Discussion Meningiomas represent 15% of all brain tumors.

These lesions are the most common extra-axial tumors in the brain and the most frequently occurring tumors of mes odermal or meningeal origin. Advances in radiologic imaging techniques, such as computed tomography (CT) scan ning and magnetic resonance imaging (MRI), have improved the surgeon s ability t o predict the success for complete removal of the mass. Imaging information abou t the dural attachment site, location and severity of edema, and displacement of critical neurovascular structures is useful for planning the operative approach and affects outcome. Neuroradiologists and neurosurgeons must be aware of both the typical and atypic al imaging appearances of meningiomas, as there is some correlation with differe nt histologic types of tumor. The World Health Organization (WHO) classifies meningiomas into 3 categories: (1 ) typical or benign (88-94%), (2) atypical (5-7%), and (3) anaplastic or maligna nt (1-2%). Significant factors contributing to recurrence include atypical and m alignant histologic types (WHO classification) and heterogeneous tumor contrast enhancement on CT scans. Meningiomas arise from arachnoid cells, particularly those packing the arachnoid villi, which protrude as fingerlike projections into the walls of the dural vei ns and sinuses. Most meningiomas grow inward toward the brain as discrete well-d efined, dural-based masses and are spherical or lobulated. Flat tumors termed en plaque infiltrate the dura and grow as a thin carpet or sheet of tumor along th e convexity dura, falx, or tentorium. Dural attachment of meningiomas can be ped unculated or broad-based (sessile). Because the pia and arachnoid form a membran ous barrier between brain and tumor, some meningiomas grow into the subarachnoid space, but invasion of the brain is infrequent. MRI is preferred for the diagnosis and evaluation of brain meningiomas. CT scann ing well depicts bony hyperostosis, which may be difficult to appreciate on MRI. CT scanning may, however, fail to demonstrate en plaque and posterior fossa men ingiomas. CT scanning has limitations in performing direct imaging in any other plane than axial. However, with the onset of spiral CT scanning and, more recently, multis ection or multidetector-row CT (MDCT) scanning, the quality of sagittal and coro nal images that can be reconstructed from axial data has increased significantly . CT scanning is less helpful than MRI in differentiating different types of sof t tissue. Tumors of the meningioma group are usually very vascular and often produce enlar gement of the arteries that supply them. The most characteristic vascular findin g of a meningioma is a contribution to the blood supply of the neoplasm by branc hes of the external carotid system. Whenever it is possible to show that the ext ernal carotid artery shares in the blood supply of an intracranial tumor, it is most likely to be a meningioma. On the other hand, cranial tumors that invade th e meninges may have an evident blood supply in the angiograph from a branch of t he external carotid artery; however, bone destruction is usually also evident. M etastatic tumor invading the bones or the meninges and even gliomas that become exophytic may exhibit such a finding. 1. Enlarged vascular supply With a meningioma, the artery that most often becomes enlarged is the middle men ingeal (or its branches) and the other meningeal arteries. After a meningioma has evoked a reaction of the outer periosteum of the skull, t he superficial temporal, or some other extracranial branches of the external car otid artery will participate in the tumor blood supply. In attempting to determi ne whether the external carotid artery is indeed involved in the supply of a tum or, it is essential to pay careful attention to the relative sizes of the branch

es of the middle meningeal artery, in particular. It should be determined if pos sible, whether small branches enter the tumor area from an apparently enlarged a rtery. Several routine steps may be helpful to determine whether a branch of the extern al carotid artery is or is not supplying a tumor. First, the size of the trunk o f the middle meningeal artery should be scrutinized. If there is an increased bl ood flow through the middle meningeal trunk (which is necessary to supply a tumo r) the artery usually becomes tortuous in its initial portion before it bifurcat es. The presence of tortuosity per se is not necessarily an indication of an inc reased blood flow through this artery. Some patients have a tortuous initial por tion of the middle meningeal artery without having a neoplasm, but, if the tortu ous segment is longer than I or 2 cm, it is probably pathologic.Second, the rela tive sizes of the various branches of the middle meningeal artery should be note d since a branch involved in the supply of a tumor will fill slightly earlier an d be larger than the other branches. Third, a branch to a meningioma may not app ear to be enlarged at its origin from the middle meningeal trunk; if the artery is followed to its periphery, however, it will be noted that, instead of getting smaller, it actually becomes larger as it approaches the region of the neoplasm . It is observed chiefly in the external carotid circulation, and rarely in the internal carotid system. Such a finding is an important sign of blood supply of a tumor and is believed t o be due to a reversal of blood flow in the many arterioles which anastomose wit hin the meninges and the bone. They may join a principal vessel feeding the tumo r, preceding either from an adjacent branch of the middle meningeal, from access ory meningeal branches, or from superficial temporal arteries involved in the bl ood supply of the bone. By virtue of this reversal of flow, more blood is drawn into the final segment o f the artery to increase the blood supply of the neoplasm. Finally, a careful se arch should be made for multiple branches arising from any vessel in question, e specially near its termination. Such branches may be very inconspicuous, or they may be extremely prominent. When external carotid angiography alone is performed, the abnormal vessels are e asier to visualize than when there is superimposition of branches of the interna l carotid artery. The term sunburst appearance has been applied to this very dis tinctive angiographic finding which is characteristic of meningiomas but also se en in certain other vascular neoplasms, such as hemangiopericytomas. It is belie ved that the sunburst appearance is due to a radial distribution of the small ar terial branches which seem to spring from a central point which probably represe nts the original site from which the blood supply was drawn at the beginning of the growth of the tumor. After a meningioma has evoked a reaction of the outer periosteum of the skull, t he superficial temporal, or some other extracranial branches of the external car otid artery will participate in the tumor blood supply. In attempting to determi ne whether the external carotid artery is indeed involved in the supply of a tum or, it is essential to pay careful attention to the relative sizes of the branch es of the middle meningeal artery, in particular. It should be determined if pos sible, whether small branches enter the tumor area from an apparently enlarged a rtery. Several routine steps may be helpful to determine whether a branch of the extern al carotid artery is or is not supplying a tumor. First, the size of the trunk o f the middle meningeal artery should be scrutinized. If there is an increased bl ood flow through the middle meningeal trunk (which is necessary to supply a tumo r) the artery usually becomes tortuous in its initial portion before it bifurcat es. The presence of tortuosity per se is not necessarily an indication of an inc reased blood flow through this artery. Some patients have a tortuous initial por tion of the middle meningeal artery without having a neoplasm, but, if the tortu ous segment is longer than I or 2 cm, it is probably pathologic.Second, the rela tive sizes of the various branches of the middle meningeal artery should be note d since a branch involved in the supply of a tumor will fill slightly earlier an d be larger than the other branches . Third, a branch to a meningioma may not ap

