Spontaneous Subdural Hemorrhage Revealing a Meningioma in Pregnancy: A Rare Neurosurgical Emergency — A Case Report and Literature Review

Spontaneous Subdural Hemorrhage Revealing a Meningioma in Pregnancy: A Rare Neurosurgical Emergency — A Case Report and Literature Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Spontaneous Subdural Hemorrhage Revealing a Meningioma in Pregnancy: A Rare Neurosurgical Emergency — A Case Report and Literature Review Youstina Mohsen, Ahmed Mosbah, Magdy Ashraf, Samer Serag, Amr M. Shams This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7352910/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Although most meningiomas are benign, slowly growing tumors that can be asymptomatic and discovered incidentally, they can scarcely present for the first time as spontaneous intracranial hemorrhages. This case report presents a pregnant woman who was misdiagnosed with extradural hemorrhage (EDH) only to discover intraoperatively that it was a subdural hematoma (SDH) overlying a meningioma. The patient presented with a five-day history of headache and newly developed drowsiness, blurring of vision and vomiting on the day of admission. After excluding possible obstetric causes, a magnetic resonance imaging (MRI) was performed, revealing features of EDH. The decision for evacuation was made, and during preoperative preparation, her GCS score deteriorated to 9. After the bone flap was elevated, no EDH was found. Opening the dura revealed an SDH overlying a bluish grayish tumor. Evacuation and total excision of the tumor were successfully performed, adequate hemostasis was achieved, and histopathology revealed a meningothelial meningioma (WHO grade I) with intratumoral bleeding. The patient was discharged after 6 days with no complications. This unique case highlights the importance of considering intracranial hemorrhage as a differential diagnosis for pregnant patients presenting with neurological symptoms such as headache and blurred vision, among other obstetric differentials such as preeclampsia and eclampsia, making the diagnosis more challenging. Additionally, we should consider the presence of meningioma as a cause of unexplained intracranial hemorrhage to be surgically prepared to address it intraoperatively in the setting of not being diagnosed beforehand to ensure complete resection and prevent rebleeding. Meningioma pregnancy subdural hematoma evacuation rare case report Figures Figure 1 Figure 2 Introduction Meningiomas are considered to be the most common primary extra-axial brain tumors that mostly develop as benign slowly growing lesions classified by the WHO as grade I, with a lower incidence of more aggressive types classified as grades II and III. Despite their benign nature, meningiomas can cause significant morbidity and mortality, particularly when they are located near critical neurovascular structures (1–3). Its incidence increases with advancing age, peaking around the sixth decade (1,2,4). Epidemiological studies consistently report a higher prevalence in females, with a risk that is twice that of males or higher, depending on the age group. Meningiomas also occur at a younger age in females than in males, around middle age (1,2,5). Since most lesions are benign and grow slowly, patients can be asymptomatic and discovered incidentally or with insidious and slow progression of neurological symptoms depending on the affected location (3,5–7). Considering that meningiomas are more frequent in females than males, hormonal factors such as progesterone are hypothesized to be involved (8). This raises the following question: are meningiomas more common in pregnant females? The overall incidence of meningiomas during pregnancy is lower than that in the general female population because meningiomas typically present in older age groups (9,10). However, this does not negate the faster growth of meningiomas during pregnancy induced by hormones, which makes it even more challenging than the normal population owing to a harder diagnosis, since the symptoms may mimic other obstetric conditions, such as preeclampsia, eclampsia and hyperemesis gravidarum, a higher rate of complications and a higher risk of mortality if not promptly diagnosed and treated (10–12). Boŝnjak et al. presented two cases in which unsuspected meningioma hemorrhaged, and they reviewed the literature for 145 similar cases dating from the pre-CT era until the date of publication of the study, stating that the risk of bleeding is only up to 2.4%, which clearly outlines the rarity of the event occurrence (13). Magnetic resonance imaging (MRI) has been proven to have excellent performance in diagnosing meningiomas and even predicting their WHO grade (14); however, in the setting of overlying hemorrhage, a sufficient amount of blood can mask the presence of the meningioma on imaging, leading to its discovery intraoperatively or even postoperatively with the recurrence of bleeding (15,16). In this study, we report a unique case of a middle-aged pregnant woman who presented with an extradural hematoma (EDH) on preoperative MRI and who was discovered intraoperatively to have a subdural hematoma (SDH) overlying a meningioma. To the best of our knowledge, this is the first reported case of a hemorrhagic convexity meningioma presenting as a presumed hematoma in a pregnant patient. Case Presentation A forty-four-year-old pregnant female patient presented to the emergency department at Mansoura University hospitals (MUH) after referral from her obstetrician presented with headache for 5 days and blurring of vision, vomiting and drowsiness on the day of presentation. The patient is pregnant in her second trimester, and as this is an old-age pregnancy, the obstetrician she is following with prescribed her low-dose aspirin as an antiplatelet since the first day of pregnancy. The patient had no history of trauma or previous operations. On examination, her GCS score was 14, and was drowsy, her pupils were round, regular and reactive to light; otherwise, the results of the other neurological examinations were normal, with