A rare cause of exophthalmos

Clinical History

A 82-year-old man presented with a history of right parietal low-grade meningioma operated 18 years before. He reported severe headache for one year with recent worsening of symptoms with left hemiplegia and painless progressive exophthalmos of the right eye. Fundus examination was normal in both eyes.

Imaging Findings

Brain MRI was performed and showed multiple extra-axial masses isointense on T1 and T2 (Fig. 1, 2), with a strong homogeneous enhancement post-gadolinium (Fig. 3, 4 and 5). The lesions were located in the right interhemispheric frontotemporo-parietal region with endo-orbital extension through the superior orbital fissure causing exophthalmos grade III.

Discussion

Multiple intracranial meningiomas are a condition where there is more than one meningioma in several intracranial locations in the same patient without signs of neurofibromatosis. Incidence varies from 1 to 10% [1].

On CT imaging, meningiomas are well-defined extra-axial masses, which displace the adjacent brain. Most are iso- to slightly hyperdense compared with normal brain, and there is a strong uniform enhancement after intravenous contrast.
MRI may show hypo- to isointense signal lesions on T1-weighted imaging and iso- to hyperintense on T2-weighted imaging with a strong homogeneous enhancement post gadolinium. Most meningiomas show a characteristic dural thickening that tapers peripherally (dural tail sign), accurately localising the tumour in the dural or subdural space [2].

The prognosis of multiple intracranial meningioma does not differ from benign solitary meningiomas despite the multiplicity. However, the simultaneous occurrence of different grades of malignancy is observed in one-third of multiple meningiomas. Surgery remains the best option for treatment of symptomatic lesions [1].

Differential Diagnosis List

Final Diagnosis

Multiple intra-cranial meningiomas

URL:	https://www.eurorad.org/case/12839
DOI:	10.1594/EURORAD/CASE.12839
ISSN:	1563-4086