*Co esponding au ho : Mohamed Aziz.
Copy igh © 2025 Au ho (s) e ain he copy igh o his a icle. This a icle is published unde he e ms o he C ea i e Commons A ibu ion License 4.0.
Angioma ous meningioma: Case epo o a a e umo and a b ie e iew o he
li e a u e
Amanda Canellas 3, Lady Gonzalez Pe ez 3, Melissa Pe ez 3, Thomas Saliba 2, Shabnam Yazdanpanah 2, Ali eza
Izadian Bidgoli 2, Ja ie Aleman 4, Jessica Jahoda 1, 5 and Mohamed Aziz 1, *
1 Resea ch W i ing and Publica ion (RWP), LLC, NY, USA.
2 Ame ican Uni e si y o he Ca ibbean School o Medicine, Sin Maa en.
3 S . Geo ge's Uni e si y School o Medicine, G enada.
4 Uni e sidad Ibe oame icana (UNIBE), San o Domingo, Dominican Republic.
5 Memo ial Heal hca e Sys em, Pemb oke Pines, FL, USA.
Wo ld Jou nal o Biology Pha macy and Heal h Sciences, 2025, 24(02), 108-117
Publica ion his o y: Recei ed on 27 Sep embe 2025; e ised on 02 No embe 2025; accep ed on 05 No embe 2025
A icle DOI: h ps://doi.o g/10.30574/wjbphs.2025.24.2.0986
Abs ac
Angioma ous meningioma (AM), a a e Wo ld Heal h O ganiza ion (WHO) G ade I sub ype o meningioma, which
p esen s special diagnos ic and he apeu ic challenges. Ou pa ien is a 56-yea -old male wi h a his o y o c anial
adia ion he apy 15 yea s ago, who was p esen ing wi h p og essi e neu ological symp oms, including se e e
headaches, gene alized onic-clonic seizu es, pe sonali y change, and le homonymous hemianopia. The imaging
s udies e ealed a la ge (5.2 x 4.8 x 4.1cm) he e ogeneously enhancing, highly ascula mass in he igh pa ie o-
occipi al a ea wi h se e e pe i umo al edema and mass e ec . The complexi y o he diagnosis was due o he high
ascula i y and du al loca ion, as well as he pa ien 's his o y
The mul idisciplina y umo boa d discussion ecommended su gical esec ion. Du ing su ge y, he umo was
ma kedly ascula (mo e han 60% o mass olume) and equi ed ex eme a en ion o hemos asis when pe o ming a
Simpson G ade II esec ion. Pa hology showed a WHO G ade I AM wi h nume ous local ascula spaces, meningo helial
cells, hyalinized pe i ascula scle osis, and a ophic nuclea a ypia. EMA, CD31, CD34, p oges e one ecep o , and
SSTR2A we e posi i e; EMA and Ki-67 we e low, and molecula analysis e ealed monosomy 22. E en a e e-
explo a ion due o pos ope a i e hemo hage, he pa ien had ull neu ological eco e y. Pos ope a i e seizu e isk
con inued o be con olled a ou -yea ollow-up. This case highligh s he diagnos ic complexi y and a i y o AMs,
especially in pa ien s wi h p io adia ion ea men , and demons a es how good p ognoses can be achie ed wi h
ex ensi e, specialized ea men despi e ini ial complica ions.
Keywo ds: Angioma ous meningioma; Vascula ; Radia ion-Induced Meningiomas; MR Spec oscopy; Simpson G ade
I esec ion.
1. In oduc ion
Meningioma is a umo ha a ises om he meningeal memb anes co e ing he b ain and spinal co d. Al hough
meningioma is no a umo o he b ain pa enchyma, i may cause neu ological impai men by exe ing mass e ec on
su ounding b ain issue, c anial ne es, and essels. I is he mos common p ima y umo o he b ain. Mos
meningiomas ha e a slow g ow h pa e n and a e o en asymp oma ic, as hey may ma u e o e a long pe iod.
None heless, he esul an mass e ec can cause se ious neu ological mo bidi y depending on hei size and he loca ion
o hei ana omical posi ion. [1]
Wo ld Jou nal o Biology Pha macy and Heal h Sciences, 2025, 24(02), 108-117
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Like o he mo phologically di e en o ms o meningiomas, he AM sub ype cha ac e izes a mo phologic a ian in
which he e is a i id p oli e a ion o ascula channels ha may ake up mo e han hal o he umo mass and may
esul in se e e pe i umo al edema and massi e su ge ies because o he h ea o se e e bleeding. [2] Al hough hey
a e usually benign, hei a ious his ological sub ypes may pose a lo o diagnos ic and managemen challenges. AM is
one o hese e y a e a ian s comp ising only 2-2.5% o all meningiomas. [3] [4] Ea lie , AM was conside ed a sepa a e
en i y due o i s abundan ascula i y o ming a ne wo k embedded in meningo helial cells. This p ominen ea u e
made i di icul o di e en ia e om o he ascula neoplasias o he cen al ne ous sys em. [5] Howe e , o e ime
and as molecula p o iling and IHC ha e ad anced, he classi ica ion and biological beha io we e cla i ied, and i is
cu en ly classi ied as a WHO g ade I meningioma sub ype in he mos ecen 2021 WHO Classi ica ion o Tumo s o he
Cen al Ne ous Sys em. [6]
AM has unique adiological and pa hological ea u es, o en posing a diagnos ic dilemma and equi ing a comp ehensi e
diagnos ic app oach ha includes ad anced imaging, his opa hological s udies, immunohis ochemical (IHC) analyses,
and molecula s udies. [7] [8] Mo eo e , p io c anial adia ion he apy his o y, as in he case o ou pa ien , is also a
known isk ac o o he de elopmen o meningioma, which u he complica es he managemen o he pa ien and
long- e m moni o ing. [8] Due o hei a i y, AMs emain unde ep esen ed in he li e a u e. Mos o ou knowledge
has been de i ed om e ospec i e se ies o indi idual case epo s. This case epo aims o highligh he clinical,
adiological, and pa hological peculia i ies o AM, unde sco e he diagnos ic complexi ies, and discuss ea men
op ions o his a e meningioma, he eby expanding knowledge o his umo .
