Intracranial Hemorrhage from Meningioma: 2 Novel Risk Factors

BACKGROUND: Meningiomas are the most common benign intracranial tumor. Although meningiomas are slow growing and potentially highly vascularized, hemorrhage of these tumors is rare. We propose 2 novel modifiable risk factors that may provoke intratumoral hemorrhage of a World Health Organization grade I meningioma. CASE DESCRIPTION: We outline the clinical presentation of a 56-year-old female with spontaneous subarachnoid hemorrhage with intraventricular extension in a coma from a petroclival meningioma taking escitalopram for depression and high-dose estrogen replacement therapy for menopause. Pathology confirmed the diagnosis of World Health Organization grade I meningioma. Postoperatively, the patient declined neurologically and developed vasospasm of the basilar artery, as well as seizures, fever, and new-onset atrial fibrillation. CONCLUSIONS: Spontaneous hemorrhage of meningiomas is a rare event. Known risk factors are age older than 70 or younger than 30; intraventricular or convexity location; malignant, fibrous, or angioblastic histopathology; and presence of hypertension, anticoagulation therapy, and traumatic brain injury. We propose 2 new risk factors to be considered that may predispose to hemorrhage of a meningioma: serotonin-modulating therapy and high-dose estrogen-replacement.