Multiple intracerebral intravascular papillary endothelial hyperplasia

Case report: Multiple brain intravascular papillary endothelial hyperplasia: incidence, diagnostic challenges, and management approach

Multiple hemorrhagic brain lesions are mainly diagnosed based on clinico-radiological features integrated with histological data. Intravascular papillary endothelial hyperplasia (IPEH), or Masson's tumor, is a very rare entity, particularly when localized in the brain. In this study, we describe a case of multiple recurrent brain IPEHs and provide details on the diagnostic phase, therapeutic approaches, and related challenges. A 55-year-old woman presented with a relapsing neurological deficit. Brain magnetic resonance imaging (MRI) revealed a hemorrhagic right frontal-parietal lesion. When new neurological symptoms occurred, subsequent MRI scans detected more bleeding cerebral lesions. She underwent a series of single hemorrhagic lesion debulking. For any samples that underwent histopathological examination, the first results were not informative; the second and the third results revealed hemangioendothelioma (HE); and the fourth results led to the IPEH diagnosis. Interferon alpha (IFN-α) and subsequently sirolimus were prescribed. Both were well tolerated. Clinical and radiological features remained stable 43 months after starting sirolimus therapy and 132 months after the first diagnosis. To date, 45 cases of intracranial IPEH have been reported, mostly as single lesions without parenchymal location. They are usually treated by surgery and sometimes by radiotherapy upon recurrence. Our case is notable for two main reasons: because of the consecutive recurrent multifocal exclusively cerebral lesions and the therapeutic approach we used. Based on multifocal brain recurrence and good performance, we propose pharmacological therapy, including IFN-α and sirolimus, to stabilize IPEH.

Intraventricular Masson tumor: case report and systematic review of primary intracranial intravascular papillary endothelial hyperplasia

Intracranial Masson tumor (intravascular papillary endothelial hyperplasia, IPEH) is a benign lesion that is thought to originate from a reactionary process in response to compromised blood flow. IPEH may be classified into one of three subtypes based on etiology as it may result from the excessive proliferation of endothelial cells within a normal vessel (primary), vascular malformation (type II), or organized hematoma (type III). We report the case of a 79-year-old woman who presented with confusion, gait instability, and urinary incontinence. Neuroimaging revealed a hemorrhagic lesion within the right lateral ventricle, which was successfully resected. To our knowledge, this is the first reported case of an intraventricular IPEH and 33rd case of primary intracranial IPEH. We further performed a systematic review of the literature on all prior type I intracranial IPEH cases and discuss the importance of long-term follow-up in intracranial IPEH.

Masson's tumor presenting as a left frontal intraparenchymal hemorrhage resulting in severe expressive aphasia during pregnancy: case report

Intravascular papillary endothelial hyperplasia (IPEH), commonly known as Masson's tumor, is a benign lesion that manifests as an excessive proliferation of endothelial cells within a vessel wall. IPEH is extremely rare in the brain, with only 36 intracranial cases previously described in the literature. It is commonly mistaken for more malignant pathologies, such as angiosarcoma. Careful histopathological examination is required for diagnosis, as no clinical or radiographic features are characteristic of this lesion. In this first published case of intracranial IPEH presenting during pregnancy, the authors describe a 32-year-old female with a left frontal intraparenchymal hemorrhage resulting in complete expressive aphasia at 28 weeks 6 days' gestation. An MRI scan obtained at a local hospital demonstrated an area of enhancement within the hemorrhage. The patient underwent a left frontoparietal craniotomy for hematoma evacuation and gross-total resection (GTR) of an underlying hemorrhagic mass at 29 weeks' gestation. This case illustrates the importance of multidisciplinary patient care and the feasibility of intervention in the early third trimester with subsequent term delivery. While GTR of IPEH is typically curative, the decision to proceed with surgical treatment of any intracranial lesion in pregnancy must balance maternal stability, gestational age, and suspected pathology.

Intravascular Papillary Endothelial Hyperplasia of the Pineal Region: A Case Report and Review of the Literature

BACKGROUND

Intravascular papillary endothelial hyperplasia (IPEH) is a benign vascular lesion that is uncommon in the central nervous system. To our knowledge, there has been only one previous report of occurrence in the pineal region. We present a second case and a review of the literature.

