Spontaneous intracerebral hematoma caused by cerebral neoplasms Report of eight verified cases
MICHAEL SCOTT, M.D.
Department of Neurosurgery, Division of Neurological and Sensory Sciences, Temple University Health Sciences Center, Philadelphia, Pennsylvania In eight of 590 consecutive patients operated on by the author for a proven brain tumor, the preoperative diagnosis was complicated by a spontaneous intracerebral hematoma caused by the neoplasm. The presenting symptoms were those of hypertensive intracerebral hemorrhage or brain tumor. The pathology underlying spontaneous bleeding from a cerebral neoplasm is reviewed and diagnostic suggestions discussed. KEVWORDS spontaneous intracerebrai hematoma 9 primary intracerebral tumors 9 metastatic brain tumors
i
NTRACRANIALhemorrhage from a brain tumor can mask the cause of bleeding, confuse the diagnosis, and affect treatment and prognosis. We are reporting our experience with eight such cases verified at operation. Clinical Material
In our 80 patients with spontaneous intracerebral hematomas of verified etiology, eight (10%) of the hematomas were caused by a primary or metastatic neoplasm (Table 1); if the six metastatic tumors had been excluded the incidence would have been 2.5%. The hematomas were all large, over 4 cm in diameter. The patients' symptoms and signs suggested two diagnostic categories. The first was classical spontaneous intracerebral 338
hemorrhage with a history of hypertension, sudden headache, coma or stupor, hemiparesis or hemiplegia, and bloody cerebrospinal fluid (Cases 1, 3, and 6, Table 2). The second was brain tumor with symptoms and signs of increased intracranial pressure and focal neurological signs (Cases 2, 4, 5, 7, and 8, Table 2). Cerebral angiography was carried out in four of the eight patients, and in three of these revealed a space-occupying lesion of unknown etiology. Isotope brain scans were done in two patients, and both studies suggested a tumor. Diagnosis was made by biopsy of the blood clot, suspected tumor, or the cavity wall (Table 1). Two patients died after surgery. The other six patients died 2, 3, 6, 6, and 12 months, and 12 years, after the operation because of the original cerebral neoplasm.
J. Neurosurg. / Volume 42 / March, 1975
Cerebral neoplasms causing intracerebral hematoma Discussion Clinical Aspects
TABLE l
Etiology of spontaneous intracerebral hematomas in 80 patients operated on by author
The usual cause of a spontaneous inNo. of tracerebral or subarachnoid hemorrhage is Diagnosis Cases either an aneurysm, a vascular malformation, hypertension 43 (53.7%) or hypertensive cerebrovascular disease. arteriovenous malformations 8 (10.0%) Brain tumor is an uncommon cause. berry aneurysms 5 (6.2%) Locksley, et al., TM Russell, 13 Courville quoted blood dyscrasia(leukemia) 1 (1.2%) by Locksley, and Mutlu, et a l . ) 2 have brain tumors 8 (10.0~) metastatic chorioepithelioma 1 reported autopsies on people who died from metastatic carcinoma of lung 1 spontaneous subarachnoid or spontaneous incystic astrocytoma,Grade 2 1 tracerebral hemorrhage. They found that a vascular tumor (no biopsy) 1 primary or metastatic brain tumor was the metastatic melanoma 4 cause of either subarachnoid or intracerebral etiologyunverified 15 (18.8~) cerebral atherosclerosis 10 hemorrhage in only 2% or 3% of their necropruptured artery, no aneurysm 3 sies. YasargiW reported that cerebral cerebral embolus 1 angiography done on patients with sponundetermined 1 taneous subarachnoid hemorrhage revealed total 80 an incidence of 1% to 2% due to a brain tumor. Glass and Abbot? found in their series of 162 patients with cerebral neoplasms that approximately 5% had symptoms of subarachnoid hemorrhage. In the series of 590 patients operated on by the author for a cerebrovascular disease, along with the inproven cerebral neoplasm, eight (1.7%) had a creasing reports in the literature of sponspontaneous intracerebral hematoma caused taneous intracranial and spinal epidural by the tumor; the incidence of subarachnoid bleeding from their use makes it important to hemorrhage in this series could not be deter- rule out this medication as the cause of the mined because a spinal tap was omitted if bleeding? 