Parasellar meningioma presenting by stroke and bilateral occlusion of the internal carotid arteries: A case report

Cerebrovascular stroke caused by skull base meningioma has been rarely reported. A 30-year-old male presented (April 2015) with acute right-sided hemiplegia. His brain neuroimaging (computerized tomography and magnetic resonance imaging) showed left ischemic infarction in the territory of middle cerebral artery. Magnetic resonance imaging also showed a right parasellar solid lesion which extended to the right basisphenoid and cavernous sinus and attenuated the right internal carotid artery. It also had left smaller parasellar extension. The lesion enhanced uniformly and strongly following gadolinium injection. Digital subtraction angiography using selective catheterization of both common carotid and left vertebral arteries (07/13/2015) showed occlusion of both internal carotid arteries and faint visualization of left terminal internal carotid artery and its bifurcation. The right internal carotid artery and its branches were not visualized. Left vertebral injection showed prominent left vertebral and basilar arteries and filling of both internal carotid arteries through posterior communicating arteries. A faint blush of contrast was noticed at the parasellar region coinciding with meningioma. The patient received three treatment sessions of gamma knife radiosurgery as follow: 20 cc of the tumor was treated with 12 Gy (15 August 2015), 1.7 cc was treated with 10 Gy (31 January 2016), and 2.5 cc was treated with 11 Gy (13 August 2016) which resulted in complete clinical recovery and tumor size reduction. Compensation from the posterior communicating and external carotid arteries might explain the complete clinical recovery after tumor size reduction with gamma knife radiosurgery.