2. Case p esen a ion
2.1. Clinical p esen a ion
A 56-yea -old man was e e ed o he neu ology depa men by his p ima y physician because o he p og essi e and
g adual onse o neu ological symp oms. The pa ien s a ed expe iencing mild and in e mi en headaches, which
occu ed in he on al egion and became se e e and pe sis en a e 18 mon hs. In he las 6 mon hs, he expe ienced
h ee gene alized onic-clonic seizu es, and ha is he eason why he was e e ed o he neu ologis . G adual
pe sonali y changes we e no ed by amily membe s, including i i abili y, social wi hd awal, and an inabili y o unc ion
e ec i ely. Occasional isual symp oms we e p og essi e, including le homonymous hemianopia and diplopia. His
wi e said ha he had unde gone p e ious c anial adia ion he apy 15 yea s ago o ea a pi ui a y adenoma. No amily
his o y o CNS umo s o gene ic synd omes we e epo ed. Medical his o y included pi ui a y adenoma s a us pos
anssphenoidal esec ion and adju an adia ion he apy, con olled hype ension, and ype 2 diabe es melli us.
2.2. Physical examina ion
Neu ologically, he pa ien p esen ed wi h le homonymous hemianopia (con i med by con on a ional es ing o he
isual ield) and mild igh hemipa esis (4+/5 s eng h), as well as sligh impai men in cogni i e abili y, as indica ed
by a Mon eal Cogni i e Assessmen (MoCA) sco e o 24/30. The e was bila e al papilledema. No o he ocal
neu ological impai men s we e de ec ed. The ini ial lab es s included a comple e blood coun , an ex ensi e me abolic
panel, coagula ion s udies, and umo ma ke s (CEA, PSA), all o which we e wi hin he no mal ange. The le el o an i-
epilep ic d ug was he apeu ic a e he ini ia ion o seizu e con ol by le e i ace am.
2.3. Imaging indings
The CT head scan showed a he e ogeneously enhancing, la ge mass in he igh pa ie o-occipi al a ea, measu ing 5.2 x
4.8 x 4.1cm, wi h se e e su ounding asogenic edema and a mild mass e ec , esul ing in an 8 mm midline shi . The
MRI B ain Scan wi h Ggadolinium o he lesion exhibi ed a signal o isoin ensi y on he T1-weigh ed images and
he e ogeneous hype in ensi y on he T2/FLAIR images. Subsequen con as imaging e ealed in ense, he e ogeneous
enhancemen , along wi h mul iple p ominen eeding essels and d aining eins. The e was hickening and inc eased
enhancemen o he du a ma e in a linea ashion, ape ing away om a lesion (du al ail sign). Massi e pe ilesional
edema was sp ead in o he whi e ma e . CT angiog aphy e ealed ha he ascula supply o igina ed om b anches
o he middle meningeal a e y and he supe icial empo al a e y, and he ea ly enous d ainage sugges ed high- low
ea u es. The MR Spec oscopy showed a high choline (Cho) peak and a low N-ace ylaspa a e (NAA) peak, indica ing a
neoplas ic p ocess.
2.4. Di e en ial diagnosis and mul idisciplina y umo boa d discussion
The main clinical/ adiological conside a ions included angioma ous meningioma (WHO G ade I),
hemangiope icy oma/soli a y ib ous umo , me as a ic disease, high-g ade glioma wi h p ominen ascula i y,
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a e io enous mal o ma ion wi h mass o ma ion, a ypical meningioma wi h p ominen ascula i y, and p ima y CNS
lymphoma. The du al-based loca ion wi h a du al ail sign, high-in ensi y enhancemen , and high ascula i y suppo ed
he diagnosis o angioma ous meningioma as he leading di e en ial diagnosis. The case was discussed in he neu o-
oncology umo boa d, which included ep esen a i es om neu osu ge y, neu o-oncology, adia ion oncology, and
neu opa hology. Due o he symp oma ic p esen a ion o he pa ien , mass e ec , and umo size, su ge y was
ecommended as he ini ial ea men . The obse ed high ascula i y on imaging aised he deba e o e whe he o use
p eope a i e emboliza ion o di ec su gical in e en ion, wi h a ocus on me iculous hemos asis.
