Subarachnoid hemorrhage from brain tumors in childhood

Human genome-wide analysis and identification of the hyperphosphorylation-elicited interactions between subarachnoid tau protein and phosphoprotein-binding domains

Abnormally hyperphosphorylated tau can be recognized by a variety of phosphoprotein-binding domains (PBDs) to elicit downstream tau signaling in neuropathology, which has been found to have a potential association with subarachnoid hemorrhage. In this study, the genome-wide binding behavior of tau phosphorylation sites (p-sites) to PBDs involved in subarachnoid hyperphosphorylation events was systematically profiled at molecular level by integrating peptide docking, structural minimization, affinity scoring, and binding assay, from which a number of potent PBD-p-site interaction pairs were identified. It was revealed that the PBD domains exhibit distinct binding preferences for phosphotyrosine, phosphoserine, and phosphothreonine p-sites; the PBD-recognition specificity of different tau p-sites is not overlapped with each other, and their phosphorylations would therefore regulate varying biological functions in tau signaling. A number of PBD-p-site pairs were identified to have potent binding potency as compared to others. The KCIP-pS[393-399] pair was found as a strong binder, which was further optimized with a rational peptide design protocol to derive a number of affinity-improved phosphopeptides. Structural analysis revealed diverse noncovalent chemical forces across the complex interface of KCIP domain with a designed high-affinity pS[393-399]-d4, which confers both stability and specificity to the domain-peptide complex system, with affinity improved by 10.9-fold relative to the native pS[393-399].

Optic Pathway–Hypothalamic Glioma Apoplexy: A Report of Two Cases and Systematic Review of the Literature

Background

Hemorrhage into optic pathway–hypothalamic glioma (OPHG) is rare. Variable clinical presentations and outcomes are associated with such pathology. We aim to present two infants presented with OPHG and a systematic review of the literature.

Methods

We describe two cases of infants presenting with sudden decreased vision, poor feeding, and irritability due to OPHG. Both patients underwent urgent craniotomy and subtotal resection followed by chemotherapy. We systematically reviewed the literature using PubMed, Google Scholar, and Embase. In addition, we included all English published reports for all ages discussing the optic pathway (optic nerve and optic chiasm) or hypothalamic glioma associated with hemorrhage from the year of the first reported case (1970) to January 2022.

Results

Of 17,949, 44 articles met the inclusion criteria of this review. A total of 56 cases were described with a mean of 21.35 years (0.5–70), with the male gender 52% and the female gender 45%. The hemorrhage location was sellar/suprasellar in 43% cases. Histopathology of included cases was pilocytic astrocytoma in 41%, followed by pilomyxoid astrocytoma in 16% cases. The outcome was unfavorable; 37.5% cases showed improvement, whereas 18% cases resulted in death.

Conclusion

Apoplexy of the OPHG can be fatal and associated with poor outcomes. A systematic review of the literature has shown that younger age, pilocytic or pilomexyoid astrocytoma histopathology, and chiasmal/hypothalamic locations are associated with a higher risk of intertumoral hemorrhage and poor prognosis. Further genetic studies for OPHG may provide information for high-risk patients.

Optic pathway-hypothalamic glioma hemorrhage: a series of 9 patients and review of the literature

OBJECTIVEHemorrhage (also known as apoplexy) in optic pathway gliomas (OPGs) is rare. Because of the variable presentations and low incidence of OPG hemorrhages, little is known about their clinical course and the best treatment options. The aim of this work was to review risk factors, clinical course, and treatment strategies of optic glioma hemorrhages in the largest possible number of cases.METHODSA total of 34 patients were analyzed. Nine new cases were collected, and 25 were identified in the literature. Data regarding demographics, radiological and histological features, treatment, and outcome were retrospectively reviewed.RESULTSThe majority of patients were younger than 20 years. Only 3 patients were known to have neurofibromatosis. The histopathological diagnosis was pilocytic astrocytoma in the majority of cases. Five patients had intraorbital hemorrhages, whereas 29 patients had intracranial hemorrhage; the majority of intracranial bleeds were treated surgically. Six patients, all with intracranial hemorrhage, died due to recurrent bleeding, hydrocephalus, or surgical complications. No clear risk factors could be identified.CONCLUSIONSIntracerebral OPG hemorrhages have a fatal outcome in 20% of cases. Age, hormonal status, neurofibromatosis involvement, and histopathological diagnosis have been suggested as risk factors for hemorrhage, but this cannot be reliably established from the present series. The goals of surgery should be patient survival and prevention of further neurological and ophthalmological deterioration.

