Intracranial metastases from unsuspected choriocarcinoma. Onset suggestive of cerebrovascular disease

Neoplastic cerebral aneurysm from metastatic tumor: a systematic review of clinical and treatment characteristics

OBJECTIVE

Neoplastic cerebral aneurysm (NCA) is a very rare event. The authors aimed to characterize the clinical and treatment details of this poorly defined entity.

MATERIALS AND METHODS

A computerized systematic literature search was performed in PubMed, Medline, Web of Science, Cochrane Library, Embase, Google Scholar, Science Direct and Scopus. Keywords used were as follows: "aneurysm"; "myxoma"; "choriocarcinoma"; "oncotic aneurysm"; "neoplastic aneurysm". Only reports with cerebral aneurysm resulting from metastatic tumor and contained adequate clinical information pertinent to the analysis were included. Clinical and treatment characteristics were analyzed.

RESULTS

Ninety-two studies reporting 96 cases of neoplastic cerebral aneurysm were identified. NCA from cardiac myxoma accounted for 60.4%, while NCA from choriocarcinoma and other tumors accounted for 26.1% and 13.5%, respectively. The rates of intracranial hemorrhages were 19.6% in NCA from myxoma, 100% in NCA from choriocarcinoma, and 84.6% in NCA from other tumors. 75.9% of NCA from myxoma were managed conservatively, 92% of NCA from choriocarcinoma were treated by surgery and/or chemotherapy, and 69.2% of NCA from other tumors were treated by surgery with or without chemotherapy. The mortality rates were 11.4% in NCA from myxoma, 60.9% in NCA from choriocarcinoma, and 92.3% in NCA from other tumors. According to a multiple logistic regression model, "pathology (P = 0.002)" is significantly correlated with outcome.

CONCLUSIONS

Neoplastic cerebral aneurysms are usually complicated with cardiac myxoma, choriocarcinoma and lung carcinoma. NCA from cardiac myxoma were probably multiple and rarely associated with intracranial hemorrhage, while the majority of NCA from choriocarcinoma and other tumors were single and presented with intracranial hemorrhage. The prognosis is quite good in NCA from cardiac myxoma, while NCA from malignant tumors were associated with poor outcome.

Ruptured cerebral oncotic aneurysm from choriocarcinoma: report of two cases and review of the literature

The study design involved case reports and review of the literature. Oncotic aneurysm from choriocarcinoma is an extremely rare event that should be known by all neurosurgeons and suspected in women of childbearing age. The purpose of this article is to report the authors' experience and to provide insight on clinical presentation and radiological signs to aware the reader to this entity and then to prevent misdiagnosis. The authors report two cases of ruptured oncotic aneurysm treated at their institution in 2010. A review of the literature was performed to discuss the pathogenesis and the role of the neurosurgeon. Chemotherapy is the treatment of choice making surgery necessary only for patients with large intracerebral haematoma that represents an immediate threat.

Intracerebral hemorrhage as initial presentation of gestational choriocarcinoma: a case report and literature review

Choriocarcinoma is the most malignant tumor of gestational trophoblastic neoplasia. It grows rapidly and metastasizes to the lung, liver, and, less frequently, to the brain. One rare case of metastatic cerebral choriocarcinoma with initial presentation of intracerebral hemorrhage is reported. A 40-year-old woman initially presented sudden onset of headache. Intracerebral hemorrhage resulting from ruptured pseudoaneurysm was suspected. Emergent surgery with excision of the pseudoaneurysms was performed. Metastatic choriocarcinoma was accidentally found with positive immunohistochemical staining of cytokeratin and β subunit of human chorionic gonadotropin (β-HCG). Choriocarcinoma with brain metastases was diagnosed. She then received chemotherapy with regimen of etoposide, methotrexate, actinomycin-D, cyclophosphamide, and vincristine (EMACO). Elevated serum β-HCG (30.3 mIU/mL) and new pulmonary lesions were noted by computed tomography 4 months after completion of EMACO. Salvage chemotherapy with etoposide, methotrexate, actinomycin-D, etoposide, and cisplatin (EMAEP) regimen was given. Seven months later after completion of EMAEP, two new pulmonary lesions were detected by positron emission tomography (PET) scan. So she received video-assisted thoracoscopic surgery with tumor excision. Pathologic report confirmed the diagnosis of lung metastases. The patient recovered well. She is free of disease for 12 months. The diagnosis of metastatic cerebral choriocarcinoma was only made by histopathology after craniotomy. Metastatic choriocarcinoma should be always in the differential diagnosis for women at childbearing age presenting with unexplained stroke-like symptoms. In addition, PET scan may be valuable in detecting occult metastatic lesions of choriocarcinoma.

Multiple brain metastases from adenoid cystic carcinoma of the parotid gland. Case report and review of the literature

BACKGROUND

Adenoid cystic carcinoma is a slow-growing malignant tumor occurring in the head and neck. Intracranial involvement usually results from direct skull invasion from adjacent primary sites. To our knowledge, this is the first reported case of multiple brain parenchymal metastases manifesting with hemorrhage.