6 tumor was suspected. Spontaneous subarachnoid hemorrhage Pathologic Aspects from a brain tumor has been reported as Locksley, et al., 1~ cited the following types simulating a ruptured cerebral aneurysm, x;3,5,~'or as a confusing symptom from a of neoplasms as possible but unusual causes of cerebral hemorrhage: primary tumors, pituitary tumor ~,~,~ or brain abscess?,' A history of a malignant melanoma of the such as gliomas, meningiomas, papillomas of skin, a pelvic chorioepithelioma, or in fact the choroid plexus, chordomas, hemangiany extracerebral malignancy or blood omas, pituitary adenomas, and perivascular dyscrasia should alert the surgeon to the sarcomas; and metastatic tumors such as possibility that the "spontaneous" brain bronchogenic carcinomas, chorioepithelihemorrhage might be caused by a metastatic omas, and malignant melanomas. brain tumor or by a hematologic abnorAccording to Zulch: TM "Hemorrhage into mality, rather than by the usual causes such tumors occurs mostly in oligodendroglioma as aneurysm, vascular malformation, or and glioblastoma but also in cerebral hypertensive cerebrovascular disease. An metastasis (hypernephroma, melanoma), and adequate preoperative hematologic survey may simulate a stroke. The pathogenesis of a should be done on all patients suspected ofin- rupture of blood vessels is understandable in tracranial hemorrhage to rule out a blood the huge disorderly fistulous vessels of dyscrasia. glioblastoma but less well understood in the None of the patients in our series had been oligodendroglioma. Smaller hemorrhages receiving anticoagulants previous to their into the necrotized parts of the glioblastoma hemorrhage. However, the frequent use of multiforme are part of its variegated picture these drugs for cardiac disease, throm- and causes the brownish and reddish color of bophlebitis, and occasionally for occlusive these tumors." J. Neurosurg. / Volume 42 / March, 1975
339
M. Scott TABLE 2 Summary of eight cases of spontaneous intracerebral hematoma caused by a cerebral neoplasm
Clinical Data Case No.
Age (yrs) 26 38 56 53 46
69 57 8
51
Symptoms
Clinical Signs*
headache, coma, It decerebrate rigid, coma, hemiplegia; melanoma bp 136/80, NBD skin removed 8 yrs prev. prog. hemiplegia, aphasia motor aphasia, rt hemiplegia, bp 140/88, NBD headache, stupor, stupor, rt hemiplegia, rt convulsion bp 138/90, NBD headache for 6 wks, ataxia no choke, marked rt to rt, melanoma skin cerebellum impairment NBD removed 3 yrs prey. headache, aphasia, partly drowsy, partial motor aphasia, NBD removed cystic astrocytoma It front, x-ray therapy 10 yrs prev. sudden headache, coma; no focal signs, NBD melanoma removed rt axilla 6 too. prev. anomia, rt hemiparesis, anomia, rt hemiparesis, NBD headache bronchogenic carcinoma, cerebral metastasis treated with mustard and x-ray therapy
sudden weakness rt arm, NBD
X-ray Studies skull negative
Spinal Tap pink, 300 mm pink, 480 mm pink, 400 mm
skull negative, angiogram positive, rt cerebellar mass skull negative, angiogram positive, It frontal lobe mass skull negative, isotope scan positive, rt frontal mercury scan & angiogram positive, It temporal lobe angiogram negative, air study positive
* NBD = no bleeding diathesis.