2.5. Su gical excision
A igh pa ie o-occipi al c anio omy was done using ameless s e eo ac ic na iga ion. The umo 's in aope a i e
appea ance showed e y high ascula i y (i was es ima ed a mo e han 60% o he mass olume), necessi a ing he
use o mul iple bipola coagula ion ools and hemos a ic agen s. Ul asonic aspi a ion was employed o debulk he
umo , wi h cau ion being aken no o cu o eeding essels un il umo olume had been educed. The umo was
lobula ed, well-ci cumsc ibed, and highly ascula ized on i s su ace. Comple e umo esec ion was made possible by
a Simpson G ade II esec ion, in which he du a a achmen s o he umo a e coagula ed a he han esec ed, as in a
Simpson G ade I esec ion, o dec ease he isk o uncon olled bleeding signi ican ly. Some o he in aope a i e
measu es included con olled hypo ension, he essen ial applica ion o hemos a ic agen s (Su gicel, Gel oam), ca e ul
bipola coagula ion, and empo a y occlusi e a e ial blockage. The blood loss was se e e (800mL) bu ole a ed.
Hemos asis was done ho oughly be o e closing.
2.6. Pa hology indings, immunohis ochemis y, and molecula s udies
The emo ed umo was composed o se e al agmen s o so , highly ascula , eddish-b own issue, measu ing a o al
agg ega e o 5.8 x 4.2 x 3.7 cm. G oss examina ion displayed a he e ogeneous umo su ace wi h p ominen dense
ascula i y in e spe sed wi h mo e solid a eas. The umo exhibi ed se e al cys ic spaces illed wi h blood. Mic oscopic
examina ion e ealed ea u es o a meningioma wi h a la ge angioma ous componen , indica ing high angiogenesis and
p oli e a ion o ec a ic blood essels wi h hin walls, comp ising app oxima ely 65 pe cen o he umo mass. The
ascula s uc u es anged in size om capilla y-like o la ge , dila ed channels lined by endo helial laye s. The egula
meningo helial cells we e a anged in lobules and indis inc who ls, wi h o al nuclei and eosinophilic cy oplasm,
be ween he ascula componen s. The e we e no psammoma bodies. P ominen hyalinized pe i ascula scle osis was
no ed in many a eas o he umo . Sca e ed la ge, biza e (bu no a ypical) nuclei ha we e no mi o ically ac i e we e
no ed h oughou he umo . These abno mal cells a e his ologically e e ed o as ancien change o degene a i e
nuclea a ypia and a e no conside ed signs o malignancy. (Figu e 1 A, B, C, D) The e was no e idence o b ain in asion,
nec osis, o a ypical ea u es, and mi o ic ac i i y was e y a e (less han 1-2 mi oses pe 10 high-powe ields).
Immunohis ochemis y (IHC) e ealed ha meningo helial cells exhibi ed s ong, di use EMA (epi helial memb ane
an igen) s aining. The ex ensi e ascula ne wo k was cha ac e ized by posi i e s aining o CD31 and CD34. The umo
cells also exp essed p oges e one ecep o and SSTR2A. The umo cells we e nega i e o CK7, CK20, TTF-1, S-100, and
Ki-67 p oli e a ion index was low <2%. Molecula s udies did no iden i y any pa hogenic mu a ions. The esul s o he
ch omosomal analysis e ealed monosomy 22, a cha ac e is ic o meningioma gene ics. No molecula changes we e
iden i ied ha could be a ge ed he apeu ically. Pa hology p o ided a inal diagnosis o angioma ous meningioma, 5
cm, WHO G ade I, comple ely esec ed.
2.7. Pos ope a i e managemen
Pos ope a i e hemo hage a he su gical si e, which was iden i ied on a ou ine 6-hou CT scan, complica ed he
eco e y o he pa ien and was cha ac e ized by an enhanced s a e o d owsiness and ocal neu ological impai men s.
Re-explo a ion, due o an eme gency, showed a small poin o a e ial bleeding, which was con olled using bipola
coagula ion. I was ollowed by ansien ce eb al edema, which was ea ed wi h dexame hasone and manni ol. The
pa ien 's neu ological condi ion p og essi ely imp o ed o e 72 hou s. These complica ions led o an 8-day s ay in he
hospi al. On discha ge, he had weak esidual igh -sided weakness bu in ac cogni ion and mild, s able isual ield
impai men s.
2.8. Follow-up and ou come
The WHO G ade I and ull esec ion o he pa ien ’s umo we e good p ognos ic indica o s. None heless, adia ion
he apy his o y can also con ibu e o a sligh isk o ecu ence and he need o con inue moni o ing i . A ollow-up
plan was wo ked ou including, MRI b ain wi h gadolinium a 3 mon hs, 6 mon hs, and annually ollowing 2 yea s o
seizu e- ee li e, and neu ological examina ion a 6 mon hs and subsequen ly annually. G adual ape ing o he an i-
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epilep ic medica ion was o be conside ed a e 2 yea s o con inuous seizu e- ee li e. The e was endoc ine ollow-up
because o he his o y o pi ui a y umo , and pa ien educa ion abou seizu e p ecau ions and symp om ecogni ion.
The pa ien achie ed ull neu ological eco e y a e 9 mon hs, and he mass e ec symp oms had esol ed. P ope an i-
epilep ic managemen was able o b ing abou long- e m seizu e con ol. The e was a es o a ion o quali y o li e wi h
he leas long- e m sequelae. The pa ien did no exhibi any signs o ecu ence o complica ions a ou -yea ollow-
up.