CASE DESCRIPTION

A 28-year-old woman presented with 1 month of headaches and visual auras. Brain magnetic resonance imaging scan demonstrated a 2.6- × 1.8- × 1.3-cm nonenhancing T1-hypointense, T2-/fluid-attenuated inversion recovery-hyperintense pineal region mass with cerebral aqueduct obstruction and hydrocephalus. She underwent placement of a right extraventricular drain followed by complete surgical resection. Histologic analysis was consistent with IPEH.

CONCLUSIONS

Although rare, IPEH is an entity that should be considered in the differential diagnosis for intracranial masses with radiographic features characteristic of vascular lesions. Tissue sampling is imperative for distinction from more malignant entities. Complete resection is curative and is the standard of care when feasible. Given the risk of local progression and neurologic compromise with subtotal resection of central nervous system lesions, further study regarding adjuvant treatment options is warranted.

Staged Management of Intracranial Masson Tumor: An Unexpected Gauntlet: Case Report and Review of the Literature

BACKGROUND

Intravascular papillary endothelial hyperplasia (IPEH), also known as Masson tumor, is a benign lesion consisting of a reactive proliferation of endothelial cells with papillary formations related to thrombi. It has been reported in many different anatomic areas. Gross total resection is the elected treatment. Intracranial IPEH is rare, and only a few cases have been reported. This article reports a complicated case of cavernous sinus Masson tumor.

CASE DESCRIPTION

A 51-year-old woman presented because of hemicraneal headache, left facial paresthesia, and diplopia (due to a slight left ocular external rectum muscle paresis) that she had experienced the previous 60 days. She had previously received a diagnosis of neurofibromatosis type I. Contrast-enhanced magnetic resonance imaging showed a 3.5-cm contrast-enhanced tumor adjacent to the left cavernous sinus involving the Meckel cave that extended around the distal petrous portion of the left internal carotid artery. Two possibilities as a differential diagnosis were suggested: meningioma or neurogenic tumor. After a staged surgical procedure, the histopathologic findings were unexpected and showed IPEH (Masson tumor) as the cause of the mass. Despite having benign features, the IPEH showed recurrences over time, so adjuvant 3-dimensional conformal radiation therapy was initiated.

CONCLUSIONS

IPEH is prone to recurrences after subtotal resection. In the present case, successful surgical treatment and adjuvant radiotherapy showed an excellent outcome. To date, no adjuvant therapy has been established as a go-to option.

Masson's tumor of the pineal region: case report

Intracranial intravascular papillary endothelial hyperplasia (IPEH), also referred to as Masson's tumor, is a condition that rarely occurs in the nervous system. IPEH most frequently occurs extracranially in the skin of the face, skull, neck, and trunk and can easily be mistaken clinically, radiologically, and histologically for angiosarcoma, organizing hematoma, or other vascular malformations. IPEH accounts for roughly 2% of all vascular tumors and is extremely rare intracranially, with only 23 reported cases compared with more than 300 cases of IPEH occurring in the skin and subcutaneous tissue. To date, it has never been reported to occur in the pineal region. The authors report the case of a patient with an IPEH in the pineal region who underwent complex resection and experienced reversal of neurological symptoms.

Intracerebral Masson's Tumor-Slow-Filling Vascular Lesion Demonstrated by Indocyanine Green Video Angiography

BACKGROUND

Intravascular papillary endothelial hyperplasia, or Masson's tumors, are benign vascular lesions that are rarely seen intracranially. The vascular characteristics of these lesions are also unknown.

CASE DESCRIPTION

We report the case of a 24-year-old male patient with a 3-year history of headache and dizziness. Neuroradiologic imaging showed a slow-growing lesion consistent with a low-grade glioma. Intraoperative appearance was of a vascular lesion that was slow filling as demonstrated with indocyanine green video angiography. Histologic analysis following resection revealed intravascular papillary endothelial hyperplasia (Masson's tumor).