Globus and Saperstein 6 stated that tumors as a rule show some seepage of blood from blood vessels into the surrounding tissue. Goran, et al., 7 quoted Oldberg who in 1933 reviewed Cushing's series of 832 gliomas and found 31 instances of gross hemorrhage from the tumor, a ratio of 1 to 27, or 3.7%. Cerebral hemorrhage is less commonly caused by m e n i n g i o m a s than by other primary or metastatic cerebral neoplasms. 1 Cushing and Eisenhardt ~ did not mention cerebral h e m a t o m a as either a presenting symptom or associated finding in 313 cases of operated meningiomas listed in their classic m o n o g r a p h ; neither did Hoessley and Olivecrona 9 in their report of 280 operated and verified parasagittal meningiomas. Goran, et al., 7 stated that hemorrhage into meningiomas is exceedingly rare and reported five cases of endotheliomatous meningiomas with intracerebral hemorrhage. They and 3"t0
others suggested that the production of hemorrhage from meningiomas is possibly caused by rupture of a small group of angiomatous vessels in an otherwise purely endothelial tumor. 4,7 Askenasy and B e h o r a m I reported the histology of seven meningiomas of the lateral ventricle including two that presented as ruptured aneurysms. They stated that subarachnoid h e m o r r h a g e is u n c o m m o n in patients with intraventricular meningiomas and that the mechanism of hemorrhage associated with meningiomas of the lateral ventricle does not appear similar to that of the bleeding malignant tumor. They believed that the slow growth of the intraventricular meningiomas is paralleled, in response to the demand for increased blood supply, by a corresponding enlargement of feeding arteries which become tortuous and less resistant to blood pressure changes. They assumed that J. Neurosurg. / Volume 42 / March, 1975
Cerebral neoplasms causing intracerebral hematoma TABLE 2 (continued)
Operation Pathology
Comments
Result
large clot, rt prefrontal malignant melanoma
died 3 mos postop recurrent bleed
large clot, metastatic chodoepithelioma It frontal
died 15 days postop
no primary tumor at autopsy; metastasis to lung, kidneys, spleen, & GI tract
large clot It interior capsule, vascular tumor large black liquid clot rt cerebellum, small tumor in cavity, metastatic melanoma large clot in recurrent astrocytoma It frontal lobe
reoperated 8 mos later, tumor recurrence recovered
died 6 mos after second operation; no autopsy died 1 yr postop
recovered
died at home 12 yrs postop
black melanoma cortex & underlying recovered large hematoma, rt frontal metastatic melanoma large black hematoma, it temporal died 2 mos postop lobe melanoma
died at home 6 mos postop no history of any primary lesion
large clot in metastatic tumor, It frontal died 7 days postop metastatic bronchogenic carcinoma
the intraventricular location of these pathological vessels favors their rupture, just as aneurysms and vascular malformations tend to bleed into the subarachnoid space. Skultety t' reported the case of a patient who had sudden headache without any neurological deficit. The spinal fluid was xanthochromic. At operation a fibroblastic m e n i n g i o m a with a layer of acute hemorrhage over its surface was found in the right sphenoid fossa. Harispe, et al., 8 stated that the metastatic cerebral lesions from pelvic choriocarcinoma usually present as acute emergencies and should be suspected in cases of apparent spontaneous cerebral hemorrhage. Three of their six patients had a previous history of a hydatidiform mole. In three the cerebral symptoms were sudden and in one, the slow progression suggested tumor. Because of the blood clot and the small size of the J. Neurosurg. / Volume 42 / March, 1975
metastasis, this histological diagnosis can be easily missed. Urinary gonadotropins were excessive in three of their patients and normal in two. " T h e present possibility of controlling choriocarcinoma by chemotherapy makes the suspicion and histologic diagnosis of metastasis to the brain clinically important. ''8 Daum and Navarro-Artiles 3 reported that occasionally diffusion of blood or leukocytes into the subarachnoid space or ventricular cavities from a necrotic tumor can cause a subacute or acute meningeal syndrome and mimic a ruptured a n e u r y s m with intracerebral h e m a t o m a or a brain abscess. Six of their nine tumor patients had bloody CSF, and in three the CSF suggested an aseptic meningitis. Five of the t u m o r s were angioreticulomas and four malignant gliomas. They believed that a cerebral tumor should be considered in the search for the cause of an acute meningeal syndrome? 341
M. Scott References 1. Askenasy HM, Behoram AD: Subarachnoid hemorrhage in meningiomas of lateral ventricle. Neurology (Minneap) 10:484-489, 1960 2. Cushing H, Eisenhardt L: Meningiomas, Their Classification, Regional Behavior, Life History, and Surgical End Results. New York, Hafner Publishing Co., 1962, pp 3-55 3. Daum S, Navarro-Artiles G: Les tumeurs c6r6brales, r6v616es par un syndrome m6ning6 aigu: hemorrhagie sous-arachnoidienne ou Meningit~ aseptique. Sem Hop Paris 46:544-549, 1970 4. EI-Banhawy A, Walter W: Meningioma with acute onset. Acta Neurochir (Wien) 10:194-206, 1962 5. Glass B, Abbott KH: Subarachnoid hemorrhage consequent to intracranial tumors. Review of the literature and report of seven cases. Arch Neuroi Psychiatry 73:369-379, 1955 6. Globus JH, Saperstein M: Massive hemorrhage into brain tumor. Its significance and probable relationship to rapidly fatal termination and antecedent trauma. JAMA 120:348-352, 1942 7. Goran A, Ciminello V, Fisher RG: Massive hemorrhage into brain meningiomas. Arch Neuroi 13:65-69, 1965 8. Harispe L, Creissard P, Foncin JE, et al: (Neurosurgical manifestations of placental chorio-carcinoma. A study of 6 patients). Ann Med Interne (Paris) 122:849-854, 1971 (Fre) 9. Hoessly GF, Olivecrona H: Report on 280 cases of verified parasagittal meningiomas. J Neurosurg 12:614-626, 1955 10. Locksley HB, Sahs AL, Sandier R: Report on the cooperative study of intracranial
342
l 1. 12.