intact motor and sensory examinations. A series of investigations done were as follows: blood grouping (AB +ve); complete blood count revealing mild neutrophilic leukocytosis (WBCs 11.93*10 3 /mL, neutrophil number 9.82*10 3 /mL), normal red blood cell indices for pregnancy (HGB 11.7 g/dL, MCV 86.0 fL, MCH 31.0 pg, MCHC 36.0 g/dL) and normal platelet count (347 k/µl); blood gases and electrolytes that revealed respiratory alkalosis (pH 7.506, PCO2 29.1 mmHg, HCO3- 22.5 mmol/L) and mild hypokalemia (2.94 mmol/L); prothrombin time and INR which were normal (11.6 seconds and 1.0, respectively); liver enzymes which were elevated (SGPT 161 U/L, SGOT 117 U/L); and serum total bilirubin, serum albumin, serum creatinine and random blood glucose which were all normal. After neurology consultation, the neurologist suspected dural sinus thrombosis and ordered MRI. Additionally, obstetric consultation was done to exclude any obstetric-related emergency. Non-contrast MRI of the brain revealed a well-defined extra axial space-occupying lesion measuring 6*3.5*5 cm, seen in the left parietal region displaying low signal intensity (SI) on T1 and areas of high SI denoting blood component, mixed SI on T2, and a blooming effect on SWIs. It exerts a mass effect in the form of compression upon the related cortical sulci, compression of the left lateral ventricle and minimal rightward deviation of midline structures. All these signs are coping with left parietal EDH (Figure 1). Decision for surgical evacuation was made, and during preoperative preparation of the patient, her GCS score dropped to 9, and her pupils became unequal. Surgery started by shaving a wide area of the head to explore and evacuate the EDH; a question mark incision was made to the skin and subcutaneous tissue; the temporalis muscle was dissected toward the skull base; and the frontotemporoparietal flap of bone was elevated starting from the superior temporal line. After elevation of the flap, no EDH was found, but the dura was bluish, and the brain was very tense, suggesting the bleeding was subdural instead. A C-shaped incision of the dura was made, followed by evacuation of the subdural hematoma, which was found to be overlying a bluish grayish soft dural base mass (Figure 2). The tumor was successfully excised and sent for histopathological examination, and the total time of surgery was 3 hours. Histopathological examination revealed a meningiothelial meningioma (WHO grade I) with no evidence of malignancy. The sections revealed prominent lobules, whorls, and collagenized blood vessels. Thorough examination revealed few mitotic figures and no detected necrosis, but wide areas of hemorrhage with excess hemosiderin deposition were detected. After surgery, the patient stayed in the ICU for 2 days, then in the ward for 4 days and was finally discharged without any complications during her hospital stay. Discussion Owing to the rarity of this condition, hemorrhagic meningiomas appear to be only described in the literature as case reports. Hence, the risk factors and mechanisms of bleeding have yet to be confirmed and are still unclear. In a systematic review published in 2020, they attempted to outline the natural history of bleeding meningiomas through the available literature of 190 cases, 109 of which were females. They reported that among the different types of intracranial bleeding associated with the condition, SDH represented the second most common type to occur after intracerebral hemorrhage ( 17 ) despite the previous literature stating otherwise ( 18 ). The proposed risk factors for hemorrhage are age greater than 70 years or less than 30 years; location within the ventricle or on the convexity; malignant, fibrous, or angioblastic histopathology; and the presence of hypertension; anticoagulation therapy; and traumatic brain injury ( 13 ). It is already well established that female sex hormones increase the growth rate of meningiomas not only through hormonal pathways but also through increased blood volume and vascularization ( 10 ). Recently, it was proposed to also be considered as a risk factor for hemorrhagic meningiomas in a case report done on a patient who did not have any of the risk factors associated with this condition other than taking hormone replacement therapy together with serotonin-modulating therapy ( 19 ), which leads us to consider the possibility of pregnancy as not only a factor for faster growth of the tumor but also for hemorrhagic meningioma presentation just like with, similar to our case. Literature was searched for cases of pregnant females with a convexity tumor presenting for the first time with hemorrhage, but to the best of our knowledge ours is the first to be reported. We found only four research papers discussing hemorrhagic meningiomas, two of which were during pregnancy and two were in early postpartum period, with multiple differences from our study. Table 1 summarizes those differences between the four case reports and ours, highlighting the rarity of our case. In all four cases, the tumor was discovered preoperatively either before pregnancy as for the first patient or in the acute event of hemorrhage when imaging was performed, whether during pregnancy like in the second or postpartum as for the other two patients. This is unlike our case, where the tumor was discovered only intraoperatively. The first two cases were pregnant patients but did not have convexity tumors, so the bleeding was not subdural and the occurrence of acute hemorrhage was not the first presentation for either patient. Although the second two had convexity tumors with subdural hemorrhages, which is the common type for this position, they occurred in the postpartum setting. Table 1: A summarized review of 5 case reports on hemorrhagic meningiomas in pregnancy, including our case Reviews on the topic gathered the possible pathophysiologic mechanisms behind acute peritumoral hemorrhagic onset with meningiomas: rupture from excessive or unusual blood vessels; direct vascular invasion by tumor cells; extensive tumor infarction; stretching and rupture of subdural