Glioblastoma Mimicking Subarachnoid Hemorrhage of Unknown Etiology: A Case Report

BACKGROUND

Glioblastoma is the most common primary malignant tumor of the brain. Common radiologic findings using initial computed tomography (CT) reveal an intra-axial lesion with perifocal edema. Here, we present a rare case of diffuse subarachnoid hemorrhage (SAH) detected on an initial CT image in a patient without intracranial aneurysm in whom the final diagnosis was glioblastoma.

CASE DESCRIPTION

We report the rare case of a 57-year-old man with glioblastoma in the right temporal lobe who presented with a sudden onset of disturbance of consciousness as an initial manifestation. Initial CT of the head revealed a diffuse SAH. Digital subtraction angiography revealed no cerebral aneurysm or dissection of intracranial arteries. The patient was treated for SAH of unknown etiology with conservative therapy, and a repeat digital subtraction angiography demonstrated no vascular disease. Eventually, he was discharged without any neurologic deficit. A follow-up CT of the brain revealed an intracerebral hemorrhage in the right temporal lobe, and magnetic resonance imaging revealed a ring enhancing lesion in the anterior section of right temporal lobe. The patient was transferred to our department, where he underwent surgical resection, and a pathologic diagnosis of glioblastoma was made.

CONCLUSIONS

We present a rare case of glioblastoma mimicking SAH of unknown etiology and recommend including glioblastoma in the differential diagnosis of SAH of unknown etiology.

Hemorrhagic Pilocytic Astrocytomas in Adults: A Case Report and Literature Review

Pilocytic astrocytomas are histologically benign tumors, generally found in the pediatric population. Onset of symptoms is generally insidious, predominantly stemming from mass effect upon nearby structures. Patients harboring a pilocytic astrocytoma may present with gait disturbance, headaches, cranial nerve deficits, as well as hydrocephalus, depending on the exact location. Although cases of adult pilocytic astrocytomas in the adult population are described, they are quite uncommon. We present a case of an adult female presenting with acute neurological compromise resulting from an acutely hemorrhagic posterior fossa pilocytic astrocytoma. Her initial neurological assessment was consistent with a Glasgow coma scale of 4T, as the patient was experiencing decerebrate posturing. An emergent external ventricular drain was placed in the emergency department for acute hydrocephalus as a temporizing measure, prior to evacuation of the associated subdural and intratumoral hemorrhages, as well as resection of the mass. After a long hospital course and extensive rehabilitation, the patient made a remarkable recovery and eventually gave birth to a child via Caesarean section three years after her initial presentation.

Primary Ewing sarcoma of the tentorium presenting with intracranial hemorrhage in a child

Spontaneous intracerebral hemorrhage in children is usually related to cerebrovascular conditions. Brain tumors presenting with spontaneous bleeding account for approximately 10% of intracranial hemorrhages in children. The occurrence of primitive central nervous system lesions in the Ewing sarcoma family of tumors (ESFT) not related to bone or metastatic disease is a rare condition. The authors report on a child who presented with intracranial bleeding secondary to a nonmetastatic tentorial ESFT confirmed by detection of the fusion gene EWS-ERG. A detailed review of the literature reveals that most primary intracranial ESFT had a meningeal attachment, and that almost half of them presented at diagnosis with hemorrhage. Distinguishing between ESFT and other intracranial neoplasms is essential because the treatment and prognosis differ remarkably from that of other tumors, namely central primitive neuroectodermal tumors (PNETs). Whereas adjuvant treatment for ESFT consists of local or regional radiotherapy and chemotherapy containing alkylating agents, central PNETs are generally treated with whole neuraxis radiation and platinum-based chemotherapy. Additionally, the prognosis for intracranial ESFT might be better than the one for nonpineal central PNETs.

