F. P., and WATSON,

JACOBSON, H. E., LUBETZKY, H. W., SHAPIRO, J. E., and

CARTON, C , 1959. Intracranial meningiomas: a roentgen study of 126 cases. Radiology, 72, 356. MOSELEY, I. F., 1976. Personal communication.
SAUER, J., FIEBACK, O., OTTO, H., LOHR, E., STROTGES,

H. W., and BERTAG, W., 1971. Comparative studies of WICKBOM, I., and STATIN, S., 1958. 5th Symposium Neurocerebral scintigraphy, angiography and encephalography diologique. Acta Radiologica, 50, 175. for diagnosis of meningioma. Neuroradiology, 2, 102-106. WITCOFSKI, R. L., MAYNARD, C. D., and ROPER, T. J., 1967. SCHUNK, H., DAVIES, M., and DRAKE, M., 1964. A study of A comparative analysis of the accuracy of the technetium meningiomas with correlation of hyperostosis and tumour brain scan. Journal of Nuclear Medicine, 8,187-196. vascularity. American Journal of Roentgenology, 91, 431443.

D. D., 1973. Dynamic scintigraphy in intracranial meningiomas. Radiology, 109,109-115. TRAUB, S. P., 1961. Roentgenology of intracranial meningiomas (Springfield, Illinois, Charles C. Thomas Co.).

Book reviews
Neuroradiologie. By J. Metzger, J. Simon, G. Salamon, and H. Fischgold, pp. 622, 726 illus., 1976 (France, Masson et Cie), F770. This is a further volume in the French series Traite de Radiodiagnostic and edited by J. Metzger, J. Simon, G. Salamon and H. Fischgold. It contains contributions by these and a number of other authors and covers the neuroradiological investigation and diagnosis of brain tumours. The sections in this volume discuss: (1) lesions of the skull vault; (2) hemispheric tumours; (3) ventricular and paraventricular tumours; (4) pituitary lesions; (5) mid-brain and adjacent lesions; (6) infra sub-tentorial tumours; (7) intramedullary tumours in the posterior fossa; (8) tumours of the foramen magnum region. To bring the whole volume up to date there is afinalsection on computerized axial tomography consisting of two separate chapters, one from Philadelphia and one from the Marseille Group. The illustrations are of excellent quality and many are D. SUTTON. accompanied by explanatory line diagrams. This volume contains a wealth of information beautifully presented and should prove of great value to all concerned with the neuroYear Book of Diagnostic Radiology. 1976 edition, pp. 456 logical sciences, and in particular to neuroradiologists. It (Year Book Medical Publishers; distributed in U.K. by reflects great credit on the French school of neuroradiology. Lloyd Luke (Medical Books) Ltd.), 14-70. I imagine that the authors have been overtaken by the The material covered in this volume, which is nowadays impact of EMI scanning whilst the book was still in produccompletely devoted to radiodiagnosis and ultrasound, repre- tion. However, the two final chapters on EMI scanning sents literature reviewed up to May 1975. Allowing for the present an excellent summary of the present state of the art obvious limitations of the abstract form, the choice of papers in a subject which is expanding rapidly. The volume can be is sensible and the editors' comments at the end of all the recommended without reservation to all neuroradiologists. abstracts are, on the whole, pertinent and instructive. The Even those who have little French should benefit from series remains deservedly popular and this year's edition studying the excellent illustrations. will be no exception. D. SUTTON.
P. ARMSTRONG.

Atlas of Normal Vertebral Angiograms. By P. Ross and G. H. duBoulay, pp. 126, illus., 1976 (London, Butterworth), 15-00. This small atlas consists of eight anatomical drawings of the hind brain and its related arteries and veins. These anatomical drawings are beautifully done and all the important blood vessels are labelled. The rest of the atlas consists of reproductions of vertebral angiograms in various phases again with the individual vessels labelled. There is a short introductory text on the arteries and veins and a good bibliography. The X-ray illustrations are subtractions. On the whole these are of high quality but a few are a little disappointing. This atlas should prove most valuable to students of neuroradiology in clarifying the difficult anatomical problems raised by the blood vessels in the posterior fossa. It will also provide a useful reference book for departments of neuroradiology. The price is rather high for such a slender volume but in these days it represents good value for money.

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