veins; fragility of arterial and venous walls due to rapid tumor growth; and progressive vessel parietal weakening due to variation in tumoral stromal support ( 13 , 17 , 24 ). In alignment with our case, Lefranc et al. presented four patients without a history of trauma who developed subdural hemorrhage on top of meningeal tumor, and after histopathological examination of the specimens they proved that the bleeding started intratumorally where the specimens contained blood clots with hemosiderin deposition, concluding that the tumor had to be excised in the same setting as the evacuation since it was the source ( 15 ). This may explain the misdiagnosis of our patient pre-operatively, suggesting that the EDH observed was only the intratumoral hemorrhage (ITH) masking the presence of the tumor with mixed areas of high and low signal intensities and its extension subdurally. In a study looking further into ITH, Kuzeyli et al. reported that ITH is a rare event in meningiomas with a mortality risk of 40–55%, and that the bleeding is usually found extratumorally, according to the location of the tumor, mostly in the subarachnoid space. When both types of bleeding occur together, it is possibly related to a large amount of bleeding that is located in the peripheries of the tumor, leading to capsular rupture and a subsequent SDH or subarachnoid hemorrhage ( 25 ). The proposed mechanisms of ITH include erosion or disruption of the blood vessels by the tumor, distortion of the vessels by the tumor, venous hypertension, endothelial proliferation with secondary vascular occlusion and necrosis, and foci of abnormal blood vessels in a number of non-angioblastic meningiomas ( 25 ). The only risk factor for our patient that could lead to hemorrhagic meningioma other than the fact that she was pregnant was her intake of prophylactic low-dose aspirin. A case report presented a 66-year-old female patient with hemorrhagic meningioma after intake of low-dose aspirin. They explained that since aspirin is known to increase the risk of hematoma enlargement and postoperative hemorrhage, it could be a potential risk factor for hemorrhagic meningioma; however, the patient’s prothrombin time and partial thromboplastin time were within normal ranges ( 26 ). This finding is similar to that of our patient, whose platelet count, prothrombin time and INR were normal. In contrast, studies assessing the risk of intracranial hemorrhage in patients with primary or metastatic brain tumors who are using antiplatelets concluded that there was no association ( 27 , 28 ). Our case highlights a very critical aspect of hemorrhagic meningiomas which is misdiagnosis pre-operatively which may lead to fatal consequences. MRI has very characteristic signs for accurately diagnosing typical meningiomas; additionally, atypical diagnostic features are also known ( 29 ). Unfortunately, owing to the rarity and misdiagnosis of hemorrhagic meningiomas, even with MRI, we still do not fully understand or have enough data on the radiographic features of this condition. A study on this issue revealed that no specific pattern of features could be expected in case of hemorrhagic meningiomas since the imaging shows absent dural tail and mixed signal intensities on both T1 and T2 of MRI, aligning with what happened with our case ( 30 ). To conclude, this is a very unique case that sheds light on the importance of considering intracranial hemorrhage as a differential diagnosis for pregnant patients presenting with neurological symptoms such as headache and blurred vision, among other obstetric differentials like pre-eclampsia and eclampsia, making the diagnosis more challenging. Additionally, the findings highlight the importance of considering meningioma as a differential diagnosis for unexplained intracranial hemorrhage since it can be masked on imaging. Taking that into account will allow better surgical planning and technique to be used in the setting there is a tumor so that the treatment could effectively remove the source of hemorrhage to prevent the recurrence of bleeding if not removed. This case also prompts further research on risk factors for bleeding from meningiomas focusing on the risk of pregnancy and the use of prophylactic low-dose aspirin. Abbreviations EDH: extradural hemorrhage SDH: subdural hematoma MRI: magnetic resonance imaging GCS: Glasgow coma scale WHO: world health organization MUH: Mansoura university hospital SI: signal intensity ITH: intratumoral hemorrhage INR: international normalized ratio Declarations Ethics and Guidelines: Mansoura Faculty of Medicine IRB policies exempt case reports from ethical approval Consent to participate: An informed consent has been obtained from the patient to write about the case and there are no contents in this paper that may disclose the identity or break the confidentiality of the patient Informed consent to publish: Consent for publication was obtained from the patient and the all authors on the manuscript Clinical trial number: Not applicable Availability of data and materials: Not applicable owing to the study design Competing interests: The authors declare that they have no competing interests Dual publication: The authors declare that no information in this study has been published elsewhere Funding: No funding has been received Author contribution Y.M. gathered data, explored the literature and wrote the first draft and did the edits of the manuscript; A.M., M.A., S.S. dealt with the patient, did the operation and collected full history; A.M.S. was the supervisor and read, edited and approved the manuscript. 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Antiplatelet medications and risk of intracranial hemorrhage in patients with metastatic brain tumors. Blood Adv. 2022 Mar 8;6(5):1559–65. Watts J, Box G, Galvin A, Brotchie P, Trost N, Sutherland T. Magnetic resonance imaging of meningiomas: a pictorial review. Insights Imaging. 2014 Feb;5(1):113–22. Huang RB, Chen LJ, Su SY, Wu XJ, Zheng YG, Wang HP, et al. Misdiagnosis and Delay of Diagnosis in Hemorrhagic Meningioma: A Case Series and Review of the Literature. World Neurosurg. 