Figu e 1 Mic oscopic examina ion o he excised angioma ous meningioma
1A: Low powe iew showing angioma ous meningioma wi h ascula componen (o ange a ow), meningeal cell componen (g een a ow), wi h
he mass a achmen o he du a (blue a ow) (H&E s ain X20); 1B: Low powe iew showing p ominen ascula componen (>65% o he umo
mass) showing ascula s uc u es o di e en sizes, om capilla y-like o he la ge and dila ed channels lined by endo helial laye s (H&E s ain
X20); 1C: High powe iew showing p ominen pe i ascula hyalinized scle osis (H&E s ain X40); 1D: High powe iew showing sca e ed la ge,
biza e (bu no a ypical) nuclei ha a e no mi o ically ac i e. These abno mal cells a e his ologically e e ed o as ancien change o degene a i e
nuclea a ypia and a e no conside ed signs o malignancy (H&E s ain X60).
3. Discussion
3.1. Backg ound: (His o y, epidemiology, WHO classi ica ion)
While meningiomas a e now well-unde s ood and de ined wi hin neu opa hology, his was no always he case, and he
ield's ea ly e minology e lec s a pe iod o scien i ic ambigui y. Ea ly medical li e a u e e med meningiomas as
" ungoid umo s," "epi heliomas," and "du al sa comas," highligh ing unce ain y in hei "his ogenesis." [4] O e ime,
he e minology sui ed be e he clinical and pa hological eali ies, and “meningioma” became he p e e ed e m,
popula ized by Ha ey Cushing in he 1920s o umo s a ising om he meninges. [10] The de elopmen o o he
echniques in mic oscopy and IHC p o ided he means o subclassi y meningiomas in o mul iple a ian s o his ology.
[11] As in he case o o he mo phologically dis inc a ian s o meningiomas, he AM sub ype desc ibes a mo phologic
a ian whe e an abundance o ascula channels de eloped in he amewo k o he meningioma. [12]
Due o i s p ominen ascula i y, AM is diagnos ically challenging, as i may be mis aken o o he ascula neoplasms,
such as hemangioblas oma and hemangiope icy oma. The meningiomas ha e been one o he mos he e ogeneous, bo h
his ologically and clinically, o all p ima y in ac anial umo s since hei o mal classi ica ion. [2] [4] AMs a e a e.
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Howe e , he unusual ascula i y o hese umo s has caused diagnos ic di icul ies and he necessi y o di e en ia e
hem om o he highly ascula umo s o he CNS. [7] Recen e iews no e ha he biological beha io o AMs ypically
alls in o he ange o o he WHO G ade I en i ies, bu since hey a e less common, much o wha we know abou hem
is based on small e ospec i e se ies and case s udies. [6] [7]
Depending on he speci ic se ies, meningiomas make up abou 20-30% o p ima y b ain umo s annually, esul ing in a
yea ly incidence o app oxima ely 4.5 pe 100,000. [6] [11] Abou 80% o meningiomas diagnosed a e benign based on
Wo ld Heal h O ganiza ion G ade I classi ica ion. [2] In addi ion, mos sub ypes o meningiomas a e mo e common and
exhibi a highe incidence a io in emales. [4] Howe e , unlike ypical meningiomas, AMs appea o ha e a sligh ly
highe male- o- emale a io. They a e mos common in middle-aged pa ien s, hough he e is limi ed speci ic age- ange
da a. [7] Due o he a i y o AMs, mos cu en li e a u e is limi ed o e ospec i e su gical se ies and case epo s, and
no la ge, popula ion-based s udies.
Meningiomas a e classi ied in o h ee his ologic g ades (I, II, III) ha co ela e wi h umo ecu ence and
agg essi eness. [6] The ib ous, meningo helial, ansi ional, and psammoma ous sub ypes o he WHO G ade I (benign)
a ian s a e he mo e common ones, and some less common a ian s include mic ocys ic, angioma ous, me aplas ic,
sec e o y, and lymphoplasmacy e- ich meningiomas. [9] The angioma ous sub ype is cha ac e ized by nume ous
ascula channels. Howe e , hese a e o en hin-walled and a e su ounded by he o he cons i uen s o a meningioma
(i.e., meningo helial o spindle cells). The ascula componen is usually p esen and p edominan ly so. [12] I is
impo an o no e ha he shee ascula i y o he AM canno ele a e i s g ade classi ica ion, unless he angioma ous
meningioma exp esses o he a ypical o malignan cha ac e is ics, such as inc eased mi o ic ac i i y, in asion o
adjacen b ain issue, o nec osis as pe he ecen classi ica ion adjus men s. [13]
The 2021 (5 h edi ion) WHO classi ica ion o meningiomas inco po a es speci ic molecula al e a ions, such as TERT
p omo e mu a ions o homozygous dele ion o CDKN2A/B. [6] [14] In he cu en classi ica ion, AM mus also no
ha bo high- isk molecula al e a ions. O he wise, high- isk molecula al e a ions may ele a e a meningioma's
classi ica ion. In addi ion, he e is a gene al lack o AM sub ype-speci ic molecula da a, so i is s ill ea ed he same as
o he G ade I a ian s, unless mo e agg essi e beha io is demons a ed. [6] [7] Finally, he WHO classi ica ion s ill
includes AMs as benign (G ade I) meningiomas. Howe e , his classi ica ion migh need o be e ised i a ypical o
molecula ad e se ac o s a e iden i ied.
