Abstract
Introduction:
In the acute neurology setting, stroke presentations are considered common relative to other diagnoses, especially among multimorbid elderly presenting with acute neurological changes. Clinicians tend to underestimate the possibility of other rare diagnoses such as brain tumors.
Case report:
Here we present a case report of an 80-year-old female who presented to the emergency department, she exhibited a seizure and stroke-like symptoms, including confusion, loss of consciousness, and slurred speech. Initial clinical assessments suggested a cerebrovascular event; however, neuroimaging later revealed a parasagittal meningioma as the cause of the symptoms.
Conclusion:
This case underscores the necessity of including brain tumors such as meningiomas in the differential diagnosis for elderly patients presenting with symptoms resembling cerebrovascular events.
Keywords
Introduction
Meningiomas are the most common primary brain tumors, accounting for approximately 14%–19% of all intracranial neoplasms. 1 These tumors arise from the meninges, the protective layers surrounding the brain and spinal cord, and are typically slow-growing and benign. However, the anatomical location of meningiomas can result in significant neurological manifestations due to their mass effect on adjacent cerebral structures.
Meningiomas commonly arise in the parasagittal region and frequently originate in the suprasellar (diaphragma selle and tuberculum selle), frontobasal, temporobasal, sphenoid wing (medial lesser wing of sphenoid), anterior clinoid or petroclival regions, cavernous sinus wall, and optic nerve sheath. 2 Meningiomas are observed more frequently in females, a trend thought to be influenced by the potential relationship between tumor growth and female sex hormones, such as estrogen and progesterone. 3 Meningiomas typically occur across all age groups, however, they show a peak in incidence during the sixth and seventh decades of life. The frequency of these tumors increases steadily as individuals age.4,5 These tumors often present with symptoms such as headaches, seizures, or focal neurological deficits caused by compression of adjacent neural structures. Rarely, documented cases of meningiomas can manifest with a stroke-like presentation, 1 due to their impact on cerebrovascular structures, leading to ischemia or hemorrhage. This unusual presentation often complicates the diagnostic process by mimicking strokes and delaying appropriate treatment. 6
This case report presents an 83-year-old female who exhibited a seizure and stroke-like symptoms, including confusion, loss of consciousness, and slurred speech. Initial clinical assessments suggested a cerebrovascular event; however, neuroimaging later revealed a parasagittal meningioma.
Case Presentation
An 83-year-old woman with a history of hypertension, atrial fibrillation, and heart failure with preserved ejection fraction presented acutely to the emergency department. Her chief complaint included staring, tongue heaviness, left-sided mouth deviation, and tonic posturing followed by loss of consciousness lasting 10 minutes, with abnormal limb movements during the first 10 seconds. According to her family, she remained confused for approximately 10 minutes after the episode and these symptoms occurred a few hours prior to her presentation to the emergency department.
On presentation, the patient exhibited aphasia, confusion, and disorientation to time and place, otherwise her neurological exam was reassuring with intact cranial nerves, normal visual fields, equal and reactive pupils, and full extraocular movements. Facial sensation and strength were normal, with symmetrical facial movements. Hearing was intact, the palate elevated symmetrically, and the gag reflex was present. Shoulder shrug and head rotation were strong, and the tongue was midline without atrophy or fasciculations. Motor strength was 5/5 throughout with mild reduction in muscle bulk, with normal tone and no involuntary movements. Sensations were intact to light touch, pinprick, and vibration in all extremities. Reflexes were 2+ and symmetric, with down going plantar responses. Coordination was intact, with normal finger-nose-finger and heel-to-shin testing. The patient Glasgow Coma Scale (GCS) score of 14. Her vital signs were as follows: blood pressure 145/90 mmHg, temperature 37.2°C, and respiratory rate 19 breaths per minute. A glucose check revealed normal blood sugar levels.
Baseline investigations, including complete blood count, C-reactive protein, and liver function tests, were normal. The ECG showed atrial fibrillation while arterial blood gas analysis was normal. Laboratory findings included an elevated troponin (31.9 ng/l) and B-type natriuretic peptide (BNP) levels (4115 pg/mL).