2021 Nov;155:e836–46. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7352910","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":526971482,"identity":"ed4aa190-ca9d-463e-81f5-02e22f97694a","order_by":0,"name":"Youstina Mohsen","email":"data:image/png;base64,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","orcid":"","institution":"Mansoura University","correspondingAuthor":true,"prefix":"","firstName":"Youstina","middleName":"","lastName":"Mohsen","suffix":""},{"id":526971483,"identity":"e6377ea5-6e27-4496-9a57-972d4ab061cc","order_by":1,"name":"Ahmed Mosbah","email":"","orcid":"","institution":"Mansoura University Hospital, Mansoura University","correspondingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"","lastName":"Mosbah","suffix":""},{"id":526971484,"identity":"44ee88a3-8d78-4429-8b93-b3f9501f5a79","order_by":2,"name":"Magdy Ashraf","email":"","orcid":"","institution":"Mansoura University Hospital, Mansoura University","correspondingAuthor":false,"prefix":"","firstName":"Magdy","middleName":"","lastName":"Ashraf","suffix":""},{"id":526971485,"identity":"8c210632-fb63-4f67-b0a5-e15d3d5bfa91","order_by":3,"name":"Samer Serag","email":"","orcid":"","institution":"Mansoura University Hospital, Mansoura University","correspondingAuthor":false,"prefix":"","firstName":"Samer","middleName":"","lastName":"Serag","suffix":""},{"id":526971486,"identity":"14be9b21-cefb-4f2e-bfa5-27b67049235d","order_by":4,"name":"Amr M. 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1","display":"","copyAsset":false,"role":"figure","size":4926882,"visible":true,"origin":"","legend":"\u003cp\u003eshows the patient’s preoperative non-contrast brain MRI showing signs consistent with EDH.\u003c/p\u003e\n\u003cp\u003e(a) Axial sections of brain MRI, showing low signal intensity (SI) on T1 (on the right side of the image) and areas of high SI denoting the blood component and mixed SI on T2 (on the left side of the image).\u003c/p\u003e\n\u003cp\u003e(b) Axial sections of brain MRI in SWI sequence showing blooming effect\u003c/p\u003e\n\u003cp\u003e(c) Brain MRI with sagittal sections on the right side and coronal sections on the left side both in T2 sequence showing mixed SI\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7352910/v1/3e4e18c1c299530c8c582cc0.png"},{"id":93338674,"identity":"716c5616-acd9-4046-867d-7fc9ea125925","added_by":"auto","created_at":"2025-10-12 14:22:33","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1116108,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperativeimages of the SDH and the tumor\u003c/p\u003e\n\u003cp\u003e(A) Clotted hematomas (SDHs) with different edges and colors mixed with the soft tissue part of the meningioma underneath after removal of the bone flap and opening the dura.\u003c/p\u003e\n\u003cp\u003e(B) After hematoma irrigation and aspiration and excision of the soft tissue part of the tumor, a residual solid part appears at the base of the lesion in the sylvian area.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7352910/v1/e5b3cbe1bd3d536ceafd4807.png"},{"id":97136433,"identity":"06fe7c7d-c66b-4e37-b8aa-21eace91eacc","added_by":"auto","created_at":"2025-12-01 09:56:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":7460639,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7352910/v1/46e4e0c9-9d1e-4a5e-934e-8188fa9c832e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Spontaneous Subdural Hemorrhage Revealing a Meningioma in Pregnancy: A Rare Neurosurgical Emergency — A Case Report and Literature Review","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMeningiomas are considered to be the most common primary extra-axial brain tumors that mostly develop as benign slowly growing lesions classified by the WHO as grade I, with a lower incidence of more aggressive types classified as grades II and III. Despite their benign nature, meningiomas can cause significant morbidity and mortality, particularly when they are located near critical neurovascular structures (1\u0026ndash;3). Its incidence increases with advancing age,\u0026nbsp;peaking around the sixth decade (1,2,4).\u0026nbsp;Epidemiological studies consistently report a higher prevalence in females,\u0026nbsp;with a\u0026nbsp;risk\u0026nbsp;that is twice that\u0026nbsp;of males or higher,\u0026nbsp;depending on the age group. Meningiomas also\u0026nbsp;occur at a\u0026nbsp;younger age in females than\u0026nbsp;in\u0026nbsp;males,\u0026nbsp;around middle age (1,2,5). Since most lesions are benign and\u0026nbsp;grow slowly, patients\u0026nbsp;can be asymptomatic and discovered incidentally or with insidious and slow progression of neurological symptoms depending on the affected location (3,5\u0026ndash;7).\u003c/p\u003e\n\u003cp\u003eConsidering that meningiomas are more frequent in females than males, hormonal factors such as progesterone are hypothesized to be involved (8). This raises\u0026nbsp;the\u0026nbsp;following\u0026nbsp;question: are meningiomas more common in pregnant females?\u0026nbsp;The overall incidence of meningiomas\u0026nbsp;during\u0026nbsp;pregnancy is lower than\u0026nbsp;that\u0026nbsp;in the general female population because meningiomas typically present in older age groups (9,10). However, this does not negate\u0026nbsp;the faster growth of meningiomas during pregnancy induced by hormones, which makes it even more challenging than\u0026nbsp;the\u0026nbsp;normal population owing to a harder diagnosis, since the symptoms may mimic other obstetric conditions, such as preeclampsia, eclampsia and hyperemesis gravidarum,\u0026nbsp;a\u0026nbsp;higher rate of complications and\u0026nbsp;a\u0026nbsp;higher risk of mortality if not promptly diagnosed and treated (10\u0026ndash;12).