Neuro-radiology
Neuroradiology (1992) 34:30-32
9 Springer-Verlag 1992
Peripheral cerebral aneurysm associated with a glioma C. S. Barker Neuroradiology Section, Radcliffe Infirmary,Oxford, UK Received: 26 April 1991
Summary. This 42-year-old man with acute subarachnoid, intraventricular and parenchymal hemorrhage from an angiographically and surgically confirmed successfully clipped, right splenial artery aneurysm, subsequently manifested a grade 3 astrocytoma at the site of the aneurysm. Intracranial aneurysms are recognized in association with metastases from cardiac myxoma and choriocarcinoma, but are rarely seen with primary brain tumors. In patients with nontraumatic peripheral aneurysms it would seem prudent to biopsy the aneurysm and/or surrounding necrotic tissue at the time of surgical clipping.
Key words: Cerebral aneurysm - Glioma - Oncotic aneurysm
Case report This 42-year-old previously well, right-handed man suddenly developed severe occipital headache and neck stiffness that improved gradually over the next few days. Recurrence during a yoga class 7 days later led to confusion, drowsiness, grand mal seizure and deep unconsciousness. Computed tomography (CT) (Fig. 1) showed extensive fresh hemorrhage within the ventricles, the medial aspect of the right occipital lobe and the splenium with mild hydrocephalus. Supportive therapy was associated with slow clinical improvement over the next few weeks. On transfer to the Radcliffe Infirmary 6 weeks later, the patient manifested a left lower homonymous quadrantanopsia. Vertebral angiography (Fig.2) demonstrated an aneurysm filling from the right splenial artery. The opacity of the aneurysm was a little fainter than the usual berry aneurysm; there was no significant delay in emptying of the aneurysm. Work-up for mycotic aneurysm with blood and urine cultures, serum biochemistry and C-reactive protein were normal, as were chest radiograph and echocardiogram. Repeat CT (Fig. 3) showed an area of low attenuation with peripheral hyperdensity in
the splenium and right medial occipital lobe. Lesion size was unchanged. Craniotomy was performed to evacuate the large clot. Medially within the clot was a large round lesion which had the appearance of an aneurysm, although it was not pulsating. The feeding vessel seen angiographically was identified, coagulated, and divided. Two smaller vessels passing into the mass were also coagulated. A curved Yasargil clip was placed across the neck of the aneurysm and its thickened wall punctured to ensure that it was no longer filling. The patient's condition improved postoperatively. Repeat angiography confirmed successful occlusion of the aneurysm. He was well at initial neurosurgical follow-up, but 5 months later complained of occipital headache and deteriorating vision. Examination confirmed worsening of his visual field defect with a full left homonymous hemianopsia. CT (Fig. 4) showed a large enhancing partially necrotic mass centered on the right medial occipital lobe but involving the corpus callosum and surrounding the right trigone. Histological examination of a stereotactic biopsy revealed grade 3 malignant astrocytoma, later treated with radiotherapy.
Discussion Intracranial aneurysms usually occur in the region of the circle of Willis and in that site are most often congenital or arteriosclerotic in origin [1]. Congenital ("berry") aneurysms may be located at the pericallosal origin but are otherwise unusual distal to the circle of Willis. Peripheral aneurysms are most commonly mycotic [2], although they may be secondary to trauma, tumor and moya moya disease. Those due to infection are usually the result of septic emboli but may rarely arise as a result of spread of a focus of infection to the vessel wall from an extravascular site [3]. Intracranial hemorrhage is well recognized in association with primary or metastatic brain tumors. Metastases are a more common cause of hemorrhage, reflecting both their greater incidence and greater propensity to bleed [4].
31
Fig.1. Day 1. Non-contrast computed tomography (CT) shows fresh hematoma within the splenium of the corpus callosum, the right medial occipital lobe and dilated lateral ventricles
Fig. 2 a, b. Day 42. Arterial phase lateral (a) and Towne (b) left vertebral angiograms show an aneurysm arising from right splenial artery
Fig. 3. Day 45. Non-contrast CT shows persistent mass in splenium and right occipital lobe. The mass is unchanged in size but now is pi cd~)minani Iy Inypodcnsc Fig.4. Seven months after presentation. Contrast-enhanced CT. The mass has increased considerably in size, enhances and is partially necrotic. There is some surrounding edema The neoplasms most commonly associated with such hemorrhage are bronchogenic carcinoma, choriocarcinoma, melanoma, and renal cell carcinoma [4]. Aneurysms are rarely implicated as the source of subarachnoid or intracerebral h e m o r r h a g e associated with metastatic and primary brain tumors. However, choriocarcinoma [5] and cardiac m y x o m a [6] are both known to cause intracranial aneurysms, and of these the former seems m o r e likely to rupture. H o [7] has reported a single case of rupture of a peripheral aneurysm associated with a metastasis from bronchogenic carcinoma. Gliomas are known to incite the development of new arterioles, which may have a b e a d e d appearance. The normal arterial vessels supplying the t u m o r m a y exhibit con-
siderable irregularity and variation in the width of their lumens [8]. Cowen et al. [91 reported on a patient with bilateral fusiform aneurysmal dilatation of the pericallosal arteries shown histologically to be associated with invasion of the vessel walls by glioma. A n English language literature search has failed to find a case of a saccular aneurysm associated with a ghoma. Unfortunately in the case described here no biopsies were t a k e n at the time of clipping of the aneurysm. However, it seems highly probable that the tumor and aneurysm were causally related. This is likely to have been a false aneurysm. These often exhibit delay in emptying and reduced opacity when c o m p a r e d to true aneurysms [10] but only the latter feature was present in this case.