3.2. Pa hogenesis and pa hophysiology
AMs a e cha ac e ized by a dis inc gene ic p o ile in con as o he common meningiomas ha usually ha e monosomy
o ch omosome 22 and NF2 gene mu a ions. S udies showed ha in AM, he e is a high p e alence o mul iple
ch omosomal polysomies, including ch omosomes 5 and 13, as well as ch omosome 20, which a e mo e common han
he common NF2 abe a ions in meningiomas. [15]. This implies a a he non-NF2-dependen pa hogenesis. Table 1
summa izes he compa ison o ch omosomal abno mali ies and mu a ions be ween common meningiomas and
angioma ous meningiomas.
Table 1 Compa ison o ch omosomal abno mali ies and mu a ions be ween common meningiomas and angioma ous
meningiomas
Fea u e
Common Meningiomas
Angioma ous Meningiomas
Common Ch omosomal
Abno mali ies
Monosomy o ch omosome 22 o a
comple e lack o copy numbe
abe a ions. Loss o ch omosome 22q is
mos equen .
Mul iple ch omosomal polysomies
(gains o en i e ch omosomes)
ep esen a dis inc gene ic p o ile.
Mos F equen
Polysomies (Gains)
Typically, ew o none.
Highly ecu en gains, especially o
ch omosomes 5, 13, and 20.
Common Gene
Mu a ions
NF2 gene mu a ion/inac i a ion is he
majo d i e (40%-60% o spo adic
cases). O he mu a ions include TRAF7,
KLF4, AKT1, PIK3CA, and SMO.
Gene ally cha ac e ized by an
absence o he common d i e
mu a ions ound in o he sub ypes,
including NF2 mu a ions.
An angiogenic swi ch, in which a se o mu a ions enables un egula ed neo ascula iza ion, is a p ocess equi ed o
umo g ow h beyond 2 mm [13]. This high angiogenesis is an addi ional cause o pe i umo al b ain edema, which is
Wo ld Jou nal o Biology Pha macy and Heal h Sciences, 2025, 24(02), 108-117
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cha ac e is ic o high ascula i y and ele a ed le els o ascula endo helial g ow h ac o (VEGF) [13]. Al hough
mode a e o se e e nuclea a ypia may be de ec ed, i is gene ally hough o be o a degene a i e p ocess as opposed
o an exp ession o agg essi e beha io [15].
3.3. Compa a i e analysis o ou case wi h he exis ing li e a u e
3.3.1. Clinical p esen a ion and adiology indings
Ou case o AM has dis inc clinical and adiological ea u es compa ed wi h simila cases epo ed in he li e a u e. The
pa ien had se e al ypical indings in line wi h p e ious epo s, such as seizu es, ecu en headaches, cogni i e and
isual impai men , hemipa esis, as well as mass e ec . [17] [18] [19] Addi ionally, his case is consis en wi h he AM
epo s in pa ien s who had p io adia ion he apy. [19] Howe e , his p esen a ion was, cha ac e ized by s ong
pe sonali y changes, which we e p obably caused by he mass e ec and he in ol emen o he on al lobe by he
umo . The same mass e ec also explained he ele a ed in ac anial p essu e and papilledema.
Al hough he inal pa hology o his umo was deemed a WHO G ade I AM, i is impo an o no e ha i exhibi ed bo h
common and uncommon adiological ea u es. I he umo has su ounding edema, d aining eins, and umo nec osis,
i is gene ally conside ed mo e a ypical and mo e malignan . [16] The size and loca ion o he umo a e also signi ican
ac o s in de e mining umo g ade, as G ade I umo s a e ypically loca ed on he loo o he skull, while highe g ades
a e ound in he dome o he skull. [16] This pa ien also had se e e asogenic edema a ound he umo , causing an 8
mm midline shi , which is a e o lowe -g ade benign meningiomas, bu common o AMs. [16] MR Spec oscopy
showed a high choline peak and a low N-ace ylaspa a e (NAA) peak o his pa ien , which can be used o di e en ia e
meningioma om o he b ain umo s. [20] A du al ail sign is o en seen in meningiomas bu is no exclusi e o hem;
he e o e, p ecau ions should be aken when in e p e ing imaging s udies. [20]
3.3.2. Diagnosis (Pa hology, immunohis ochemis y, and molecula indings)
Ou case demons a es a ypical diagnos ic pic u e ha is compa ible wi h AM, which ag ees wi h he exis ing li e a u e.
Pa hologically, he angioma ous na u e, wi h a p edominan umo componen and a signi ican numbe o hin-walled
ec a ic blood essels wi hin meningo helial cells o ganized in lobules, is ypical o his a e ype. [7] [12] Clea hyalinized
pe i ascula scle osis and dispe sed la ge, biza e nuclei, which is conside ed a degene a i e change, bu no
malignancy, is ano he e idence in a o o he WHO G ade. [7]
EMA, CD31, and CD34 a e ypical meningioma and ascula ma ke s. IHC o AMs shows s ong, di use EMA posi i i y
in meningioma cells, as well as CD31 and CD34 posi i i y in he ex ensi e ascula ne wo k. [3] The p esence o
p oges e one ecep o and SSTR2A and he absence o CK7, CK20, TTF-1, S-100, and low index o Ki-67 (<2 pe cen )
suppo he benign na u e and simila i y o common meningioma immunopheno ype. [3] The ac ha he e we e no
o he pa hogenic mu a ions in ou case, e en hough adia ion has been used in he pas , suppo s he ini ial diagnosis
o a G ade I angioma ous meningioma, which has a unique gene ic con ex in con as o o he ypes o meningioma.