\u003c/p\u003e\n\u003cp\u003eBoŝnjak et al. presented two cases in which unsuspected meningioma hemorrhaged, and they reviewed the literature for 145 similar cases dating from the pre-CT era until the date of publication of the study, stating that the risk of bleeding is only up to 2.4%, which clearly outlines the rarity of the event occurrence (13). Magnetic resonance imaging (MRI) has been proven to have excellent performance in diagnosing meningiomas and even predicting their WHO grade (14); however, in the setting of overlying hemorrhage, a sufficient\u0026nbsp;amount of blood can mask the presence of the meningioma on imaging,\u0026nbsp;leading to its discovery intraoperatively or even postoperatively with the recurrence of bleeding (15,16).\u003c/p\u003e\n\u003cp\u003eIn this study, we report a unique case of a middle-aged pregnant woman who presented with an extradural hematoma (EDH) on preoperative MRI and who was discovered intraoperatively to have a subdural hematoma (SDH) overlying a meningioma. To the best of our knowledge, this is the first reported case of a hemorrhagic convexity meningioma presenting as a presumed hematoma in a pregnant patient.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA forty-four-year-old pregnant female patient presented to the emergency department at Mansoura University hospitals (MUH) after referral from her obstetrician presented with headache for 5 days and blurring of vision, vomiting and drowsiness on the day of presentation. The patient is pregnant in her second trimester, and as this is an old-age pregnancy, the obstetrician she is following with prescribed her low-dose aspirin as an antiplatelet since the first day of pregnancy. The patient had no history of trauma or previous operations. On examination, her GCS score was 14, and was drowsy, her pupils were round, regular and reactive to light; otherwise, the results of the other neurological examinations were normal, with intact motor and sensory examinations. A series of investigations done were as follows: blood grouping (AB +ve); complete blood count revealing mild neutrophilic leukocytosis (WBCs 11.93*10\u003csup\u003e3\u003c/sup\u003e/mL, neutrophil number 9.82*10\u003csup\u003e3\u003c/sup\u003e/mL), normal red blood cell indices for pregnancy (HGB 11.7 g/dL, MCV 86.0 fL, MCH 31.0 pg, MCHC 36.0 g/dL) and normal platelet count (347 k/\u0026micro;l); blood gases and electrolytes that revealed respiratory alkalosis (pH 7.506, PCO2 29.1 mmHg, HCO3- 22.5 mmol/L) and mild hypokalemia (2.94 mmol/L); prothrombin time and INR which were normal (11.6 seconds and 1.0, respectively); liver enzymes which were elevated (SGPT 161 U/L, SGOT 117 U/L); and serum total bilirubin, serum albumin, serum creatinine and random blood glucose which were all normal. After neurology consultation, the neurologist suspected dural sinus thrombosis and ordered MRI. Additionally, obstetric consultation was done to exclude any obstetric-related emergency. Non-contrast MRI of the brain revealed a well-defined extra axial space-occupying lesion measuring 6*3.5*5 cm, seen in the left parietal region displaying low signal intensity (SI) on T1 and areas of high SI denoting blood component, mixed SI on T2, and a blooming effect on SWIs. It exerts a mass effect in the form of compression upon the related cortical sulci, compression of the left lateral ventricle and minimal rightward deviation of midline structures. All these signs are coping with left parietal EDH (Figure 1).\u003c/p\u003e\n\u003cp\u003eDecision for surgical evacuation was made, and during preoperative preparation of the patient, her GCS score dropped to 9, and her pupils became unequal. Surgery started by shaving a wide area of the head to explore and evacuate the EDH; a question mark incision was made to the skin and subcutaneous tissue; the temporalis muscle was dissected toward the skull base; and the frontotemporoparietal flap of bone was elevated starting from the superior temporal line. After elevation of the flap, no EDH was found, but the dura was bluish, and the brain was very tense, suggesting the bleeding was subdural instead. A C-shaped incision of the dura was made, followed by evacuation of the subdural hematoma, which was found to be overlying a bluish grayish soft dural base mass (Figure 2). The tumor was successfully excised and sent for histopathological examination, and the total time of surgery was 3 hours. Histopathological examination revealed a meningiothelial meningioma (WHO grade I) with no evidence of malignancy. The sections revealed prominent lobules, whorls, and collagenized blood vessels. Thorough examination revealed few mitotic figures and no detected necrosis, but wide areas of hemorrhage with excess hemosiderin deposition were detected. After surgery, the patient stayed in the ICU for 2 days, then in the ward for 4 days and was finally discharged without any complications during her hospital stay.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOwing to the rarity of this condition, hemorrhagic meningiomas appear to be only described in the literature as case reports. Hence, the risk factors and mechanisms of bleeding have yet to be confirmed and are still unclear. In a systematic review published in 2020, they attempted to outline the natural history of bleeding meningiomas through the available literature of 190 cases, 109 of which were females. They reported that among the different types of intracranial bleeding associated with the condition, SDH represented the second most common type to occur after intracerebral hemorrhage (\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e) despite the previous literature stating otherwise (\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e). The proposed risk factors for hemorrhage are age greater than 70 years or less than 30 years; location within the ventricle or on the convexity; malignant, fibrous, or angioblastic histopathology; and the presence of hypertension; anticoagulation therapy; and traumatic brain injury (\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e). It is already well established that female sex hormones increase the growth rate of meningiomas not only through hormonal pathways but also through increased blood volume and vascularization (\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e). Recently, it was proposed to also be considered as a risk factor for hemorrhagic meningiomas in a case report done on a patient who did not have any of the risk factors associated with this condition other than taking hormone replacement therapy together with serotonin-modulating therapy (\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e), which leads us to consider the possibility of pregnancy as not only a factor for faster growth of the tumor but also for hemorrhagic meningioma presentation just like with, similar to our case.