13. 14. 15. 16. 17. 18.
aneurysms and subarachnoid hemorrhage. Section 3. Subarachnoid hemorrhage unrelated to intracranial aneurysm and A-V malformation. A study of associated diseases and prognosis. J Neurosurg 24:1034-1056, 1966 Moore M: The fate of clinically unrecognized intracranial meningiomas. Neurology (Minneap) 4:837-856, 1954 Mutlu N, Berry RG, Alpers BJ: Massive cerebral hemorrhage. Clinical and pathological correlation. Arch Neurol 8:644-661, 1963 Russell DS: The pathology of spontaneous intracerebral hemorrhage. Proc R Soc Med 47:689-693, 1954 Skultety FM: Meningioma simulating ruptured aneurysm. Case report. J Neurosurg 28:380-382, 1968 Spatz R, Jordan H: (Apoplectic bleeding in hypophysial tumors). Munch Med Wochenschr 115:2021-2024, 1973 (Ger) Sreerma V, Ivan LP, Dennery JM, et al: Neurosurgical complications of anticoagulant therapy. Can Med Assoc J 108:305-307, 1973 Yasargil MG: (Subarachnoid hemorrhage). Schweiz Med Wochenschr 99:1629-1632, 1969 (Ger) Zulch KJ: Neuropathology of intracranial haemorrhage. Prog Brain Res 30:151-165, 1968
Address reprint requests to: Michael Scott, M.D., Department of Neurosurgery, Division of Neurological and Sensory Sciences, Temple University Health Sciences Center, Philadelphia, Pennsylvania.
J. Neurosurg. / Volume 42 / March, 1975
MICHAEL SCOTT, M.D.
Department of Neurosurgery, Division of Neurological and Sensory Sciences, Temple University Health Sciences Center, Philadelphia, Pennsylvania In eight of 590 consecutive patients operated on by the author for a proven brain tumor, the preoperative diagnosis was complicated by a spontaneous intracerebral hematoma caused by the neoplasm. The presenting symptoms were those of hypertensive intracerebral hemorrhage or brain tumor. The pathology underlying spontaneous bleeding from a cerebral neoplasm is reviewed and diagnostic suggestions discussed. KEVWORDS spontaneous intracerebrai hematoma 9 primary intracerebral tumors 9 metastatic brain tumors
i
NTRACRANIALhemorrhage from a brain tumor can mask the cause of bleeding, confuse the diagnosis, and affect treatment and prognosis. We are reporting our experience with eight such cases verified at operation. Clinical Material
In our 80 patients with spontaneous intracerebral hematomas of verified etiology, eight (10%) of the hematomas were caused by a primary or metastatic neoplasm (Table 1); if the six metastatic tumors had been excluded the incidence would have been 2.5%. The hematomas were all large, over 4 cm in diameter. The patients' symptoms and signs suggested two diagnostic categories. The first was classical spontaneous intracerebral 338
hemorrhage with a history of hypertension, sudden headache, coma or stupor, hemiparesis or hemiplegia, and bloody cerebrospinal fluid (Cases 1, 3, and 6, Table 2). The second was brain tumor with symptoms and signs of increased intracranial pressure and focal neurological signs (Cases 2, 4, 5, 7, and 8, Table 2). Cerebral angiography was carried out in four of the eight patients, and in three of these revealed a space-occupying lesion of unknown etiology. Isotope brain scans were done in two patients, and both studies suggested a tumor. Diagnosis was made by biopsy of the blood clot, suspected tumor, or the cavity wall (Table 1). Two patients died after surgery. The other six patients died 2, 3, 6, 6, and 12 months, and 12 years, after the operation because of the original cerebral neoplasm.
