Atypical meningioma tumour recurrence and radiation necrosis

Case contribution: Dr Radhiana Hassan


  • A 54 years old lady with atypical meningioma.
  • Presented with seizures and diagnosed 4 years ago. Tumour excision done. HPE: Atypical meningioma.
  • Post operative MRI one year later shows a small residual tumour
  • After two years, patient presented with new seizures and MRI shows recurrent lesion. Second and third operations were done to remove the tumour. Similar HPE findings of atypical meningioma.
  • Current presentation of worsening headache for 2 weeks.
MRI after first operation shows encephalomalacia due to post operative changes (white arrows) and a small residual meningioma at right parietal region.


MRI after two years show increase in size of previous residual lesion at right parietal.
Subsequent MRI shows further increase in size of right parietal lobe mass and a new smaller lesion anterior to it.
MRI after removal of larger lesion at right parietal shows residual lesion anterior to it and new changes surrounding the lesion

MRI findings:

  • worsening of previously seen intra-axial changes at right parietal lobe adjacent to previously seen extra-axial lesion
  • The abnormal lesion is hypointense on T1, isointense on T2 with irregular peripheral enhancement post contrast.
  • Significant perilesional vasogenic oedema is seen.

Diagnosis: Meningioma recurrence with radiation necrosis


  • Radiation necrosis refers to necrotic degradation of brain tissue following regional radioation for treatment of intracranial pathology or head and neck tumours
  • It can appears several months to several years after radiation therapy
  • MRI shows abnormal signal in the white matter which is high signal on T2WI, single or multiple, enhancement can be seen as soap-bubble or ‘swiss-cheese’ pattern
  • MRS shows low choline, creatine and NAA
  • MR perfusion does not show increaed rCBV in radiation necrosis, a feature helpful to differentiate with residual lesion or tumour recurrence.
Author: radhianahassan