Given the patient’s acute clinical presentation, a stroke was initially suspected, prompting a non-contrast Computed Tomography (CT) scan in the emergency department only hours after her initial presentation that showed age-related parenchymal volume loss with periventricular small vessel disease. No recent hyperdense intracranial hemorrhage or recent major territorial infarctions, or midline shifts were noted. The CT scan also revealed a previously reported meningioma, incidentally, diagnosed during an unrelated workup 5 years ago in 2019. No management was done at that time due to the asymptomatic nature of the tumor and the patient’s age. It remained unchanged in size at 14 mm and appeared more calcified compared to previous imaging, as evident in Figure 1. Although the patient’s neurological examination findings were improving at this point, an additional magnetic resonance imaging (MRI) was ordered for definitive diagnosis. The MRI was conducted the morning after the patient’s overnight admission from the emergency department and revealed age-related parenchymal volume loss with periventricular small vessel disease and multiple lacunar infarcts. It also showed a 15 × 12 × 10 mm moderately enhancing left frontal parasagittal meningioma. The lesion appeared isointense to gray matter on T1, hypointense on T2, along with FLAIR, with surrounding white matter edema. No abnormal leptomeningeal signal was noted, and the midline structures and major intracranial flow voids were preserved as evident in Figure 2. A subsequent magnetic resonance angiography (MRA) of the head and neck timed closely with the mentioned MRI revealed scanty branches of both middle cerebral arteries (MCA), normal arteries of the circle of Willis, and a hypoplastic right vertebral artery. There was no evidence of significant narrowing or obstruction, as evident in Figure 2.
Head non-contrast computed topography (CT). The figure show the meningioma at the time of the patient presentation in the coronal (A), axial (B), and sagittal (C) planes. The figure also demonstrates the meningioma at the time of its diagnosis in 2019 in the axial (D) and sagittal (E) planes. We see no difference in the size of the meningioma on both years.
Magnetic resonance imaging (MRI) and angiography (MRA) of the brain at the time of the presentation. We show the T1-weighted imaging (A), T2-weighted (B) and fluid attenuation inversion recovery (FLAIR) (C) sequences. We also show the sagittal (D) and coronal (E and F) MRA images of the head and neck.
It is important to note that the patient’s symptoms were almost completely relieved by the time the MRI was conducted. This clinical improvement, combined with the normal findings from all imaging studies, suggested the benign nature of her condition and pointed to the meningioma as the likely cause. No invasive procedures, including biopsy or surgical resection, took place, and the diagnosis of meningioma in this patient therefore remains radiological. Because she was asymptomatic from the lesion at baseline and her age and comorbidities rendered her a poor surgical candidate, a conservative, non-operative strategy was chosen.
However, due to the unique characteristics of the meningioma, close monitoring with follow-up imaging was advised to track its growth and reassess potential treatment options if similar symptoms arise in the future. After 48 hours of inpatient observation, the patient was hemodynamically stable with return to baseline cognitive status and a Glascow Coma Scale of 15, so the patient was discharged with her chronic medications unchanged, including apixaban 2.5 mg twice daily, atorvastatin 40 mg once daily, rivastigmine 3 mg once daily, and levetiracetam 250 mg once daily.
Discussion
This case highlights the rare presentation of an 83-year-old patient with a meningioma exhibiting neurological deficits mimicking stroke and seizure like activity, emphasizing the diagnostic challenges encountered in elderly patients with such presentations. Here we explain the possible explanations for such a presentation while reviewing previous cases reported in the literature.