32
References 1. Allcock J (1974) Aneurysms. In: Newton TH, Potts DG (eds) Radiology of the skull and brain: angiography. Mosby, St. Louis, pp 2445-2486 2. Olmsted WW, McGee TP (1977) The pathogenesis of peripheral aneurysms of the central nervous system: a subject review from the AFIR Radiology 123:661~666 3. Suwanwela C, Suwanwela N, Charuchinda S, Hongsaprabhas C (1972) Intracranial mycotic aneurysms of extravascular origin. J Neurosurg 36:552-559 4. Mandybur TI (1977) Intracranial hemorrhage caused by metastatic tumors. Neurology 27:650~555 5. Seigle JM, Caputy AJ, Manz HJ, Wheeler C, Fox JL (1987) Multiple oncotic intracranial aneurysms and cardiac metastasis from choriocarcinoma: case report and review of the literature. Neurosurgery 20:39-42
6. New PF, Price DL, Carter B (1970) Cerebral angiography in cardiac myxoma. Correlation of angiographic and histopathological findings. Radiology 96:335-345 7. Ho K-L (1982) Neoplastic aneurysm and intracranial hemorrhage. Cancer 50:2935-2940 8. Taveras JM, Wood EH (1976) Diagnostic neuroradiology, vol 2. Williams and Wilkins, Baltimore, pp 760-765 9. Cowen RL, Siqueira EB, George E (1970) Angiographic demonstration of a glioma involving the wall of the anterior cerebral artery. Radiology 97:577-578 10. Sedzimir CB, Occleshaw JV, Brixton PH (1968) False cerebral aneurysm. Case report. J Neurosurg 29:636-639 Dr. C.S.Barker Neuroradiology Section Department of Radiology Radcliffe Infirmary Oxford, OX2 6HE, UK
Neuroradiology (1992) 34:30-32
9 Springer-Verlag 1992
Peripheral cerebral aneurysm associated with a glioma C. S. Barker Neuroradiology Section, Radcliffe Infirmary,Oxford, UK Received: 26 April 1991
Summary. This 42-year-old man with acute subarachnoid, intraventricular and parenchymal hemorrhage from an angiographically and surgically confirmed successfully clipped, right splenial artery aneurysm, subsequently manifested a grade 3 astrocytoma at the site of the aneurysm. Intracranial aneurysms are recognized in association with metastases from cardiac myxoma and choriocarcinoma, but are rarely seen with primary brain tumors. In patients with nontraumatic peripheral aneurysms it would seem prudent to biopsy the aneurysm and/or surrounding necrotic tissue at the time of surgical clipping.
Key words: Cerebral aneurysm - Glioma - Oncotic aneurysm
Case report This 42-year-old previously well, right-handed man suddenly developed severe occipital headache and neck stiffness that improved gradually over the next few days. Recurrence during a yoga class 7 days later led to confusion, drowsiness, grand mal seizure and deep unconsciousness. Computed tomography (CT) (Fig. 1) showed extensive fresh hemorrhage within the ventricles, the medial aspect of the right occipital lobe and the splenium with mild hydrocephalus. Supportive therapy was associated with slow clinical improvement over the next few weeks. On transfer to the Radcliffe Infirmary 6 weeks later, the patient manifested a left lower homonymous quadrantanopsia. Vertebral angiography (Fig.2) demonstrated an aneurysm filling from the right splenial artery. The opacity of the aneurysm was a little fainter than the usual berry aneurysm; there was no significant delay in emptying of the aneurysm. Work-up for mycotic aneurysm with blood and urine cultures, serum biochemistry and C-reactive protein were normal, as were chest radiograph and echocardiogram. Repeat CT (Fig. 3) showed an area of low attenuation with peripheral hyperdensity in
the splenium and right medial occipital lobe. Lesion size was unchanged. Craniotomy was performed to evacuate the large clot. Medially within the clot was a large round lesion which had the appearance of an aneurysm, although it was not pulsating. The feeding vessel seen angiographically was identified, coagulated, and divided. Two smaller vessels passing into the mass were also coagulated. A curved Yasargil clip was placed across the neck of the aneurysm and its thickened wall punctured to ensure that it was no longer filling. The patient's condition improved postoperatively. Repeat angiography confirmed successful occlusion of the aneurysm. He was well at initial neurosurgical follow-up, but 5 months later complained of occipital headache and deteriorating vision. Examination confirmed worsening of his visual field defect with a full left homonymous hemianopsia. CT (Fig. 4) showed a large enhancing partially necrotic mass centered on the right medial occipital lobe but involving the corpus callosum and surrounding the right trigone. Histological examination of a stereotactic biopsy revealed grade 3 malignant astrocytoma, later treated with radiotherapy.
