Journal of Surgical Oncology 26:35-39 (1984)

Lipomatous Meningioma Associated With
Cerebral Vascular Malformation
VIRA WSANTiKUL, MD, AND w. J A N BROWN, MD
From the Department of Pathology, Faculty of Medicine, Chulalongkorn University,
Bangkok, Thailand, and Department ofPathology (Neuropatholagy), UCLA School of
Medicine, Center for the Health Sciences, 10s Angeles

A unique epileptic patient with intracranial neoplasm is reported in which
a meningioma with lipomatous and osseous components was found associated with cerebral arteriovenous malformation at the same location in
the right frontal lobe. The development of the leptomeningeal neoplasm
may have been influenced by the underlying vascular anomaly. The cerebral arteriovenous malformation and altered hemodynamics also could
have induced the sudden onset of clinical seizures, hemiparesis, and
unconsciousness.
KEYWORDS:meningioma, lipoma, arteriovenous malformation

INTRODUCTION
Rare examples of two completely different intracranial
neoplasms coexisting in the same locus have been reported [ 1-31. Most examples of tumors that are contiguous in the central nervous system (CNS) are cerebral
glioma and meningioma [4-6].The case described here
is an unusual lesion of concurrent benign leptomeningeal
neoplasm and cerebral arteriovenous malformation found
in frontal lobe. The meningioma contained many mesenchymal tissue varieties, including arachnoidal cap cells,
fat cells, and osteocytes within the same mass. This
complex is possibly explicabie on the basis of common
origin from ectomesenchymal properties of neural crest
[7]. The relationship between leptomeningeal neoplasm
and cerebral vascular malformation is also discussed.

CASE REPORT
A 69-year-old woman was hospitalized because of chest
pain, left-sided focal seizures, and left hemiparesis. She
had a long history of chronic pulmonary disease, hypertension, and diabetes mellitus. Physical and neurological
examination disclosed blood pressure of 160/90 mmHg
and, surprisingly, papilledema. Her mental status in hospital rapidly declined and she became unresponsive
shortly after admission. Constant clonic jerking of the
left leg was noted but there was no spontaneous, purposeful movement of the left extremity, and left Babinslu sign
was present. Cranial nerves were bilaterally intact.
0 1984 Alan R. Liss, Inc.

Routine blood and urine examinations were unremarkable. Electrocardiogram revealed evidence of an old myocardial infarction in the inferior left ventricular wall.
Cerebral computerized axial tomograms (CAT) demonstrated a large, low-density mass in the region of the
right frontal lobe with surrounding tissue edema (Fig. 1A).
Contrast administration increased the staining around the
rim of the mass medially and posteriorly (Fig. 1B).
The frontal horn of the right lateral ventricle was posteriorly displaced and a moderate right-to-left midline shift
affected the lateral ventricles and anterior aspect of the
falx. Carotid angiograms confirmed this right frontal
mass revealing prominent vascularity beneath the mass.
At craniotomy, encapsulated, friable, yellow tissue was
found overlying the superior and middle frontal gyri. It
appeared to arise from the region of the arachnoidal villi
in the parasagittal region and invaginated the right frontal
pole. The lesion was entirely resected after frozen section
revealed its benign nature. Prominent vascularity of the
underlying cerebral cortex was observed at surgery and
that portion of cortical tissue was resected. The patient
was well when seen 1 year after craniotomy, although
her medical problems persisted. The cerebral CAT revealed no evidence of neoplastic recurrence.
Accepted for publication September I , 1983.
Address reprint requests to Vira Kasantikul, MD, Department of
Pathology, Faculty of Medicine, Chulalongkorn University, Bangkok
10500, Thailand.

36

Kasantikul and Brown

Fig. 1 . CAT scans: (a) A well circumscribed mass with focal calcification around the rim of
the mass in the region of the right frontal lobe causing distortion of the right lateral ventricle.
(b) Perfusion enhancement demonstrating the staining around the lesion.