[15]
3.3.3. Managemen and ou comes
Managemen s a egy and su gical di icul ies wi h hype ascula i y
AMs a e benign Wo ld Heal h O ganiza ion (WHO) G ade I neoplasms [6] [21], howe e , hei ma ked hype ascula i y
dis inguishes hei su gical ea men om ha o less ascula meningiomas. Maximal sa e esec ion is he ounda ion
o managemen , as he ex en o su gical esec ion emains he bes p edic o o long- e m ecu ence isk. [22]
The goal o g oss o al esec ion (Simpson G ade I) is o en limi ed by he need o me iculous hemos asis in he AMs,
equen ly necessi a ing a Simpson G ade II esec ion whe e du al a achmen s a e coagula ed a he han excised. [6]
The p o ound hemos a ic challenges o his pa hology exempli ied by he signi ican in aope a i e bleeding and acu e
pos ope a i e complica ion obse ed in his case, highligh he li e a u e's discussion on specialized echniques o
manage hemo hage. [23] [24]
P eope a i e emboliza ion (POE) is a widely used adjunc , suppo ed by e idence showing ha i educes he umo -
o-blood loss a io and can p olong ecu ence- ee su i al. [8] [23] Howe e , he ou ine applica ion o POE emains
con o e sial due o a documen ed isk o p ocedu al complica ions, including s oke and hemo hage, anging om
2.9% o 5.6%. [24] [25] Fo high- low umo s like AM, he bene i o de ascula iza ion in educing acu e su gical isk
may ou weigh he p ocedu al isks, a conclusion suppo ed by he se ious mo bidi y expe ienced in cases wi hou POE.
Wo ld Jou nal o Biology Pha macy and Heal h Sciences, 2025, 24(02), 108-117
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Ex en o esec ion and adju an he apy
The Simpson G ade II esec ion achie ed in his pa ien signi ican ly ele a ed he long- e m isk o local ecu ence,
e en o a WHO G ade I umo . [26] The haza d a io o e ea men ollowing G ade II/III esec ion is epo ed o be
4.9 imes highe han ha o ollowing G ade I esec ion, as incomple e esec ion inc eases he p obabili y o eg ow h
o e he cou se o 10 o 20 yea s. [6] [27]
Sub o al esec ion (STR) ypically p omp s conside a ion o Adju an Radia ion The apy (ART) o bo h G ade I and
highe -g ade meningiomas. [22] [28] Howe e , ecen long- e m analyses (o e 10 yea s) sugges ha ART o WHO
G ade I esiduals may pa adoxically inc ease ecu ence a es and a highe isk o malignan ans o ma ion in ce ain
coho s. [29] The managemen decision o pu sue agg essi e obse a ion, a he han immedia e ART, is he e o e
jus i ied as a conse a i e s a egy o mi iga e hese po en ial long- e m isks. Sal age he apy, such as s e eo ac ic
adiosu ge y (SRS), emains an op ion should de ini e p og ession be obse ed. [6] [22]
Ou comes and p ognos ic implica ions
The pa ien 's excellen ou -yea ecu ence- ee su i al and unc ional eco e y align wi h he gene ally a o able
sho - e m ou comes expec ed o WHO G ade I umo s. [21] Howe e , he long- e m p ognosis is complica ed by he
con luence o he G ade II esec ion and he suspec ed unde lying e iology:
The pa ien ’s his o y o p io c anial adia ion 15 yea s ea lie alls wi hin he es ablished la ency pe iod o adia ion-
induced meningiomas (RIMs), which a e ages 17.5 o 29.7 yea s. [23] [30] RIMs a e ecognized in he li e a u e as
biologically mo e agg essi e han spo adic meningiomas, wi h ecu ence a es epo ed be ween 21% and 33%, e en
among G ade I sub ypes. [8] This his o y ac s as a po en , independen isk ac o o u u e p og ession.
This high- isk p o ile is p esen ed by he su eillance and seizu e managemen p o ocols used by he pa ien . I has
been ecommended ha all meningiomas, whe he low-g ade o no , which a e no ully excised, should ha e inde ini e
annual MRI scans. In he case o umo - ela ed epilepsy, i is s anda d p ac ice o con inue aking an i-epilep ic d ugs
(AEDs) o o e one yea in pa ien s wi h p eope a i e seizu es [31], and only when he pa ien is ee o seizu es a e
1 o 2 yea s, should one conside he g adual educ ion o hese medica ions. [29]
While managemen success ully achie ed acu e neu ologic con ol, he combina ion o echnical su gical limi a ions
(G ade II EOR) and p o ound biological isk (suspec ed RIM e iology) dic a es a li elong, s ingen su eillance p o ocol
o add ess he cumula i e p obabili y o la e ecu ence.
4. Wha ha e we lea ned om his case?
This example o AM can be use ul in clinical p ac ice in se e al ways. To begin wi h, he his o y o p e ious c anial
adia ion he apy in he pa ien p o ides e idence o a ecognized isk ac o o de eloping meningioma, which explains
he signi icance o long- e m moni o ing in pa ien s who ha e a his o y o meningioma (e en he benign ypes).