\u003c/p\u003e\n\u003cp\u003eLiterature was searched for cases of pregnant females with a convexity tumor presenting for the first time with hemorrhage, but to the best of our knowledge ours is the first to be reported. We found only four research papers discussing hemorrhagic meningiomas, two of which were during pregnancy and two were in early postpartum period, with multiple differences from our study. Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes those differences between the four case reports and ours, highlighting the rarity of our case. In all four cases, the tumor was discovered preoperatively either before pregnancy as for the first patient or in the acute event of hemorrhage when imaging was performed, whether during pregnancy like in the second or postpartum as for the other two patients. This is unlike our case, where the tumor was discovered only intraoperatively. The first two cases were pregnant patients but did not have convexity tumors, so the bleeding was not subdural and the occurrence of acute hemorrhage was not the first presentation for either patient. Although the second two had convexity tumors with subdural hemorrhages, which is the common type for this position, they occurred in the postpartum setting.\u003c/p\u003e\n\u003cp\u003eTable 1: A summarized review of 5 case reports on hemorrhagic meningiomas in pregnancy, including our case\u003c/p\u003e\n\u003cp\u003e\u003cimg src=\"https://myfiles.space/user_files/58895_8739fc6c57c1c19a/58895_custom_files/img1760097445.png\" width=\"1173\" height=\"1006\"\u003e\u003c/p\u003e\n\u003cp\u003eReviews on the topic gathered the possible pathophysiologic mechanisms behind acute peritumoral hemorrhagic onset with meningiomas: rupture from excessive or unusual blood vessels; direct vascular invasion by tumor cells; extensive tumor infarction; stretching and rupture of subdural veins; fragility of arterial and venous walls due to rapid tumor growth; and progressive vessel parietal weakening due to variation in tumoral stromal support (\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e). In alignment with our case, Lefranc et al. presented four patients without a history of trauma who developed subdural hemorrhage on top of meningeal tumor, and after histopathological examination of the specimens they proved that the bleeding started intratumorally where the specimens contained blood clots with hemosiderin deposition, concluding that the tumor had to be excised in the same setting as the evacuation since it was the source (\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e). This may explain the misdiagnosis of our patient pre-operatively, suggesting that the EDH observed was only the intratumoral hemorrhage (ITH) masking the presence of the tumor with mixed areas of high and low signal intensities and its extension subdurally. In a study looking further into ITH, Kuzeyli et al. reported that ITH is a rare event in meningiomas with a mortality risk of 40\u0026ndash;55%, and that the bleeding is usually found extratumorally, according to the location of the tumor, mostly in the subarachnoid space. When both types of bleeding occur together, it is possibly related to a large amount of bleeding that is located in the peripheries of the tumor, leading to capsular rupture and a subsequent SDH or subarachnoid hemorrhage (\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e). The proposed mechanisms of ITH include erosion or disruption of the blood vessels by the tumor, distortion of the vessels by the tumor, venous hypertension, endothelial proliferation with secondary vascular occlusion and necrosis, and foci of abnormal blood vessels in a number of non-angioblastic meningiomas (\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eThe only risk factor for our patient that could lead to hemorrhagic meningioma other than the fact that she was pregnant was her intake of prophylactic low-dose aspirin. A case report presented a 66-year-old female patient with hemorrhagic meningioma after intake of low-dose aspirin. They explained that since aspirin is known to increase the risk of hematoma enlargement and postoperative hemorrhage, it could be a potential risk factor for hemorrhagic meningioma; however, the patient\u0026rsquo;s prothrombin time and partial thromboplastin time were within normal ranges (\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e). This finding is similar to that of our patient, whose platelet count, prothrombin time and INR were normal. In contrast, studies assessing the risk of intracranial hemorrhage in patients with primary or metastatic brain tumors who are using antiplatelets concluded that there was no association (\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eOur case highlights a very critical aspect of hemorrhagic meningiomas which is misdiagnosis pre-operatively which may lead to fatal consequences. MRI has very characteristic signs for accurately diagnosing typical meningiomas; additionally, atypical diagnostic features are also known (\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e). Unfortunately, owing to the rarity and misdiagnosis of hemorrhagic meningiomas, even with MRI, we still do not fully understand or have enough data on the radiographic features of this condition. A study on this issue revealed that no specific pattern of features could be expected in case of hemorrhagic meningiomas since the imaging shows absent dural tail and mixed signal intensities on both T1 and T2 of MRI, aligning with what happened with our case (\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eTo conclude, this is a very unique case that sheds light on the importance of considering intracranial hemorrhage as a differential diagnosis for pregnant patients presenting with neurological symptoms such as headache and blurred vision, among other obstetric differentials like pre-eclampsia and eclampsia, making the diagnosis more challenging. Additionally, the findings highlight the importance of considering meningioma as a differential diagnosis for unexplained intracranial hemorrhage since it can be masked on imaging. Taking that into account will allow better surgical planning and technique to be used in the setting there is a tumor so that the treatment could effectively remove the source of hemorrhage to prevent the recurrence of bleeding if not removed. This case also prompts further research on risk factors for bleeding from meningiomas focusing on the risk of pregnancy and the use of prophylactic low-dose aspirin.