J. Neurosurg. / Volume 42 / March, 1975
Cerebral neoplasms causing intracerebral hematoma Discussion Clinical Aspects
TABLE l
Etiology of spontaneous intracerebral hematomas in 80 patients operated on by author
The usual cause of a spontaneous inNo. of tracerebral or subarachnoid hemorrhage is Diagnosis Cases either an aneurysm, a vascular malformation, hypertension 43 (53.7%) or hypertensive cerebrovascular disease. arteriovenous malformations 8 (10.0%) Brain tumor is an uncommon cause. berry aneurysms 5 (6.2%) Locksley, et al., TM Russell, 13 Courville quoted blood dyscrasia(leukemia) 1 (1.2%) by Locksley, and Mutlu, et a l . ) 2 have brain tumors 8 (10.0~) metastatic chorioepithelioma 1 reported autopsies on people who died from metastatic carcinoma of lung 1 spontaneous subarachnoid or spontaneous incystic astrocytoma,Grade 2 1 tracerebral hemorrhage. They found that a vascular tumor (no biopsy) 1 primary or metastatic brain tumor was the metastatic melanoma 4 cause of either subarachnoid or intracerebral etiologyunverified 15 (18.8~) cerebral atherosclerosis 10 hemorrhage in only 2% or 3% of their necropruptured artery, no aneurysm 3 sies. YasargiW reported that cerebral cerebral embolus 1 angiography done on patients with sponundetermined 1 taneous subarachnoid hemorrhage revealed total 80 an incidence of 1% to 2% due to a brain tumor. Glass and Abbot? found in their series of 162 patients with cerebral neoplasms that approximately 5% had symptoms of subarachnoid hemorrhage. In the series of 590 patients operated on by the author for a cerebrovascular disease, along with the inproven cerebral neoplasm, eight (1.7%) had a creasing reports in the literature of sponspontaneous intracerebral hematoma caused taneous intracranial and spinal epidural by the tumor; the incidence of subarachnoid bleeding from their use makes it important to hemorrhage in this series could not be deter- rule out this medication as the cause of the mined because a spinal tap was omitted if bleeding? 6 tumor was suspected. Spontaneous subarachnoid hemorrhage Pathologic Aspects from a brain tumor has been reported as Locksley, et al., 1~ cited the following types simulating a ruptured cerebral aneurysm, x;3,5,~'or as a confusing symptom from a of neoplasms as possible but unusual causes of cerebral hemorrhage: primary tumors, pituitary tumor ~,~,~ or brain abscess?,' A history of a malignant melanoma of the such as gliomas, meningiomas, papillomas of skin, a pelvic chorioepithelioma, or in fact the choroid plexus, chordomas, hemangiany extracerebral malignancy or blood omas, pituitary adenomas, and perivascular dyscrasia should alert the surgeon to the sarcomas; and metastatic tumors such as possibility that the "spontaneous" brain bronchogenic carcinomas, chorioepithelihemorrhage might be caused by a metastatic omas, and malignant melanomas. brain tumor or by a hematologic abnorAccording to Zulch: TM "Hemorrhage into mality, rather than by the usual causes such tumors occurs mostly in oligodendroglioma as aneurysm, vascular malformation, or and glioblastoma but also in cerebral hypertensive cerebrovascular disease. An metastasis (hypernephroma, melanoma), and adequate preoperative hematologic survey may simulate a stroke. The pathogenesis of a should be done on all patients suspected ofin- rupture of blood vessels is understandable in tracranial hemorrhage to rule out a blood the huge disorderly fistulous vessels of dyscrasia. glioblastoma but less well understood in the None of the patients in our series had been oligodendroglioma. Smaller hemorrhages receiving anticoagulants previous to their into the necrotized parts of the glioblastoma hemorrhage. However, the frequent use of multiforme are part of its variegated picture these drugs for cardiac disease, throm- and causes the brownish and reddish color of bophlebitis, and occasionally for occlusive these tumors." J. Neurosurg. / Volume 42 / March, 1975
339
M. Scott TABLE 2 Summary of eight cases of spontaneous intracerebral hematoma caused by a cerebral neoplasm
Clinical Data Case No.