Secondly, he non-speci ic and p og essi e neu ological symp oms, such as headaches, seizu es, and pe sonali y
changes, unde sco e he insidious na u e o hese umo s and he high index o suspicion equi ed in pa ien s wi h
unexplained neu ological symp oms and signs. The la ge pe i umo al edema and mass e ec , despi e he WHO G ade I
o he umo , suppo he idea ha e en he his ologically benign meningiomas may lead o se e e neu ological
impai men and necessi a e agg essi e ea men .
Thi dly, he ex ensi e ascula i y obse ed on imaging and con i med in aope a i ely, esul ing in signi ican blood
loss, highligh s he impo ance o igo ous p eope a i e planning and su gical echnique o AM. The discussion o
p eope a i e emboliza ion, which is no indica ed in his case, is an impo an conside a ion o high- ascula i y lesions.
The expe ience o he success ul Simpson G ade II esec ion, which s ikes a balance be ween su icien umo
des uc ion and a low isk o bleeding, o e s a p ac ical solu ion o he dilemma o dealing wi h such p oblema ic
si ua ions.
Las ly, he pos ope a i e complica ion o hemo hage and esul an empo a y ce eb al edema, e en wi h success ul
esec ion, is a eminde ha al hough pos -su gical complica ions may be immedia e, ca e ul obse a ion and imely
ac ions may p e en hem. Wha ul ima ely happened o he pa ien as he eco e ed his ull neu ological unc ion and
managed his seizu es in he long e m, howe e , demons a es he bene i s ha can be a ained h ough p omp , co ec
managemen .
Wo ld Jou nal o Biology Pha macy and Heal h Sciences, 2025, 24(02), 108-117
115
Abb e ia ion
• Angioma ous meningioma (AM);
• Adju an Radia ion The apy (ART);
• Immunohis ochemical (IHC);
• Sub o al esec ion (STR)
5. Conclusion
This case o angioma ous meningioma is discussed o emphasize he diagnos ic and managemen challenges o he
uncommon sub ype, especially in pa ien s wi h p e ious his o y o c anial adia ion. The main poin o his epo is
ha e en WHO G ade I umo s may ha e a high mass e ec , a high pe cen age o ascula i y, and acu e pos ope a i e
condi ions, which make hem ha d o plan and ha d o ope a e on. The case suppo s he alue o conside ing a wide
ange o diagnoses and demons a es ha posi i e long- e m neu ologic ou comes a e possible wi h mul idisciplina y
ca e. Th ough his expe ience, we hope o con ibu e o he medical communi y by lea ning abou angioma ous
meningiomas and highligh ing he need o close obse a ion in ulne able pa ien s and o de ising cul u ally speci ic
in e en ion measu es o help pa ien s eco e o he bes o hei abili y.
Compliance wi h e hical s anda ds
Acknowledgmen s
Special hanks o Jenni e Paz, Elizabe h Sanchez, and Sa a Nase o hei assis ance in e iewing he inal manusc ip .
Addi ionally, we app ecia e he assis ance o G amma ly's language edi o , which p o ided aluable w i ing suppo by
iden i ying and co ec ing e o s in g amma , spelling, punc ua ion, and s yle, ul ima ely enhancing he manusc ip .
Disclosu e o con lic o in e es
All au ho s make he ollowing decla a ions:
• Paymen /se ices in o ma ion: All au ho s ha e decla ed ha hey ecei ed no inancial suppo om any
o ganiza ion o he submi ed wo k.
• Financial ela ionships: All au ho s ha e decla ed ha hey ha e no inancial ela ionships a p esen o wi hin
he p e ious h ee yea s wi h any o ganiza ions ha migh be in e es ed in he submi ed wo k.
Da a access s a emen
All ele an da a a e included in he pape .
Au ho con ibu ions
All au ho s con ibu ed equally o p oducing his manusc ip .
S a emen o in o med consen
Consen o he publica ion o his case was ob ained om he pa ien . The pape has been su icien ly anonymized o
main ain he pa ien 's con iden iali y.
Re e ences
[1] Meye HJ, Wienke A, Su o A. ADC alues o benign and high g ade meningiomas and associa ions wi h umo
cellula i y and p oli e a ion–A sys ema ic e iew and me a-analysis. Jou nal o he Neu ological Sciences. 2020
Aug 15;415:116975.
[2] Raghuna han A, Giannini C. His opa hology o meningiomas. Biological and Clinical Landscape o Meningiomas.
2023 Jul 12:35-45.
[3] Ogasawa a C, Philb ick BD, Adamson DC. Meningioma: a e iew o epidemiology, pa hology, diagnosis, ea men ,
and u u e di ec ions. Biomedicines. 2021 Ma 21;9(3):319.
Wo ld Jou nal o Biology Pha macy and Heal h Sciences, 2025, 24(02), 108-117
116
[4] B own NJ, Penning on Z, Kuo CC, Gend eau J, Chak a a i S, Singh R, Douse DM, Van Gompel JJ. Meningioma: a
biog aphy— umo o e e ied o he o igins and “soul o neu osu ge y”. Wo ld neu osu ge y. 2023 Oc
1;178:191-201.
[5] Nowosielski M, Galldiks N, Iglsede S, Kickinge ede P, Von Deimling A, Bendszus M, Wick W, Sahm F. Diagnos ic
challenges in meningioma. Neu o-oncology. 2017 No 29;19(12):1588-98.