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eEDH: extradural hemorrhage\u003c/p\u003e\n\u003cp\u003eSDH: subdural hematoma\u003c/p\u003e\n\u003cp\u003eMRI: magnetic resonance imaging\u003c/p\u003e\n\u003cp\u003eGCS: Glasgow coma scale\u003c/p\u003e\n\u003cp\u003eWHO: world health organization\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMUH: Mansoura university hospital\u003c/p\u003e\n\u003cp\u003eSI: signal intensity\u003c/p\u003e\n\u003cp\u003eITH: intratumoral hemorrhage\u003c/p\u003e\n\u003cp\u003eINR: international normalized ratio\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics and Guidelines: Mansoura Faculty of Medicine IRB policies exempt case reports from ethical approval\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent to participate: An informed consent has been obtained from the patient to write about the case and there are no contents in this paper that may disclose the identity or break the confidentiality of the patient\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInformed consent to publish: Consent for publication was obtained from the patient and the all authors on the manuscript\u003c/p\u003e\n\u003cp\u003eClinical trial number: Not applicable\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials: Not applicable owing to the study design\u003c/p\u003e\n\u003cp\u003eCompeting interests: The authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003eDual publication: The authors declare that no information in this study has been published elsewhere\u003c/p\u003e\n\u003cp\u003eFunding: No funding has been received\u003c/p\u003e\n\u003cp\u003eAuthor contribution\u003c/p\u003e\n\u003cp\u003eY.M. gathered data, explored the literature and wrote the first draft and did the edits of the manuscript; A.M., M.A., S.S. dealt with the patient, did the operation and collected full history; A.M.S. was the supervisor and read, edited and approved the manuscript. All authors approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgement: Not applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWalsh KM. Epidemiology of meningiomas. In 2020. p. 3\u0026ndash;15.\u003c/li\u003e\n\u003cli\u003eKamenova M, Guzman R, Soleman J. Demographics and outcome of histologically confirmed intracranial meningiomas. Clinical and Translational Neuroscience. 2019 Jul 1;3(2):2514183X1989494.\u003c/li\u003e\n\u003cli\u003eFathi AR, Roelcke U. Meningioma. Curr Neurol Neurosci Rep. 2013 Apr 6;13(4):337.\u003c/li\u003e\n\u003cli\u003eFonkem E, Dandashi JA, Stroberg E, Garrett D, Harris FS, El Nihum IM, et al. A retrospective analysis of meningioma in Central Texas. J Epidemiol Glob Health. 2016;6(2):87.\u003c/li\u003e\n\u003cli\u003eLongstreth WT, Dennis LK, McGuire VM, Drangsholt MT, Koepsell TD. Epidemiology of intracranial meningioma. Cancer [Internet]. 1993 Aug 1;72(3):639\u0026ndash;48. Available from: https://onlinelibrary.wiley.com/doi/10.1002/1097-0142(19930801)72:3\u0026lt;639::AID-CNCR2820720304\u0026gt;3.0.CO;2-P\u003c/li\u003e\n\u003cli\u003eOgasawara C, Philbrick BD, Adamson DC. Meningioma: A Review of Epidemiology, Pathology, Diagnosis, Treatment, and Future Directions. Biomedicines. 2021 Mar 21;9(3).\u003c/li\u003e\n\u003cli\u003eRockhill J, Mrugala M, Chamberlain MC. Intracranial meningiomas: an overview of diagnosis and treatment. Neurosurg Focus. 2007 Oct;23(4):E1.\u003c/li\u003e\n\u003cli\u003eIchwan S, Santoso F, Aman RA, Tandian D, Fachniadin A, Nugroho SW. Estrogen and progesterone in meningioma: Bridging the gap of knowledge. Neurol Asia. 2023 Mar;28(1):1\u0026ndash;11.\u003c/li\u003e\n\u003cli\u003ePettersson-Segerlind J, Mathiesen T, Elmi-Terander A, Edstr\u0026ouml;m E, Talb\u0026auml;ck M, Feychting M, et al. The risk of developing a meningioma during and after pregnancy. Sci Rep. 2021 Apr 28;11(1):9153.\u003c/li\u003e\n\u003cli\u003eHortob\u0026aacute;gyi T, Bencze J, Murny\u0026aacute;k B, Kouhsari MC, Bogn\u0026aacute;r L, Marko-Varga G. Pathophysiology of Meningioma Growth in Pregnancy. Open Med (Wars). 2017;12:195\u0026ndash;200.\u003c/li\u003e\n\u003cli\u003eRejante EJD, Opinaldo PVA. Meningioma in pregnancy: A case series. International Journal of Neurooncology. 2023 Jul;6(2):72\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eCarbone L, Somma T, Iorio GG, Vitulli F, Conforti A, Raffone A, et al. Meningioma during pregnancy: what can influence the management? A case series and review of the literature. The Journal of Maternal-Fetal \u0026amp; Neonatal Medicine. 2022 Nov 30;35(25):8767\u0026ndash;77.\u003c/li\u003e\n\u003cli\u003eBoŝnjak R, Derham C, Popović M, Ravnik J. Spontaneous intracranial meningioma bleeding: clinicopathological features and outcome. J Neurosurg. 2005 Sep;103(3):473\u0026ndash;84.\u003c/li\u003e\n\u003cli\u003eJiang J, Yu J, Liu X, Deng K, Zhuang K, Lin F, et al. The efficacy of preoperative MRI features in the diagnosis of meningioma WHO grade and brain invasion. Front Oncol. 2023 Jan 18;12.\u003c/li\u003e\n\u003cli\u003eLefranc F, Nagy N, Dewitte O, Bal\u0026eacute;riaux D, Brotchi J. Intracranial Meningiomas Revealed by Non-Traumatic Subdural Haematomas: A Series of four Cases. Acta Neurochir (Wien). 2001 Oct 1;143(10):977\u0026ndash;83.