Age (yrs) 26 38 56 53 46
69 57 8
51
Symptoms
Clinical Signs*
headache, coma, It decerebrate rigid, coma, hemiplegia; melanoma bp 136/80, NBD skin removed 8 yrs prev. prog. hemiplegia, aphasia motor aphasia, rt hemiplegia, bp 140/88, NBD headache, stupor, stupor, rt hemiplegia, rt convulsion bp 138/90, NBD headache for 6 wks, ataxia no choke, marked rt to rt, melanoma skin cerebellum impairment NBD removed 3 yrs prey. headache, aphasia, partly drowsy, partial motor aphasia, NBD removed cystic astrocytoma It front, x-ray therapy 10 yrs prev. sudden headache, coma; no focal signs, NBD melanoma removed rt axilla 6 too. prev. anomia, rt hemiparesis, anomia, rt hemiparesis, NBD headache bronchogenic carcinoma, cerebral metastasis treated with mustard and x-ray therapy
sudden weakness rt arm, NBD
X-ray Studies skull negative
Spinal Tap pink, 300 mm pink, 480 mm pink, 400 mm
skull negative, angiogram positive, rt cerebellar mass skull negative, angiogram positive, It frontal lobe mass skull negative, isotope scan positive, rt frontal mercury scan & angiogram positive, It temporal lobe angiogram negative, air study positive
* NBD = no bleeding diathesis.
Globus and Saperstein 6 stated that tumors as a rule show some seepage of blood from blood vessels into the surrounding tissue. Goran, et al., 7 quoted Oldberg who in 1933 reviewed Cushing's series of 832 gliomas and found 31 instances of gross hemorrhage from the tumor, a ratio of 1 to 27, or 3.7%. Cerebral hemorrhage is less commonly caused by m e n i n g i o m a s than by other primary or metastatic cerebral neoplasms. 1 Cushing and Eisenhardt ~ did not mention cerebral h e m a t o m a as either a presenting symptom or associated finding in 313 cases of operated meningiomas listed in their classic m o n o g r a p h ; neither did Hoessley and Olivecrona 9 in their report of 280 operated and verified parasagittal meningiomas. Goran, et al., 7 stated that hemorrhage into meningiomas is exceedingly rare and reported five cases of endotheliomatous meningiomas with intracerebral hemorrhage. They and 3"t0
others suggested that the production of hemorrhage from meningiomas is possibly caused by rupture of a small group of angiomatous vessels in an otherwise purely endothelial tumor. 4,7 Askenasy and B e h o r a m I reported the histology of seven meningiomas of the lateral ventricle including two that presented as ruptured aneurysms. They stated that subarachnoid h e m o r r h a g e is u n c o m m o n in patients with intraventricular meningiomas and that the mechanism of hemorrhage associated with meningiomas of the lateral ventricle does not appear similar to that of the bleeding malignant tumor. They believed that the slow growth of the intraventricular meningiomas is paralleled, in response to the demand for increased blood supply, by a corresponding enlargement of feeding arteries which become tortuous and less resistant to blood pressure changes. They assumed that J. Neurosurg. / Volume 42 / March, 1975
Cerebral neoplasms causing intracerebral hematoma TABLE 2 (continued)
Operation Pathology
Comments
Result
large clot, rt prefrontal malignant melanoma
died 3 mos postop recurrent bleed
large clot, metastatic chodoepithelioma It frontal
died 15 days postop
no primary tumor at autopsy; metastasis to lung, kidneys, spleen, & GI tract
large clot It interior capsule, vascular tumor large black liquid clot rt cerebellum, small tumor in cavity, metastatic melanoma large clot in recurrent astrocytoma It frontal lobe
reoperated 8 mos later, tumor recurrence recovered
died 6 mos after second operation; no autopsy died 1 yr postop
recovered
died at home 12 yrs postop
black melanoma cortex & underlying recovered large hematoma, rt frontal metastatic melanoma large black hematoma, it temporal died 2 mos postop lobe melanoma
died at home 6 mos postop no history of any primary lesion
large clot in metastatic tumor, It frontal died 7 days postop metastatic bronchogenic carcinoma