pear to be enlarged at its origin from the middle meningeal trunk; if the artery is followed to its periphery, however, it will be noted that, instead of gettin g smaller, it actually becomes larger as it approaches the region of the neoplas m. It is observed chiefly in the external carotid circulation, and rarely in the internal carotid system. Such a finding is an important sign of blood supply of a tumor and is believed t o be due to a reversal of blood flow in the many arterioles which anastomose wit hin the meninges and the bone. They may join a principal vessel feeding the tumo r, proceeding either from an adjacent branch of the middle meningeal, from acces sory meningeal branches, or from superficial temporal arteries involved in the b lood supply of the bone. 2. The sunburst appearance By virtue of this reversal of flow, more blood is drawn into the final segment o f the artery to increase the blood supply of the neoplasm. Finally, a careful se arch should be made for multiple branches arising from any vessel in question, e specially near its termination. Such branches may be very inconspicuous, or they may be extremely prominent. When external carotid angiography alone is performed, the abnormal vessels are e asier to visualize than when there is superimposition of branches of the interna l carotid artery. The term sunburst appearance has been applied to this very dis tinctive angiographic finding which is characteristic of meningiomas but also se en in certain other vascular neoplasms, such as hemangiopericytomas.It is believ ed that the sunburst appearance is due to a radial distribution of the small art erial branches which seem to spring from a central point which probably represen ts the original site from which the blood supply was drawn at the beginning of t he growth of the tumor. The majority of meningiomas that occur over the cranial vault are supplied by br anches of the middle meningeal artery and, as explained above, sometimes by the superficial temporal artery. Some meningiomas situated in the frontal fossa may be supplied by meningeal branches which normally feed the bone in this region an d which arise from or anastomose with branches of the ophthalmic artery. Since t he circulation through the internal carotid artery is swifter than the external, eventually a significant proportion of (or most of) the tumor blood supply may be by way of the ophthalmic artery. This vessel then becomes enlarged. In such c ases it is possible to demonstrate angiographically branches arising from the su perior aspect of the ophthalmic artery and extending upward to the roof of the o rbit. Falx meningiomas arising in the frontal region (back to the coronal suture ) may receive their blood supply partly from the anterior meningeal (artery of t he falx) branch of the ophthalmic artery. The anterior meningeal artery (arising from the anterior ethmoidal branch of the ophthalmic) may become enlarged and c an be followed along the inner table of the skull in the frontal region Although frontal midline meningiomas and subfrontal (olfactory groove) meningiomas usual ly derive their blood supply from the ophthalmic artery, tuberculum sellae menin giomas often do not have a principal ophthalmic supply. Some tentorial meningiomas present another example of blood supply through the i nternal carotid artery, by way of its meningeal anastomotic branches. The tumor also receives branches from the external carotid system. Meningiomas in the posterior fossa also may be supplied by accessory meningeal a rteries. These are branches of the external carotid system entering the skull by way of the condyloid foramen and through the foramen lacerum. Anterior and post erior meningeal branches of the vertebral arteries also supply such lesions. Branches of the middle meningeal and superficial temporal arteries sometimes ove rlie the area of a neoplasm, but this does not necessarily mean that they are su pplying the lesion . The rules explained above, especially progressive vascular enlargement (paradoxical enlargement), should be followed in trying to evaluate the significance of vessels in, or about, a tumor area. An occasional branch of the external carotid artery, most often the superficial temporal artery, may appear to enlarge on the late films of serialogram. It is n ecessary, however, to differentiate between actual enlargement of a vascular seg ment and its apparent enlargement which may be caused by laminar flow. The main