CONCLUSION

Masson's tumors are slow-filling vascular lesions. The preoperative diagnosis of this lesion is difficult as it can mimic a neoplastic lesion. Conservative and surgical treatment options should therefore be carefully considered. Patients with subtotal resection must undergo long-term follow-up surveillance imaging as recurrence is a possibility.

CNS Masson Tumors: Frequent Association With Therapeutic Radiation

Masson tumor (MT, papillary endothelial hyperplasia) is an exaggerated form of thrombus reorganization rarely occurring in the central nervous system (CNS), where it presents as a mass or hemorrhage in parenchyma, meninges, or venous sinuses. MT is subclassified as type 1 arising within a histologically normal vessel, type 2 associated with a ruptured vascular malformation, and extravascular. Limited reports of CNS MT after radiosurgery, or especially external radiation therapy, have emerged. We searched our databases for cases reported from 2008 to present. Nine cases were identified, 6 of which were associated with receipt of therapeutic radiation for known lesions, with intervals of 1 to 25+ years to MT development (4 neoplasms=external beam radiation; 1 neoplasm=external beam radiation+radiosurgery, 1 arteriovenous malformation=radiosurgery). MTs were coassociated with radiation-induced vascular malformations (1 cavernoma-like, 1 massive) only in 2 of 6 irradiated patients, whereas the other 4 had MTs only. The 3 MTs in nonirradiated patients were extravascular, with 1 spontaneously developing in a hemangioblastoma. Seven of 9 MTs were intracerebral, 1 was within the spinal cord, and 1 was subdural. Papillary MT architecture was best appreciated by CD31 or CD34 immunohistochemistry, although ERG verified the endothelial monolayer population. Most CNS MTs at our institution have arisen in patients who have received therapeutic cranial radiation, many of whom received only external beam radiation. Although MTs could conceivably represent early, severe phases in radiation-induced cavernoma development, most were not found coassociated with the latter. This study further extends our knowledge of types of radiation-induced CNS vascular abnormalities.

Thirteen-year follow-up of parasellar intravascular papillary endothelial hyperplasia successfully treated by surgical excision: case report

Intracranial intravascular papillary endothelial hyperplasia (IPEH) is very rare, and to our knowledge long-term follow-up results have not been previously published. An 11-year-old boy presented with a 6-month history of progressive visual impairment in the right eye. Magnetic resonance imaging revealed a well-enhanced, large parasellar mass involving the cavernous sinus, right frontal skull base, and ethmoid and sphenoid sinuses. Frontotemporal craniotomy and subtotal resection were performed, and the diagnosis of IPEH was confirmed. The mass increased in size during the following 3 months. A second operation was performed via frontotemporal craniotomy combined with a transsphenoidal approach, and gross-total resection of the tumor was achieved. Adjuvant radiotherapy (5040 cGy) and chemotherapy with interferon were administered. The patient's visual symptoms improved, and there was no recurrence during a 13-year follow-up period. The results of this case indicate that intracranial IPEH can recur with subtotal resection; however, optimal resection with multimodal adjuvant treatment can control the disease for many years, if not permanently.

Destructive radiologic development of intravascular papillary endothelial hyperplasia on skull bone

Intravascular papillary endothelial hyperplasia (IPEH) is a rare vascular benign lesion that rarely involves the central nervous system with or without skull invasion. We report a rare case of IPEH on the skull bone, which displayed destructive radiologic development associated with hemorrhage. A 14-year-old male presented with an incidentally detected a small enhancing, left frontal osteolytic lesion. Previously, he underwent operation and received adjuvant chemoradiation therapy for cerebellar medulloblastoma. Follow-up magnetic resonance imaging revealed a left frontal bone lesion, which expanded to an approximately 2 cm-sized well-circumscribed osteolytic lesion associated with hemorrhage for 20 months. Frontal craniectomy and cranioplasty were performed. Destructive change was detected on the inner table and diploic space of the skull. The mass had a cystic feature with hemorrhagic content without dural attachment. Pathologic examination showed the capsule consisted of parallel collagen lamellae representing a vascular wall, vascular lumen, which was pathognomonic for IPEH. Immunohistochemical staining revealed that the capsule was positive for CD34 and factor VIII, which favor the final diagnosis of IPEH. This was the first case of intracalvarial IPEH.

