A case of sand-grain meningioma

Meningioma was the first tumor to be discovered and described by German pathologist VirchowMeningioma is a more common intracranial tumor, the incidence rate of about 15% to 24% of intracranial tumorsThe cause of meningioma is not entirely clearClinically found that cranial brain trauma, chromosomal mutations, hormonal receptor abnormalities, or radiation damage such as radiation therapy can be a risk factor for the occurrence of meningiomameningioma has many types, sand-shaped meningioma (psammomatous meningioma, PM) is only one of the subtypes, its incidence is relatively low, the clinical work encountered in the case is reported as follows:1Clinical datapatient male, 53 years old, due to 2 months ago no obvious trigger for dizziness, no obvious headache, duration of tens of minutes to hours, occasional nausea, no vomiting, no left ear hearing loss, no limb convulsions, no size incontinence to visit the hospital, the patient since the onset of the disease can be mental, diet and sleep can, two normal, body quality is not significantly reducedpast medical history: 17 years ago due to right ear partitis in the surgery surgery in the hospital, left the right ear hearing lossDeny the history of "hypertension, coronary heart disease,diabetes" and the history of infectious diseases such as "hepatitis and tuberculosis", no history of trauma, blood transfusion, no history of food and drug allergiesAt admission to the hospital: T36.6 degrees C, P75 times/min, R19/min, BP153/84mmHg (1mmHg - 0.133kPa), conscious, linguistic, two-sided pupils are large and large, diameter of about 3.0mm, sensitive to light, neck soft without resistance, no apparent abnormality in the heart and lungsThetension of the limbsnormal, the muscle force of the two sides limb is 5, the two-sided triceps are normal, the knee tendon shrub is normal, the two-sided paster is negative, and the Kernig is negative Auxiliary examination: Local hospital head CT (Figure 1) shows that a lump of high density shadow can be seen in the left forehead, the boundary is still clear, and the adjacent skull boundary is not clear, considering the left forehead occupaic lesions Figure 1 Patient's skull CT image.　Note: Skull CT shows the left forehead section of a clump of block high density shadow, edge irregular, part of the boundary is still clear, local and adjacent skull demarcation is not clear
patients in the hospital head MRI flat sweep and enhancement (Figure 2) show, the left forehead junction area can be seen a clump abnormal signal shadow, T1WI performance is equivalent / slightly low signal, TWI2 performance is slightly low / slightly high-reverse liquid inversion signal) performance of the iso/low mixed signal, T1WI fat suppression sequence is shown as high/low mixed signal, boundary under-clearing; It is highly likely that epidermal cysts will be considered before surgery, except for bone or cartilage tissue-derived tumors Figure 2 Patient's Skull MRI Image.　Note: The skull MRI shows the cluster abnormal signal shadow of the junction area of the left forehead, the T1WI shaft (A) is an equal/slightly lower signal, the T2WI shaft (B) is slightly lower/slightly higher, the FLAIR shaft (C) is an equal/low mixed signal, T 1WI FAT INHIBITION SEQUENCE AXIAL (D) IS A HIGH/LOW MIXED SIGNAL, ENHANCED SCANNING (E-G) LESIONS ARE SMALL PLAQUE-LIKE MILDLY ENHANCED

PATIENTS AFTER ADMISSION TO PERFECT THE RELEVANT EXAMINATION, PROPOSED LEFT PREFRONTAL LESIONS EXCISION, PATIENTFLAT CAR PUSHED INTO THE OPERATING ROOM, TRACHEA INTUBATION FULL After the success of hemp, flat, head right bit, marked left forehead arc incision, routine disinfection shop sheet, along the mark cut beginning skin, leather flap molding, electric drill drilling, milling knife opening skull, bone window 10 x 8 cm2, along the edge of the bone window hanging epidural, Radial cut-off epidural, see occupatic color white, blood transport medium, very hard texture, size of about 8 x 4 cm, with the surrounding brain tissue boundary clear, the application of grinding and grinding, full-cut tumor, proper bleeding, the application can absorb biofilm to protect the brain tissue and tightly stitch the epidural, The epidural retains a drainage tube, three sets of connecting sheetfixed skull, layer by layer to stitch muscles and skin The operation went smoothly, hemorrhage in the middle of the operation about 500 ml, no blood transfusion; Pathological results: Consider the left frontal meningioma, accompanied by the formation of a large amount of sand granules (Figure 3) a pathological picture of a patient in Figure 3 Note: A: Under the low-multiplier (x 40) sand granules in the tumor tissue of the left forehead (arrows shown as sand granules); B: High-multiplier (x 200) left forehead tumor tissue 2 Discussion meningioma is found in any part of the skull, it can be diseased in any part of the skull, on the general scene The incidence rate is higher than under the curtain, the incidence rate of the brain convex and sagging sinuses is higher than that of the brain sickle and the craniofacial base, clinical symptoms and signs vary from tumor growth site to different, typical meningioma generally has characteristic imaging performance, such as enhanced scanning has significantly enhanced and visible meninges tail signs, most of them can make correct diagnosis before surgery A small number of meningioma imaging performance is not typical, easy to cause misdiagnosis The probability of calcification in meningioma is about 20% to 27%, dense dot, line or clumps are its typical calcification manifestations, and completely calcified meninges omas are rare the incidence of sand granules in meningioma is about 10%, and the formation of many mineralized concentric circular structures and small sand granules in tumor tissue is typical of PM Sand granules are some pathological alkaline calcified spots present in tumor tissue, the diameter is about 50 to 70 m, because it is concentric circular arrangement, for many fine particle-like distribution, the form of loose sand, so called sand granules The traditional view is that in the process of rapid proliferation of tumors, ischemia occurs because the blood vessels branches at the far end of the tumor are not sufficient blood supply, and then the thrombosis , which leads to necrosis of tumor cells, and the necrosis of tumor cells merge sand particles to form sand granules after fusion Yang Ruchen and