stream of contrast substance is through the center of the artery, and the periph ery of the vessel becomes opacified after the center. The later of two films may therefore show an arterial diameter which appears to be larger than on the earl ier film. In addition, some enlargement may be a true vasodilatation due to the effect of the contrast material on the vessel wall. The angiogram usually serves to differentiate such an appearance from true enlargement. 3. The vascular rim Not all meningiomas are supplied principally by the external carotid artery and its branches. A significant number are supplied by both the external and the int ernal carotid arteries .In this case the periphery of the meningioma is supplied by branches from the internal carotid system that encircle the tumour and form the characteristic vascular rim,while the center of the tumour is supplied by br anches from the external carotid system that radiated peripherally forming the s unburst appearance,and a small percentage draw exclusively from intracranial bra nches of the internal carotid artery. An example of exclusive internal carotid s upply is the intraventricular meningioma, a tumor which is usually fed by the ch oroidal arteries 4. The venous blush Although the vessel or vessels that actually supply a meningioma can usually be seen in the angiogram, sometimes they cannot, and only a large area of abnormal density can be discerned. The intrinsic vascularity of a tumor has previously be en referred to as the tumor cloud, stain, or capillary blush. A homogeneous tumor clou d in which there is a fairly even distribution of the contrast material througho ut the tumor is characteristic of meningiomas. In addition, persistence of the t umor cloud for a considerable period of time throughout the serialogram is of gr eat importance in the diagnosis of meningiomas. The stain may still be visible even on the last film taken 8 or 9 sec after the beginning of the injection. Meningiomas usually exhibit a homogeneous cloud, but it must be appreciated that the stain can develop piecemeal; i.e., only a portion of the tumor may be opaci fied by one injection. It is not uncommon for one segment of the lesion to be su pplied by the ipsilateral external carotid artery and for the remainder of the t umor to draw from the internal carotid artery, or fill via a branch of the contr alateral external carotid system. Three (or more) parts of the tumor may fill fr om different systems. The better the tumor vessels are demonstrated by multiple selective arterial injections, the more fragmented the capillary blush. Therefor e, it is necessary to visualize all possible afferent arteries of a meningioma, and mentally combine the stains, to gain a true concept of the size and location of the total tumor cloud. The supply to the hilus of a meningioma is virtually always from the external carotid system. The intrinsic vascular outline of meningiomas is most often sharply circumscribe d and lobulated in configuration. This characteristic is in contradistinction to some gliomas (usually mixed oligodendrogliomas and astrocytomas), which may pre sent a homogeneous cloud but are not sharply circumscribed. Meningiomas usually fail to exhibit prominent draining veins. With some meningio mas, thin veins may be seen at the periphery of the tumor. Some cases of angiobl astic meningiomas may present numerous large veins with an increase in the speed of circulation through the tumor that produces early venous filling, similar to that seen with malignant tumors. Such lesions, however, that display draining v eins, may exhibit all of the other characteristics of meningiomas. In these case s, the draining vessels are usually superficial cerebral veins. Deep veins may s ometimes drain into the vein of Galen. Such veins indicate that there is invasio n of brain tissue by the meningioma or, at least, that tumor vessels have appeared which bridge the space to the surface of the brain. Intraventricular tumors, of necessity, must drain by way of the tributaries of the thalamostriate and inter nal cerebral veins. In trying to evaluate the importance of the above described characteristics of t he abnormal circulation of meningiomas, the most significant features are consid ered to be:(I) a blood supply from the external carotid system, (2) a homogeneou s but sharply circumscribed cloud, and (3) the persistence of the contrast subst

ance within the tumor. In some cases, no blood supply can be traced from the ext ernal carotid artery into the meningioma, and a diagnosis must be based on other observations. Of the latter two findings, persistence of the tumor cloud appear s to be slightly more reliable than homogeneity alone. Because of pressure on superficial cerebral veins, slowing of the circulation th rough the area of a meningioma may be seen in the absence of abnormal vascularit y. The surface veins in the tumor area fill later than normal, owing to local sl owing of the circulation. The finding is nonspecific and may be found in cases o f intracerebral tumors, as well. The development of catheters and the continued refinement of embolic materials a nd radiographically controlled interventional procedures have contributed to imp roved treatment of patients with brain meningiomas. The clinician must be aware of the active participation of the neurosurgeon and neuroradiologist in the ther apy of neurosurgical patients. The best available treatment for benign meningiomas is complete surgical resecti on of the tumor. Nevertheless, interventional neuroradiologists should contribut e in performing preoperative embolization to reduce the blood supply to the tumo r. All meningiomas are benefited by embolization, but especially those with a co mplex presentation, giant meningiomas, meningiomas exhibiting malignant or angio blastic characteristics, or meningiomas involving the skull base, scalp, or crit ical vascular structures.The preoperative embolization of meningiomas is commonl y used to facilitate surgery