Clinical Presentation and Pathophysiology
Several mechanisms have been proposed to explain stroke-like presentations in patients with meningiomas. Some tumors directly compress or encase major arteries, such as the middle cerebral or internal carotid arteries, leading to hemodynamic compromise or frank territorial infarction.7-11 Others involve venous sinus obstruction with secondary venous congestion and edema. Peritumoral edema itself, particularly in atypical or high-grade meningiomas, can acutely increase mass effect and precipitate focal deficits. 12 Finally, meningiomas are well recognized as epileptogenic lesions; seizures and their post-ictal deficits may be indistinguishable from ischemic stroke at initial presentation. 13 Our patient most likely fell into this latter category, with a frontal parasagittal meningioma and associated edema acting as the substrate for a focal-onset seizure that clinically mimicked an acute ischemic event.
The main diagnostic challenge in this case is interpreting an acute focal episode in a patient who had well established risk factors for embolic or small vessel stroke alongside a structural lesion capable of triggering seizures. In such situations, clinicians must integrate the clinical evolution of symptoms, the timing and resolution of deficits, and the full range of imaging findings rather than relying on any single element. Our case illustrates how careful correlation of clinical presentation with MRI and MRA findings can shift the diagnosis away from primary ischemic stroke and toward a tumor-related seizure in an otherwise “high-stroke-risk” patient.
To support clinicians facing similar scenarios, a practical methodological checklist can be applied when evaluating acute stroke-like presentations and systematically addressing the stroke–brain tumor differential diagnosis1,6,10,14:
Several mechanisms may explain the stroke-like presentation in this case. Meningiomas can cause acute neurological deficits by compressing adjacent brain structures, leading to sudden ischemia due to vascular compromise, venous sinus obstruction, or edema. Additionally, large tumors located near critical vascular territories may alter blood flow dynamics, thus mimicking an ischemic stroke. Launay et al 11 reported 12 cases of meningiomas, 11 of which presented with arterial narrowing without occlusion, while 1 case involved arterial occlusion due to thrombosis of the middle meningeal artery. Furthermore, the location of the meningioma is a crucial factor that significantly influences the patient’s presentation, and the symptoms experienced. For instance, the relationship between skull base meningiomas and their potential to compress the carotid artery is well documented in the literature. Transient neurological symptoms such as loss of consciousness, hemiparesis, paresthesia, and global amnesia have been observed in individuals diagnosed with skull base meningiomas. 14 In contrast, frontal meningiomas typically present with different presentations due to their specific anatomical relationships. These tumors often lead to cognitive and behavioral changes, affecting personality and memory. 7 Thus, tumor location plays a crucial role in determining the clinical presentation of meningiomas. Another possible mechanism is tumor-related seizures that temporarily disrupt neurological function, masquerading as a transient ischemic attack or stroke. Although most patients with meningiomas present with clinical manifestations like headaches or neurological deficits, seizures are also relatively common in this population. Harward et al investigated the association between meningiomas and seizure occurrence. Peritumoral brain edema secondary to meningiomas is hypothesized to induce pathophysiological alterations that contribute to epileptogenesis. 13 These mechanisms underscore the importance of considering brain tumors as a differential diagnosis for acute-onset neurological decline in elderly patients, particularly when conventional imaging does not reveal typical findings indicative of ischemic or hemorrhagic stroke.
Other examples of recent reports include Navarro and Gan 15 who reported a cranio-cervical (foramen magnum) meningioma in a 50-year-old woman causing sudden left hemisensory loss. Other cases include Devia et al, 16 a 50-year-old woman whose convexity meningioma masqueraded as an intracerebral hemorrhage (severe headache and a hyperdense temporal lesion on CT), and a 36-year-old woman with a large left sphenoid-wing meningioma encasing the ICA/MCA who presented with headache, vomiting and right hemiplegia due to left MCA infarction. 17
By contrast, our case shares some features with these reports but also differs in key ways. Like the cases above, she was an older adult with a large extra-axial tumor and acute neurological signs. However, her deficits were transient and clearly seizure-related, rather than persistent hemiparesis from infarction or hemorrhage, highlighting a somewhat different mechanism (cortical irritability rather than vascular occlusion). Overall, the literature suggests that stroke-like presentations of meningioma are uncommon and most often involve middle-aged to elderly women with convexity or skull-base lesions causing focal deficits by compression, edema, or hemorrhage. The present 83-year-old patient fits the profile of an elderly female with an extra-axial mass, but differs in that her symptoms were transient and probably ictal in origin. Table 1 below provides a comparison of previously mentioned as well as other cases of meningioma presenting with acute stroke-like symptoms. For each report we list patient age/sex, tumor location/size, presenting symptoms, imaging findings, diagnosis, and management.