Intracranial Masson tumor: case report and literature review

Intravascular papillary endothelial hyperplasia (IPEH) or Masson tumor has only been reported intracranially in 20 cases and can present as a congenital finding. This pathologic entity is an important diagnostic consideration when evaluating an infant with a congenital intracranial mass. We report a third case of a neonate who presented with the appearance of a metastatic brain tumor involving the orbit, sella, and cerebellum that was ultimately proven to be IPEH. A thorough literature review of IPEH is presented and we discuss this clinical entity and its management.

Extravascular Papillary Endothelial Hyperplasia Mimicking Neoplasm After Radiosurgery

BACKGROUND AND IMPORTANCE:

Papillary endothelial hyperplasia (PEH) is a rare form of exuberant reactive endothelial proliferation that can mimic neoplasm. We report the largest series of patients with histologically confirmed intracranial extravascular PEH developing in the field of previous treatment with stereotactic radiosurgery.

CLINICAL PRESENTATION:

We collected the clinical, radiological, surgical, and pathological findings from 4 patients in whom intracranial extravascular PEH developed after treatment with stereotactic radiosurgery. In all patients, the development of an enlarging hemorrhagic mass lesion at the site of previous radiotherapy on magnetic resonance imaging was radiographically suspicious for neoplasm and prompted biopsy or resection. All 4 patients elected to undergo biopsy or surgical resection. Histological examination of the biopsy and resection specimens in all patients demonstrated the classic features of PEH.

CONCLUSION:

The interval to the development of PEH ranged from 5 months to 6 years, 10 months. Clinical follow-up was available for 3 of the 4 patients. None of these 3 patients have demonstrated evidence of recurrence during a mean follow-up period of 22 months (range, 15–30 months). These patients share common radiological features, potentially allowing preoperative diagnosis and improved guidance of clinical management. These cases suggest a link between radiosurgery and the development of PEH. These findings also suggest that PEH should be considered in the differential diagnosis for patients treated with radiosurgery in whom a hemorrhagic mass lesion subsequently develops at or near the site of previous treatment. We think that complete surgical excision is the best treatment for intracranial PEH.

Papillary endothelial hyperplasia presenting as recurrent malignant glioma

The initial management of patients with malignant gliomas depends on accurate histologic diagnosis which, in turn, directs appropriate treatment planning. However, the diagnosis of recurrent disease is often based solely on radiological data which can occasionally be misinterpreted as showing recurrent tumor. Lack of awareness of conditions that mimic recurrent tumor and potentially confound radiological diagnosis can lead to inappropriate therapeutic decisions. We report the case of a patient whose imaging studies suggested recurrence of malignant glioma; however, surgical resection of the lesion guided by MRI scans resulted in the correct diagnosis of papillary endothelial hyperplasia and led to appropriate management of this condition that mimicked tumor recurrence. In this report, we provide a comprehensive review of this rare entity and emphasize the importance of adequately pursuing appropriate diagnostic considerations prior to making definitive treatment decisions.

Papillary endothelial hyperplasia associated with repeated bleeding

We report a case of intracranial papillary endothelial hyperplasia (PEH) with subsequent haemorrhage and the possible pathogenesis of bleeding. PEH is a slow growing tumour and for rapid enlargement the process of haemorrhage may be necessary.

Intravascular papillary endothelial hyperplasia at the superior orbital fissure: report of a case successfully treated with gamma knife radiosurgery

BACKGROUND

An intracranial lesion of intravascular papillary endothelial hyperplasia (IPEH) is extremely rare and often difficult to resect completely. We describe a case in which a lesion at the superior orbital fissure was successfully treated by postoperative radiosurgery.

CASE DESCRIPTION

A 41-year-old woman presented with progressive left abducens nerve paresis and left facial sensory disturbance over a 1-year period. Radiological examination demonstrated a left middle fossa tumor involved in the cavernous sinus. About a half removal of the tumor was performed. The pathological diagnosis was IPEH. The residual tumor was treated with gamma knife radiosurgery.

CONCLUSION

Gamma knife radiosurgery was effective to reduce the residual tumor in the present case. During a follow-up period of 2 years, the lesion has not recurred. This report suggests that additional gamma knife radiosurgery after incomplete resection of the lesion could be an alternative therapeutic modality.