the intraventricular location of these pathological vessels favors their rupture, just as aneurysms and vascular malformations tend to bleed into the subarachnoid space. Skultety t' reported the case of a patient who had sudden headache without any neurological deficit. The spinal fluid was xanthochromic. At operation a fibroblastic m e n i n g i o m a with a layer of acute hemorrhage over its surface was found in the right sphenoid fossa. Harispe, et al., 8 stated that the metastatic cerebral lesions from pelvic choriocarcinoma usually present as acute emergencies and should be suspected in cases of apparent spontaneous cerebral hemorrhage. Three of their six patients had a previous history of a hydatidiform mole. In three the cerebral symptoms were sudden and in one, the slow progression suggested tumor. Because of the blood clot and the small size of the J. Neurosurg. / Volume 42 / March, 1975
metastasis, this histological diagnosis can be easily missed. Urinary gonadotropins were excessive in three of their patients and normal in two. " T h e present possibility of controlling choriocarcinoma by chemotherapy makes the suspicion and histologic diagnosis of metastasis to the brain clinically important. ''8 Daum and Navarro-Artiles 3 reported that occasionally diffusion of blood or leukocytes into the subarachnoid space or ventricular cavities from a necrotic tumor can cause a subacute or acute meningeal syndrome and mimic a ruptured a n e u r y s m with intracerebral h e m a t o m a or a brain abscess. Six of their nine tumor patients had bloody CSF, and in three the CSF suggested an aseptic meningitis. Five of the t u m o r s were angioreticulomas and four malignant gliomas. They believed that a cerebral tumor should be considered in the search for the cause of an acute meningeal syndrome? 341
M. Scott References 1. Askenasy HM, Behoram AD: Subarachnoid hemorrhage in meningiomas of lateral ventricle. Neurology (Minneap) 10:484-489, 1960 2. Cushing H, Eisenhardt L: Meningiomas, Their Classification, Regional Behavior, Life History, and Surgical End Results. New York, Hafner Publishing Co., 1962, pp 3-55 3. Daum S, Navarro-Artiles G: Les tumeurs c6r6brales, r6v616es par un syndrome m6ning6 aigu: hemorrhagie sous-arachnoidienne ou Meningit~ aseptique. Sem Hop Paris 46:544-549, 1970 4. EI-Banhawy A, Walter W: Meningioma with acute onset. Acta Neurochir (Wien) 10:194-206, 1962 5. Glass B, Abbott KH: Subarachnoid hemorrhage consequent to intracranial tumors. Review of the literature and report of seven cases. Arch Neuroi Psychiatry 73:369-379, 1955 6. Globus JH, Saperstein M: Massive hemorrhage into brain tumor. Its significance and probable relationship to rapidly fatal termination and antecedent trauma. JAMA 120:348-352, 1942 7. Goran A, Ciminello V, Fisher RG: Massive hemorrhage into brain meningiomas. Arch Neuroi 13:65-69, 1965 8. Harispe L, Creissard P, Foncin JE, et al: (Neurosurgical manifestations of placental chorio-carcinoma. A study of 6 patients). Ann Med Interne (Paris) 122:849-854, 1971 (Fre) 9. Hoessly GF, Olivecrona H: Report on 280 cases of verified parasagittal meningiomas. J Neurosurg 12:614-626, 1955 10. Locksley HB, Sahs AL, Sandier R: Report on the cooperative study of intracranial
342
l 1. 12.
13. 14. 15. 16. 17. 18.
aneurysms and subarachnoid hemorrhage. Section 3. Subarachnoid hemorrhage unrelated to intracranial aneurysm and A-V malformation. A study of associated diseases and prognosis. J Neurosurg 24:1034-1056, 1966 Moore M: The fate of clinically unrecognized intracranial meningiomas. Neurology (Minneap) 4:837-856, 1954 Mutlu N, Berry RG, Alpers BJ: Massive cerebral hemorrhage. Clinical and pathological correlation. Arch Neurol 8:644-661, 1963 Russell DS: The pathology of spontaneous intracerebral hemorrhage. Proc R Soc Med 47:689-693, 1954 Skultety FM: Meningioma simulating ruptured aneurysm. Case report. J Neurosurg 28:380-382, 1968 Spatz R, Jordan H: (Apoplectic bleeding in hypophysial tumors). Munch Med Wochenschr 115:2021-2024, 1973 (Ger) Sreerma V, Ivan LP, Dennery JM, et al: Neurosurgical complications of anticoagulant therapy. Can Med Assoc J 108:305-307, 1973 Yasargil MG: (Subarachnoid hemorrhage). Schweiz Med Wochenschr 99:1629-1632, 1969 (Ger) Zulch KJ: Neuropathology of intracranial haemorrhage. Prog Brain Res 30:151-165, 1968
Address reprint requests to: Michael Scott, M.D., Department of Neurosurgery, Division of Neurological and Sensory Sciences, Temple University Health Sciences Center, Philadelphia, Pennsylvania.
J. Neurosurg. / Volume 42 / March, 1975
