J Korean Med Sci.  2017 Nov;32(11):1896-1902. 10.3346/jkms.2017.32.11.1896.

Coexistence of Radiation-Induced Meningioma and Moyamoya Syndrome 10 Years after Irradiation against Medulloblastoma: a Case Report

• Han JY
• Choi JW
• Wang KC
• Phi JH
• Lee JY
• Chae JH
• Park SH
• Cheon JE
• Kim SK

• KMID: 2390322
• DOI: http://doi.org/10.3346/jkms.2017.32.11.1896

Abstract

Radiotherapy is one of the standard treatments for medulloblastoma. However, therapeutic central nervous system irradiation in children may carry delayed side effects, such as radiation-induced tumor and vasculopathy. Here, we report the first case of coexisting meningioma and moyamoya syndrome, presenting 10 years after radiotherapy for medulloblastoma. A 13-year-old boy presented with an enhancing mass at the cerebral falx on magnetic resonance imaging (MRI) after surgery, radiotherapy (30.6 Gy craniospinal axis, 19.8 Gy posterior fossa) and chemotherapy against medulloblastoma 10 years ago, previously. The second tumor was meningioma. On postoperative day 5, he complained of right-sided motor weakness, motor dysphasia, dysarthria, and dysphagia. MRI revealed acute cerebral infarction in the left frontal lobe and both basal ganglia. MR and cerebral angiography confirmed underlying moyamoya syndrome. Four months after the meningioma surgery, the patient presented with headaches, dysarthria, and dizziness. Indirect bypass surgery was performed. He has been free from headaches since one month after the surgery. For patients who received radiotherapy for medulloblastoma at a young age, clinicians should consider the possibility of the coexistence of several complications. Careful follow up for development of secondary tumor and delayed vasculopathy is required.

Keyword

Meningioma; Moyamoya Syndrome; Medulloblastoma; Radiation-Induced Vasculopathy; Radiation-Induced Tumor; Radiotherapy

MeSH Terms

Adolescent
Aphasia
Basal Ganglia
Central Nervous System
Cerebral Angiography
Cerebral Infarction
Child
Deglutition Disorders
Dizziness
Drug Therapy
Dysarthria
Follow-Up Studies
Frontal Lobe
Headache
Humans
Magnetic Resonance Imaging
Male
Medulloblastoma*
Meningioma*
Moyamoya Disease*
Radiotherapy

Figure

• 

  Fig. 1 Initial presentation: medulloblastoma. Axial (A) and sagittal (B) contrast-enhanced MRI show a strongly enhancing lesion in the cerebellum with surrounding leptomeningeal enhancement, suggesting leptomeningeal seeding. Second presentation: meningioma. A 9 × 7 mm round shape mass (arrow) based on the falx cerebri at the high vertex with peripheral enhancement is shown in axial T2 weighted (C), contrast-enhanced sagittal (D). MRI = magnetic resonance imaging.

• 

  Fig. 2 Acute brain infarction after removal of the radiation-induced tumor. Axial diffusion weighted images (A) show diffusion restriction at the left frontal lobe and both basal ganglia, which indicates acute infarction. Retrospective review of MRI shows bilateral steno-occlusion of the internal carotid artery bifurcation and its branches (arrows) on T2-weighted axial image (B). MRA reveals marked narrowing of the main trunk of both middle cerebral arteries with rather preserved portions of their distal branches (C). Conventional cerebral angiography (D) shows steno-occlusion at the terminal portion of the right internal carotid artery and left internal carotid artery confirming moyamoya syndrome. MRI = magnetic resonance imaging, MRA = magnetic resonance angiography.

• 

  Fig. 3 Third presentation: moyamoya syndrome. T2-weighted axial image shows chronic change of infarction at the left frontal lobe (arrows) and bilateral basal ganglia (A). Perfusion MRI demonstrates delayed time to peak in the both middle cerebral artery territories and aggravated perfusion in the left anterior cerebral artery territory (arrows) (B). MRI = magnetic resonance imaging.

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