other studies believe that the nucleosome of the sand granules may be the matrix vesicles in the meningioma, its composure on the collagen fibers so that the mineralization of the mineralization of fibers and the mineralized particles deposited on it composed of the collective structure of the concentric dome of the sand in the meningocococcal structure Kubota and other researchers, such as electroscopy, immunoastic , and immunofluorcence, studied the sand granula to meningoma, and found calcifieds, collagen bundles and VI collagen as their main components Tunio and other studies have found that there are mRNA cells near the sand granules that express bone bridge protein, and it is consistent with the position of the sand granules, because it inhibits cell calcification, so it is considered that the two are related: bone bridge protein can keep the mineralization degree of the sand granules at a certain level Reviewing the CT image data, the left front altration is represented as a large calcification density shadow, connected to the epidural with the epidural, and intracranial epidermal-like cysts can also be seen calcification, which is mostly caused by inflammatory reactions, embedded in or surrounded by cysts, in the bridge small brain corner area and saddle area is more common epidermis-like cysts are a congenital embryonic tumor or acquired tumor (surgery, trauma, etc.), the imaging performance varies depending on the composition of the sac contents, the expression is more uniform and low signal on T1WI, the T2WI is shown as a significant lying high signal, the diffuse weighted imaging (weighted, D) WI) on the performance of significantly high signal, a few due to intracytic bleeding or high lipid content in T1WI and T2WI performance of high/low mixed signal, enhanced scanning can be shown as no significant reinforcement, when the cyst internal bleeding or infection can be shown as light moderate strengthening, when calcification can be shown as a significantlow signal intracranial epidermis-like cyst form many arrears rules, there is drill seam growth characteristics, DWI on the high signal is an important basis for diagnosis of intracranial epidermal-like cysts, this group of cases did not perform DWI examination before surgery, there is a certain impact on diagnosis, careful observation of the case enhancement scan is mildly uneven reinforcement, and the typical epidermis-like cyst is not significantly strengthened is also different This example can identify the epidermal cyst by reviewing CT data or line DWI examination, but it is still difficult to identify tumors from the intracranial bone or cartilage source Cartilon tumor is relatively rare in the central nervous system, its incidence rate is about 0.2% to 0.3% of intracranial primary tumor, cranial cartilage tumor is mostly located in the slope and saddle side, brain convex and brain substance is visible, intracranial cartilage tumor in MRI flat sweep is mixed signal, the calcification component of the tumor in T1WI and TWI2 is shown as low signal, the non-calcitized part is not evenly present on TWI CT and MRI examination in the diagnosis of PM have advantages and disadvantages, CT on calcification and bone structure observation is more sensitive to MRI, for fine bone damage and bone hyperplhedesity show clear, and MRI for soft tissue resolution is better, for the tumor mixed components show better, its Can be imaging from any angle, for the tumor display more comprehensive, such as this case patient in the hospital direct line MRI examination resulting in difficult to identify with epidermal-like cysts, if there is a CT image, can provide more information on differential diagnosis, so the combined CT and MRI examination, to improve the accuracy of PM diagnosis is very helpful literature reports that the calcification of meningioma can be seen in PM and fibroid symbiosis, completecal PM and osteoma caused misdiagnosis, imaging alone can not be completely distinguished between the two, postoperative pathological diagnosis is the gold standard for the diagnosis of the disease This case of meningioma is a completely calcified type, located in the left forehead, the main clinical performance is dizziness, the duration of varying; there are also literature reports that in CT thin-layer scans, incomplete thin lines between PM and the intracranial plate can be seen with a slightly low density shadow, while there is no such sign between the bone tumor and the intracranial plate In this case, the patient did not see this indication because the CT imaging data was provided to the hospital and did not provide a thin-layered image No other literature has been consulted and no reports have been reported on this sign, so the sign situated on it It has been reported that PM can be shown as a high signal on T1WI, but relatively rare, the main principle is that the interface between the larger calcium salt particles and the aqueous solution can form a water molecular layer, which can reduce the resonance frequency of water molecules at that level, thus shortening the longitudinal relaxation time, in T1WI performance of high signal the main component of sand granules in meningioma is hydroxyapatite, which has a large surface area and is mostly hexagonal crystal line, so at some stage of its mineralization, T1WI presents a high signal The high signal of calcification is easily confused with bleeding and lipid components Niiro and other studies have shown a significant increase in the growth rate of non-calcified meninges and meningomas Nakasu and others found that non-calcified meninges had high proliferating potential, while diffuse calcified meningioma had lower proliferation potential Das argues that the sand granule scarage in tumor cells hinders the growth and necrosis of tumor cells, and even blocks the metastasis of tumor cells Due to the short postoperative time of this patient, there is no obvious sign of recurrence at present, and further follow-up is required Although studies have shown that the probability of recurrence of PM after surgery is very low, regular imaging examination after surgery is still very necessary in general, although PM lacks some characteristic imaging manifestations, familiarity with pm's pathological characteristics, combined multimodal examination methods (including CT and multi-sequence MRI examinations), identification of imaging signs, to improve the accuracy of PM diagnostics