Intravascular Papillary Endothelial Hyperplasia of the Central Nervous System-Four Case Reports-

Four rare cases of intracranial intravascular papillary endothelial hyperplasia (IPEH) manifesting as cranial nerve disturbances occurred in 16-, 18-, 24-, and 28-year-old females. Magnetic resonance imaging showed all lesions as isointense with strong enhancement on T1-weighted images, and as hyperintense on T2-weighted images. All lesions were removed via craniotomies. Histological examination found vascular structures and papillary spaces lined with endothelial cells showing immunoreactivity for CD31. Complete removal was curative in two cases, whereas incomplete removal resulted in cure in one case and residual deficits in one case. Iatrogenic deficits should be avoided in IPEH treatment by surgery. Differentiation from neoplasm such as angiosarcoma depends on histological characteristics.

Intravascular papillary endothelial hyperplasia arising within a posteroinferior cerebellar artery aneurysm: case report and review of the literature

OBJECTIVE AND IMPORTANCE

Intravascular papillary endothelial hyperplasia (IPEH) is an atypical proliferation of endothelium that results in abnormal organization for thrombus formation. Intracranial IPEH is a rare entity and has not been reported to arise from within an intracranial aneurysm. Furthermore, the elapsed time during which acquired intracranial IPEH develops has not been previously documented.

CLINICAL PRESENTATION

In this case report, a patient with facial and neck pain was noted to have an enhancing mass lesion lateral to the medulla in magnetic resonance imaging scans. Angiography revealed a vascular mass adjacent to the posteroinferior cerebellar artery. Normal magnetic resonance imaging and magnetic resonance angiographic findings had been obtained for the patient 29 months earlier.

INTERVENTION

During surgery, a thrombosed, 2.5-cm, posteroinferior cerebellar artery aneurysm was resected and noted to contain florid IPEH. There has been no evidence of recurrence in 1 year of follow-up monitoring. A literature search revealed 13 cases of intracranial IPEH, in which recurrence was observed for incompletely resected lesions.

CONCLUSION

IPEH can develop in a relatively short time, can present as a hypervascular mass lesion or within an intracranial aneurysm, and should be completely resected to prevent recurrence.

Intravascular papillary endothelial hyperplasia causing cauda equina compression: case report

OBJECTIVE AND IMPORTANCE

Intravascular papillary endothelial hyperplasia (Masson's vegetant hemangioendothelioma) is a rare condition affecting the neuraxis. In the literature, only one case of this lesion involving the vertebral canal with spinal cord compression has been reported. We present a case of cauda equina compression due to this abnormality.

CLINICAL PRESENTATION

A 17-year-old boy was admitted at our hospital with pain, numbness, paresis of the left lower extremity, and bladder dysfunction of approximately 1 month's duration. Computed tomography and magnetic resonance imaging of the spine revealed a tumor within the spinal canal at the T12-L1 level.

INTERVENTION

The patient underwent a T12-L1 laminectomy. An epidural red nodular tumor was visualized and totally resected. The findings of the pathological examination were compatible with intravascular papillary endothelial hyperplasia. At follow-up examination 1 month after the operation, the patient had complete resolution of the pain, and the motor deficit and bladder dysfunction had improved significantly.

CONCLUSION

This rare benign vascular lesion may be clinically and histopathologically mistaken for an angiosarcoma. Because the intravascular papillary endothelial hyperplasia can be cured by complete surgical resection, it is important to distinguish between these two lesions to avoid inappropriate aggressive treatment.

Intracranial papillary endothelial hyperplasia: occurrence of a case after surgery and radiosurgery

Papillary endothelial hyperplasia (PEH) is considered a form of endothelial proliferation rather than a true neoplasm and is usually located in the skin or subcutis. We report a case of intracranial PEH that occurred after surgery for glioma and subsequent radiosurgery. CT and MR revealed an enhancing extra-axial mass located left posterolateral to the brainstem. Intracranial PEH is rare; to our knowledge, development of an intracranial PEH after surgery and radiosurgery has not been previously reported.