Comparison cases of a meningioma presenting with acute stroke-like symptoms.
Definitive diagnosis and grading of meningiomas normally rely on histopathological examination, supported by immunohistochemistry and, increasingly, molecular profiling.3,8 Modern histological techniques, including special dyes and advanced staining protocols, can enhance visualization of tumor–brain interfaces, tumor margins, vascular involvement, and cellular architecture, thereby improving diagnostic accuracy and helping to distinguish meningiomas from other dural-based or extra-axial lesions. 18 Sava et al, 18 for example, described a series of new dyes for central nervous system sections that provide improved contrast and structural detail in CNS tumor specimens. In the present case, however, no tissue diagnosis was obtained because the patient was managed conservatively for clinical reasons; consequently, our classification of the lesion as a meningioma is based on its characteristic extra-axial location, imaging appearance, calcification, and homogeneous contrast enhancement. This scenario reflects common real-world practice in very elderly or medically fragile patients, where imaging and clinical evolution often guide management in the absence of histology.
Literature Review
A review of the literature reveals that meningiomas presenting with a stroke-like presentation are rare but documented. Studies indicate that the incidence of meningioma increases with age, and its symptoms may overlap with common cerebrovascular diseases, leading to potential misdiagnosis. Ischemic symptoms associated with meningiomas are often attributed to vascular compression or invasion, with most cases located near the Middle Cerebral Artery (MCA) or major dural sinuses. 1 For example, Ahmad et al reported a case involving a 75-year-old woman who presented with stroke-like symptoms including sudden onset weakness on the right side, dysphagia, and aphasia for 6 hours; imaging later revealed an ischemic stroke in the left MCA alongside an incidental finding of an atypical meningioma. 1 Similarly, Gopal Raman et al 14 documented a case where occlusion of the left MCA was caused by a medial sphenoid wing meningioma. In another study by Dodiyi-Manuel and Ilodibia, 5 both internal carotid arteries were occluded due to a parasellar meningioma compressing nearby structures. However, the patient being presented in this case report showed no evidence of vascular occlusion upon further investigation, suggesting that the sole cause of her symptoms was the meningioma—unlike the cases presented by Ahmad et al., Ko et al., and Hamed et al. This case parallels our own; there was no evidence of vascular compromise contributing to the stroke-like symptoms; rather, the meningioma was determined to be the exclusive etiology of the patient’s clinical presentation. Our case emphasize the essential need to consider meningiomas as potential mimickers of stroke to facilitate prompt and appropriate intervention. This highlights the critical role of advanced imaging in diagnosing elderly patients with stroke-like symptoms, especially when routine imaging does not provide conclusive evidence of vascular compromise explaining their presentation.
Conclusion
This case underscores the necessity of including brain tumors such as meningiomas in the differential diagnosis for elderly patients presenting with symptoms resembling cerebrovascular events. This is important to prevent unnecessary management using thrombolytic agents that can lead to devastating conditions especially among elderly patients with multiple comorbidities.
Footnotes
Acknowledgements
The authors thank the patient and their family for cooperation and agreeing to report this case.
Ethical Considerations
The Institutional Review Board at the University of Jordan approved the reporting of this case report.
Consent to Participate
A written informed consent was obtained from the patient for publication of the details of their medical case and any accompanying images.
Author Contributions
AD, SJ, and MH conceptualized the idea and wrote the first draft; AAT supervised the project and revised and edited the manuscript.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
The data that support the findings of this study are not publicly available due to privacy reasons but are available from the corresponding author upon reasonable request.