The specimen consisted of multiple segments of friable Focal calcium deposits and bone were also noted. Polytissue weighing 5 gm. Microscopically, the mass was gonal cells with ill-defined borders and bland uniform
composed of several mesenchymal tissues one of which nuclei typical of meningioma were interspersed in the
was well differentiated adipose tissue (Fig. 2). These fatty tissue (Fig. 3). Neither mitotic figures nor pleomature fat cells contained a “hole” in the nucleus morphism were seen. Invasion of underlying brain was
(“Lochkern”) characteristic of true fatty tissue. Reticular not found beneath the neoplasm. However, clusters of
and collagenous fibers interlaced through the fatty tissue. numerous thick-walled arteries and veins of various cali-

Lipomatous Meningioma and Cerebral Vascular Malformation

Fig. 2. Lipomatous meningioma showing admixture of meningocytes and adipose tissue cells.
Note intranuclear inclusion (arrow). Hematoxylin and eosin ( X 250).

Fig. 3. Focus of meningioma with psammona bodies. Hematoxylin and eosin ( X 120)

37

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Kasantikul and Brown

Fig. 4. Clusters of arteries and veins representing arteriovenous malformation in frontal cortex
beneath the meningioma. Hematoxylin and eosin ( X 48).

bers as well as focal calcification were present in the
underlying cerebral cortex producing a typical arteriovenous malformation (Fig. 4). Elastic tissue stains revealed
a wavy, elastic lamina in these arteries. Recent hemorrhages and hemosiderin-laden macrophages were also
present. There were no meningocytes in any portion of
the tissue containing the anomalous vascular channels.

DISCUSSION
The parasagittal location and attachment of this tumor
to the leptomeninges and the syncytial appearance of
neoplastic cells in association with psammoma bodies are
all diagnostic features of a meningioma. The lesion reported here, however, is unusual in that it contained so
much adipose tissue and bone. Additionally, it rested on
a separate mass of arteriovenous malformation. Such a
lesion is at least uncommon and we are unaware of its
previous description.
Intracranial meningioma is, of course, a common neoplasm and accounts for 15% of all primary intracranial
neoplasms [8]. Occasionally adipose tissue and bone are
present within the leptomeninges as well as in a meningioma [9-101. Although some confusion existed earlier
with regard to various mesenchymal tissue such as fat,
cartilage, and bone in meningioma, there seems to be
general agreement that such tissue varieties are exemplifying the rnultipotentiality of their common origin from
ectomesenchymal properties of the neural crest. Cells of

the crest may differentiate into many cell types including
Schwann cells, meningocytes, and mesenchymal cells
[7]. It is, therefore, not surprising to encounter bone and
lipomatous tissue in leptomeningeal neoplasm as observed in the present meningioma.
Arteriovenous malformation may comingle with other
neoplasms, including neurilemmoma and meningioma
[ll-131. But in the present instance the arteriovenous
malformation was distinctly separated from the overlying
leptomeningeal mass. The contiguity of these two different lesions might suggest that the growth of one tumor
could have been influenced by the presence of the other,
or the two lesions could have a coincidental origin. Cushing and Eisenhardt [ 141 stated that leptomeningeal tumors
may be related to chronic irritation of arachnoid cells by
whatever process. Cerebral neoplasm is certainly a source
of irritation and hence might also stimulate lesions in the
leptomeninges. Gass and van Wagenen [4] described a
case of oligodendroglioma in a 56-year-old woman that
occurred in relation to an overlying small superficial
meningioma. Tanaka et a1 [6j have published details of a
case in which meningioma occurred 23 years after partial
removal of an oligodendroglioma at the same site. Kasantikul and Brown 1121 have reported two examples of
cerebral meningioangiomatosis in which focal arachnoidal hyperplasia as well as a fully developed independent
meningioma have been found in association with underlying cerebral lesions. These data suggest that certain

Lipomatous Meningioma and Cerebral Vascular Malformation

39

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ACKNOWLEDGMENTS
This study was supported by the following grants
USPHS HD 05617, USPHS HD 04612, and NIN CDS
79-05. Dr. Kasantikul was the recipient of an Ananthama
hidol Foundation Fellowship, Bangkok, Thailand.

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