[6] Louis DN, Pe y A, Wesseling P, B a DJ, C ee IA, Figa ella-B ange D, Hawkins C, Ng HK, P is e SM, Rei enbe ge
G, So ie i R. The 2021 WHO classi ica ion o umo s o he cen al ne ous sys em: a summa y. Neu o-oncology.
2021 Aug 1;23(8):1231-51.
[7] Ve ma PK, Nanga wal B, Ve ma J, Dwi edi V, Meh o a A, Das KK, Mau ya VP, Bhaiso a KS, Singh J, S i as a a AK,
Beha i S. A clinico-pa hological and neu o- adiological s udy o angioma ous meningioma: Agg essi e look wi h
benign beha iou . Jou nal o Clinical Neu oscience. 2021 Jan 1;83:43-8.
[8] Jung IH, Kim JY, Pa k SH, Chang WS. Consecu i ely occu ing adia ion-induced meningiomas wi h a ious
pa hologic diagnoses: a case epo . Jou nal o he Ko ean Socie y o S e eo ac ic and Func ional Neu osu ge y.
2021 Sep 24;17(2):103-9.
[9] Liu Y, Lin W, Zheng X, Huang Y, Li Y, Deng X. Clinical and imaging ea u es o angioma ous meningioma: a
e ospec i e analysis o 28 cases. J Clin Neu osci. 2021;83:43–8.
[10] Ba hélemy EJ, Sa kiss CA, Lee J, Sh i as a a RK. The his o ical o igin o he e m “meningioma” and he ise o
na ionalis ic neu osu ge y. Jou nal o Neu osu ge y. 2016 No 1;125(5):1283-90.
[11] F anca RA, Della Monica R, Co ino S, Chia io i L, De Ca o MD. WHO g ade and pa hological ma ke s o
meningiomas: clinical and p ognos ic ole. Pa hology-Resea ch and P ac ice. 2023 Ma 1;243:154340.
[12] Hwang J, Kong DS, Seol HJ, Nam DH, Lee JI, Choi JW. Clinical and adiological cha ac e is ics o angioma ous
meningiomas. B ain umo esea ch and ea men . 2016 Oc 31;4(2):94.
[13] Ansa i SF, Shah KJ, Hassaneen W, Cohen-Gadol AA. Vascula i y o meningiomas. InHandbook o clinical neu ology
2020 Jan 1 (Vol. 169, pp. 153-165). Else ie .
[14] Soni N, O a M, Ba hla G, Szeke es D, Desai A, Pillai JJ, Aga wal A. Meningioma: molecula upda es om he 2021
Wo ld Heal h O ganiza ion Classi ica ion o CNS Tumo s and imaging co ela es. Ame ican Jou nal o
Neu o adiology. 2025 Feb 1;46(2):240-50.
[15] Abedal haga i MS, Me ill PH, Bi WL, Jones RT, Lis ewnik ML, Ramkissoon SH, Tho ne AR, Dunn IF, Be oukhim
R, Alexande BM, B as ianos PK. Angioma ous meningiomas ha e a dis inc gene ic p o ile wi h mul iple
ch omosomal polysomies including polysomy o ch omosome 5. Onco a ge . 2014 Sep 25;5(21):10596.
[16] Hale AT, Wang L, S o he MK, Chambless LB. Di e en ia ing meningioma g ade by imaging ea u es on magne ic
esonance imaging. Jou nal o Clinical Neu oscience. 2018 Feb 1;48:71-5.
[17] Yang L, Ren G, Tang J. In ac anial angioma ous meningioma: a clinicopa hological s udy o 23 cases.
In e na ional Jou nal o Gene al Medicine. 2020 Dec 30:1653-9.
[18] Gkasda is G, Vasilje ic A, Ca ala S, Pelissou-Guyo a I, Guyo a J, Dumo C, Pica T, Be houma M. Pu ely cys ic
meningioma: Case epo and sys ema ic e iew o he li e a u e. Clinical Neu ology and Neu osu ge y. 2022 Dec
1;223:107498.
[19] Demaisip PD, Juangco DN, Nic Junn CT, Al a ez N. A Meningioma wi h Ex ensi e Pe i umo al Edema Mimicking
Me as a ic B ain Tumo : A Case Repo . B ain Tumo Resea ch and T ea men . 2023 Ap 1;11(2):140-4.
[20] Lyndon D, Lansley JA, E anson J, K ishnan AS. Du al masses: meningiomas and hei mimics. Insigh s in o
imaging. 2019 Feb 6;10(1):11.
[21] Hasselbla M, Nol e KW, Paulus W. Angioma ous meningioma: a clinicopa hologic s udy o 38 cases. The
Ame ican jou nal o su gical pa hology. 2004 Ma 1;28(3):390-3.
[22] Roge s L, Ba ani I, Chambe lain M, Kaley TJ, McDe mo M, Raize J, Schi D, Webe DC, Wen PY, Vogelbaum MA.
Meningiomas: knowledge base, ea men ou comes, and unce ain ies. A RANO e iew. Jou nal o neu osu ge y.
2015 Jan 1;122(1):4-23.
[23] Chun YS, Oh CW, Han JS, e al. P eope a i e emboliza ion signi ican ly educes blood loss o umo olume a io.
J Ce eb o asc Endo asc Neu osu g. 2013;15(3):148-154. doi:10.7461/jcen.2013.15.3.148.
