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Report of Foramen Magnum Meningioma

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Case presentation: Patient, female, 43 years old, evaluated with a complaint of neck pain and headache that started seven months before. Her neck pain got worse after 3 months, leading her to use a lot of analgesics, without improvement. She was evaluated in other service and a brain CT was performed, without alterations. The condition evolved progressively with pain and weakness in the Right Upper Limb (RUL) and Left Upper Limb (LUL), in addition to low back pain, pain like shocks in the Left Upper Limb (LLL) and difficulty in evacuating. On physical examination, cranial nerve pair testing was obtained without abnormalities. The strength examination (using MRC Scale graduation) showed grade 4 in RUL and grade 5 in LUL, grade 4 proximal in Right Lower Limb (RLL) and grade 5 distal in RLL and LLL. She had hypoesthesia on the right side of the body and her deep osteotendin reflexes were exalted with bilateral Babinski sign. Brain and cervical MRI were requested, revealing an expansive lesion in the craniocervical transition, compressing the spinal cord and the medulla, suggestive of a foramen magnum meningioma prompting neurosurgery evaluation. A complete tumor ressection was performed, leading to a great clinical improvement.
Discussion: Meningiomas originating from the foramen magnum (FMM) are uncommon, being diagnosed in only 1.8% to 3.2% of intracranial meningiomas, with a higher prevalence in females. They present a slow growth pattern with insidious clinical symptoms and late diagnosis. They are classified as ventral, ventrolateral and dorsal, which is essential for the conduct in an integrated manner. The clinic of patients with foramen magnum tumors is diverse, encompassing headache, neck pain, upper limb pain, weakness and low back pain. Magnetic resonance imaging (MRI) is the gold standard test for diagnosis. Surgical treatment is indicated for growing and symptomatic tumors.
Final Considerations: The FMM has a variable clinical presentation, making its diagnosis challenging. The physical examination can be an important clue when bilateral signs of upper motor neuron lesion are present, as it is an important differential diagnosis of spastic paraparesis. Clinicians must be aware that asymmetric sensory abnormalities, as seen in this case, can happen as a result of non-uniform tumor growth and partial compression of spinotalamic tract.

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