Discussion Intracranial aneurysms usually occur in the region of the circle of Willis and in that site are most often congenital or arteriosclerotic in origin [1]. Congenital ("berry") aneurysms may be located at the pericallosal origin but are otherwise unusual distal to the circle of Willis. Peripheral aneurysms are most commonly mycotic [2], although they may be secondary to trauma, tumor and moya moya disease. Those due to infection are usually the result of septic emboli but may rarely arise as a result of spread of a focus of infection to the vessel wall from an extravascular site [3]. Intracranial hemorrhage is well recognized in association with primary or metastatic brain tumors. Metastases are a more common cause of hemorrhage, reflecting both their greater incidence and greater propensity to bleed [4].
31
Fig.1. Day 1. Non-contrast computed tomography (CT) shows fresh hematoma within the splenium of the corpus callosum, the right medial occipital lobe and dilated lateral ventricles
Fig. 2 a, b. Day 42. Arterial phase lateral (a) and Towne (b) left vertebral angiograms show an aneurysm arising from right splenial artery
Fig. 3. Day 45. Non-contrast CT shows persistent mass in splenium and right occipital lobe. The mass is unchanged in size but now is pi cd~)minani Iy Inypodcnsc Fig.4. Seven months after presentation. Contrast-enhanced CT. The mass has increased considerably in size, enhances and is partially necrotic. There is some surrounding edema The neoplasms most commonly associated with such hemorrhage are bronchogenic carcinoma, choriocarcinoma, melanoma, and renal cell carcinoma [4]. Aneurysms are rarely implicated as the source of subarachnoid or intracerebral h e m o r r h a g e associated with metastatic and primary brain tumors. However, choriocarcinoma [5] and cardiac m y x o m a [6] are both known to cause intracranial aneurysms, and of these the former seems m o r e likely to rupture. H o [7] has reported a single case of rupture of a peripheral aneurysm associated with a metastasis from bronchogenic carcinoma. Gliomas are known to incite the development of new arterioles, which may have a b e a d e d appearance. The normal arterial vessels supplying the t u m o r m a y exhibit con-
siderable irregularity and variation in the width of their lumens [8]. Cowen et al. [91 reported on a patient with bilateral fusiform aneurysmal dilatation of the pericallosal arteries shown histologically to be associated with invasion of the vessel walls by glioma. A n English language literature search has failed to find a case of a saccular aneurysm associated with a ghoma. Unfortunately in the case described here no biopsies were t a k e n at the time of clipping of the aneurysm. However, it seems highly probable that the tumor and aneurysm were causally related. This is likely to have been a false aneurysm. These often exhibit delay in emptying and reduced opacity when c o m p a r e d to true aneurysms [10] but only the latter feature was present in this case.
32
References 1. Allcock J (1974) Aneurysms. In: Newton TH, Potts DG (eds) Radiology of the skull and brain: angiography. Mosby, St. Louis, pp 2445-2486 2. Olmsted WW, McGee TP (1977) The pathogenesis of peripheral aneurysms of the central nervous system: a subject review from the AFIR Radiology 123:661~666 3. Suwanwela C, Suwanwela N, Charuchinda S, Hongsaprabhas C (1972) Intracranial mycotic aneurysms of extravascular origin. J Neurosurg 36:552-559 4. Mandybur TI (1977) Intracranial hemorrhage caused by metastatic tumors. Neurology 27:650~555 5. Seigle JM, Caputy AJ, Manz HJ, Wheeler C, Fox JL (1987) Multiple oncotic intracranial aneurysms and cardiac metastasis from choriocarcinoma: case report and review of the literature. Neurosurgery 20:39-42
6. New PF, Price DL, Carter B (1970) Cerebral angiography in cardiac myxoma. Correlation of angiographic and histopathological findings. Radiology 96:335-345 7. Ho K-L (1982) Neoplastic aneurysm and intracranial hemorrhage. Cancer 50:2935-2940 8. Taveras JM, Wood EH (1976) Diagnostic neuroradiology, vol 2. Williams and Wilkins, Baltimore, pp 760-765 9. Cowen RL, Siqueira EB, George E (1970) Angiographic demonstration of a glioma involving the wall of the anterior cerebral artery. Radiology 97:577-578 10. Sedzimir CB, Occleshaw JV, Brixton PH (1968) False cerebral aneurysm. Case report. J Neurosurg 29:636-639 Dr. C.S.Barker Neuroradiology Section Department of Radiology Radcliffe Infirmary Oxford, OX2 6HE, UK
