Acute haemorrhagic presentation of an intracranial meningioma

Acute haemorrhagic presentation of a meningioma is an extremely rare event. In a review of the literature, 44 such cases were found and only eight of them presented with sudden onset of coma. The outcome in these eight cases was, with few exceptions, poor. We report the case of a 72-year-old woman who presented with sudden onset of coma due to a massive haemorrhage into a frontal meningioma. The diagnosis was suspected on the basis of a non-enhanced computed tomographic (CT) scan and considering the clinical status of the patient, emergency evacuation of the haematoma and complete macroscopic resection of the tumour was performed without further diagnostic procedures. The patient fully recovered. Clinical examination and contrast enhanced CT scan at 3 months follow-up were considered normal. The prognosis for haemorrhagic presenting meningiomas is poor especially for those presenting with acute onset of coma. The outcome seems to be improved with rapid decompression and tumour removal. We would like to stress the need to keep the diagnostic procedures to a minimum once a haemorrhagic decompensating meningioma is suspected despite the risks associated with an incomplete radiological work up before surgery. Complete or at least gross tumour removal at the time of emergency surgery seems to be associated with a better outcome and should be attempted in all patients, even those presenting with acute signs of herniation.