Cerebellar pilocytic astrocytoma presenting with intratumor bleeding, subarachnoid hemorrhage, and subdural hematoma

INTRODUCTION

Massive intracranial hemorrhage is a very rare initial presentation of cerebellar pilocytic astrocytomas. There are no reports in the medical literature on a cerebellar pilocytic astrocytoma presenting with intratumor bleeding (ITB), subarachnoid hemorrhage (SAH), and subdural hematoma (SDH).

CASE REPORT

A 15-month-old boy presented with lethargy and nausea to our hospital. Magnetic resonance imaging showed a mass with ITB at the left cerebellar hemisphere in addition to SDH in the posterior fossa and SAH at the interpeduncular cistern. The patient underwent emergency surgery. On incising the dura, we found SDH, the tumor was visible at the cerebellar cortex, and near total removal followed. Microscopic examination of tissue sections revealed a pilocytic astrocytoma.

DISCUSSION

The authors' case is the first report with a presentation including ITB, SAH, and SDH. The presumed mechanism of the SAH and SDH was leaking of the ITB into subarachnoid and subdural spaces.

Undiagnosed medulloblastoma presenting as fatal hemorrhage in a 14-year-old boy: case report and review of the literature

INTRODUCTION

A 14-year-old boy with no significant medical history presented to the emergency room with a sudden onset of severe headache of 1 day's duration. On admission, a non-contrast computed tomography (CT) of the head showed a posterior fossa hemorrhagic mass.

MATERIALS AND METHODS

He was immediately intubated and underwent placement of an external drainage tube. A magnetic resonance imaging (MRI) was performed, which showed a large hemorrhagic mass with upward cerebellar herniation.

RESULTS

Despite aggressive measures, he deteriorated and was pronounced brain dead 2 days after admission. Pathological examination of the mass revealed a medulloblastoma with extensive neuronal and astrocytic differentiation.

CONCLUSION

This case represents one of the few cases of rapid, hemorrhagic expansion associated with a previously undiagnosed medulloblastoma. The topic of hemorrhage due to previously unrecognized brain tumors is discussed and the value of imaging methods used in the diagnostic assessment is emphasized.

Fatal haemorrhage in medulloblastoma following ventricular drainage. Case report and review of the literature

Haemorrhage in medulloblastoma is reported to be very rare. The authors report a case of a 13-year-old boy who presented with headache, unsteadiness, diplopia and papilloedema due to posterior fossa medulloblastoma causing obstructive hydrocephalus. Six hours following placement of an external ventricular drain, he suddenly became comatose with respiratory arrest. The cause was marked upward herniation of the anterior vermis and downward herniation of the cerebellar tonsils due to massive spontaneous intratumoural haemorrhage extended into the ventricular system. This atypical clinical course of fatal haemorrhage in medulloblastoma after insertion of external ventricular drainage is reported and the literature discussed.

Intracranial tumoural haemorrhage--a report of 58 cases

In order to study the computerized tomographic (CT) appearances and clinical characteristics of intracranial tumoural haemorrhage (ITH), we analyzed retrospectively fifty-eight patients with ITH and reviewed the literature. As a result, 91% patients had acute or subacute onset and 26% manifested haemorrhage as their first symptoms. CT scanning indicated that intratumoural bleeding occurred in 23 cases, bleeding into parenchyma 18 cases, subarachnoid space 6 cases, ventricle 3 cases and subdural space 8 cases. Thirty-eight patients had emergency operations and the others had selective operations. Both tumours and haematomas were removed all together in all patients. Fifty-five patients were cured or improved and three died during the perioperative stage in our series. Among the patients with ITH, there were 21 metastatic tumours, 19 gliomas, 10 meningiomas, 6 pituitary adenomas, 1 melanoma and 1 acoustic neurilemoma. The onset of most ITH resembled that of cerebrovascular diseases. The location of ITH and the CT appearances of ITH varied in different cerebral tumours. Radical removal of brain tumours with haemorrhage is an effective treatment for ITH, which can greatly decrease the perioperative mortality rate and improve the prognoses of patients.