\u003c/li\u003e\n\u003cli\u003eJenson M, Nguyen QH, Fiester P, Patel J, Rao D. Meningiomas Can Present as Intracranial Hemorrhage in Rare Cases: A Case Report of a Patient With a History of Minor Trauma and Massive Intracranial Hemorrhage. Cureus. 2022 Jun;14(6):e25823.\u003c/li\u003e\n\u003cli\u003ePereira BJA, de Almeida AN, Paiva WS, de Aguiar PHP, Teixeira MJ, Marie SKN. Assessment of hemorrhagic onset on meningiomas: Systematic review. Clin Neurol Neurosurg. 2020 Dec;199:106175.\u003c/li\u003e\n\u003cli\u003eKim JH, Gwak HS, Hong EK, Bang CW, Lee SH, Yoo H. A case of benign meningioma presented with subdural hemorrhage. Brain Tumor Res Treat. 2015 Apr;3(1):30\u0026ndash;3.\u003c/li\u003e\n\u003cli\u003ePressman E, Penn D, Patel NJ. Intracranial Hemorrhage from Meningioma: 2 Novel Risk Factors. World Neurosurg. 2020 Mar;135:217\u0026ndash;21.\u003c/li\u003e\n\u003cli\u003eLee K, Lall RR, Chandler JP, Bigio EH, Mao Q. Pineal chordoid meningioma complicated by repetitive hemorrhage during pregnancy: Case report and literature review. Neuropathology. 2013 Apr 12;33(2):192\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eRivkin. Cerebellopontine Angle Chondroid Meningioma Apoplexy Complicating a Third Trimester Pregnancy: Case Report and Review of the Literature. J Clin Gynecol Obstet. 2013;\u003c/li\u003e\n\u003cli\u003eKumar S, Gupta V, Khandelwal N. Hemorrhage in meningioma: An unwanted outcome of pregnancy. Neurol India. 2013;61(3):329.\u003c/li\u003e\n\u003cli\u003eSadegh Masoudi M, Zafarshamspour S, Ghasemi-Rad M, Soleimani N, Rakhsha A, Lincoln C. Acute Subdural Hemorrhage of a Convexity Meningioma in the Postpartum Period; Case Report and Literature Review. Bull Emerg Trauma. 2019 Jul;7(3):324\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eNiiro M, Ishimaru K, Hirano H, Yunoue S, Kuratsu J. Clinico-pathological study of meningiomas with haemorrhagic onset. Acta Neurochir (Wien). 2003 Jan 1;145(9):767\u0026ndash;72.\u003c/li\u003e\n\u003cli\u003eKuzeyli K, \u0026Ccedil;akir E, Usul H, Karaarslan G, Yazar U, Baykal S, et al. Intratumoral haemorrhage: a clinical study. Journal of Clinical Neuroscience. 2004 Jun;11(5):490\u0026ndash;2.\u003c/li\u003e\n\u003cli\u003eMiyazawa T, Uozumi Y, Toyooka T, Shima K. Hemorrhage from a Falx Meningioma After Internal Use of Low-Dose Aspirin. Journal of Stroke and Cerebrovascular Diseases. 2008 Sep;17(5):325\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eMa S, Patell R, Miller E, Ren S, Marquez-Garcia J, Panoff S, et al. Antiplatelet medications and intracranial hemorrhage in patients with primary brain tumors. Journal of Thrombosis and Haemostasis. 2023 May;21(5):1148\u0026ndash;55.\u003c/li\u003e\n\u003cli\u003eMiller EJ, Patell R, Uhlmann EJ, Ren S, Southard H, Elavalakanar P, et al. Antiplatelet medications and risk of intracranial hemorrhage in patients with metastatic brain tumors. Blood Adv. 2022 Mar 8;6(5):1559\u0026ndash;65.\u003c/li\u003e\n\u003cli\u003eWatts J, Box G, Galvin A, Brotchie P, Trost N, Sutherland T. Magnetic resonance imaging of meningiomas: a pictorial review. Insights Imaging. 2014 Feb;5(1):113\u0026ndash;22.\u003c/li\u003e\n\u003cli\u003eHuang RB, Chen LJ, Su SY, Wu XJ, Zheng YG, Wang HP, et al. Misdiagnosis and Delay of Diagnosis in Hemorrhagic Meningioma: A Case Series and Review of the Literature. World Neurosurg. 2021 Nov;155:e836\u0026ndash;46. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Meningioma, pregnancy, subdural hematoma, evacuation, rare, case report","lastPublishedDoi":"10.21203/rs.3.rs-7352910/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7352910/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAlthough most meningiomas are benign, slowly growing tumors that can be asymptomatic and discovered incidentally, they can scarcely present for the first time as spontaneous intracranial hemorrhages. This case report presents a pregnant woman who was misdiagnosed with extradural hemorrhage (EDH) only to discover intraoperatively that it was a subdural hematoma (SDH) overlying a meningioma.\u003c/p\u003e\u003cp\u003eThe patient presented with a five-day history of headache and newly developed drowsiness, blurring of vision and vomiting on the day of admission. After excluding possible obstetric causes, a magnetic resonance imaging (MRI) was performed, revealing features of EDH. The decision for evacuation was made, and during preoperative preparation, her GCS score deteriorated to 9. After the bone flap was elevated, no EDH was found. Opening the dura revealed an SDH overlying a bluish grayish tumor. Evacuation and total excision of the tumor were successfully performed, adequate hemostasis was achieved, and histopathology revealed a meningothelial meningioma (WHO grade I) with intratumoral bleeding. The patient was discharged after 6 days with no complications.\u003c/p\u003e\u003cp\u003eThis unique case highlights the importance of considering intracranial hemorrhage as a differential diagnosis for pregnant patients presenting with neurological symptoms such as headache and blurred vision, among other obstetric differentials such as preeclampsia and eclampsia, making the diagnosis more challenging. Additionally, we should consider the presence of meningioma as a cause of unexplained intracranial hemorrhage to be surgically prepared to address it intraoperatively in the setting of not being diagnosed beforehand to ensure complete resection and prevent rebleeding.\u003c/p\u003e","manuscriptTitle":"Spontaneous Subdural Hemorrhage Revealing a Meningioma in Pregnancy: A Rare Neurosurgical Emergency — A Case Report and Literature Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-12 14:06:29","doi":"10.21203/rs.3.rs-7352910/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2f7db353-b19a-4c49-87eb-74721412217c","owner":[],"postedDate":"October 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-27T11:08:10+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-12 14:06:29","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7352910","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7352910","identity":"rs-7352910","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}