CASE DESCRIPTION

A 60-year-old male experienced sudden onset of hemiparesis caused by an intracerebral hematoma in a brain metastasis from adenoid cystic carcinoma. The primary parotid tumor was treated 15 months before the appearance of the brain metastases. The hemorrhagic metastasis was resected, and cranial irradiation was performed. The brain metastasis had increased cellular atypism compared with the primary tumor. The patient remained well and free of neurologic dysfunctions until 5 months after the radiotherapy was completed; he died of systemically advanced disease 8 months after the craniotomy.

CONCLUSION

Hematogeneous brain metastases of adenoid cystic carcinoma are quite rare and cannot be distinguished from those of other cancers radiologically. We assume that the intratumoral hemorrhage is related to the tendency of the tumor to spread around the vessels. Although radiation therapy is not curative, it is beneficial in controlling tumor regrowth.

Vestibular schwannoma with repeated intratumoral hemorrhage

A symptomatic hemorrhage from a vestibular schwannoma is extremely rare, despite its relatively high incidence in the cerebellopontine angle. Much more unusual are repeated intratumoral hemorrhages. The authors report on such a rare case of repeated intratumoral hemorrhage from a vestibular schwannoma, presenting with sudden exacerbation of headache, nausea and vomiting. This second hemorrhage was confirmed by CT scan on the day of the onset of symptomatic exacerbation, which was 9 days after the initial CT scan, showing an enlarged amount of blood within the tumor. The MRI scan confirmed this CT finding. After removal, the tumor proved to be a typical vestibular schwannoma of mixed Antoni types A and B. Thin-dilated vessels with hemorrhage and hemosiderin-laden macrophages were observed. The patient's postoperative course was uneventful. A total of 28 reported cases of a single intratumoral hemorrhage in vestibular schwannomas, and one reported case of repeated hemorrhage are reviewed.

Clinical and radiological pictures of hepatocellular carcinoma with intracranial metastasis

Hepatocellular carcinoma (HCC) with extrahepatic spreading is not uncommon. In order to delineate the clinical and radiological pictures of HCC with intracranial metastasis, 33 documented cases were analysed. Eighteen had brain parenchymal metastasis without skull involvement; the other 15 cases disclosed skull metastasis with brain invasion. The underlying HCC are mainly of expanding (13/33, 39.4%) and multifocal (13/33, 39.4%) types. Eighteen cases (18/33, 54.5%) had mental changes not related to hypoglycaemia or hepatic encephalopathy. Eighteen cases (18/20, 90%) disclosed hyperdense mass lesions by non-contrast computed tomography (CT) scans and 17 cases showed homogeneous enhancement (17/22, 77.3%) by post-contrast CT images. In the non-skull involved group, five cases (5/12, 41.7%) disclosed ring-shape enhancement and 14 cases (14/16, 87.5%) had perifocal oedema, which were not seen in the skull involved group. Eight cases (8/33, 24.2%) presented as intracerebral haemorrhage. Twelve (12/33, 36.4%) died of brain herniation. Most (14/18, 77.8%) non-skull involved cases had simultaneous lung metastasis without bony metastasis, while the skull involved group often (10/15, 66.7%) disclosed extracranial bony metastasis without lung metastasis. The difference in extracranial metastasis was statistically significant (P < 0.05). The multivariate survival analysis disclosed that lower lactate dehydrogenase level (< or = 316 U/L, P = 0.029) and treatments (surgery or radiation, P = 0.001) were positively associated with longer survival. In conclusion, HCC with intracranial metastasis is symptomatic and life-threatening. Half the cases may come from pulmonary metastasis and the other half may be from bony metastasis. Brain irradiation or surgery can prolong their survival.

Metastatic choriocarcinoma with neoplastic aneurysms cured by aneurysm resection and chemotherapy. Case report

A case of choriocarcinoma with brain and lung metastasis is reported. The patient was admitted for treatment of a cerebral hemorrhage from neoplastic aneurysms and, following removal of the hematoma and resection of the aneurysms, her carcinoma was successfully managed with chemotherapy. She has survived for 6 years after onset without neuroimaging evidence of recurrence. Surgical treatment of metastatic lesions followed by prolonged intensive chemotherapy are indicated for the improved prognosis of choriocarcinoma.

Intracranial oncotic aneurysms from choriocarcinoma. Case report and review of the literature

Intracranial oncotic aneurysms are very rare. Only twelve reported cases were from choriocarcinoma. We present a new case with two aneurysms disappearing after chemotherapy, the second in the literature but the first case with persistence of all arteries.

A ruptured cerebral aneurysm from choriocarcinomatous origin--a case report and a review

A case of a ruptured metastatic aneurysm of choriocarcinoma is reported. The fourteen other cases of the literature are summarized. The pathological significance of this rare presentation of metastatic disease is discussed. The treatment of choice is defined as excision followed by chemotherapy and whole brain irradiation. The prognosis remains poor.

Hemorrhage: a complication of metastatic testicular choriocarcinoma

Patients with choriocarcinoma are at risk for hemorrhage. The majority of reported cases have occurred in patients with gestational trophoblastic disease. Although choriocarcinoma in the male is a less common entity, a similar tendency exists. In 3 male patients at Memorial Sloan-Kettering Cancer Center hemorrhage developed as a direct consequence of metastatic choriocarcinoma. The blood loss was massive and resulted in the death of 2 patients. Hemorrhage occurred in two distinct settings: immediately after chemotherapy and in patients with rapidly progressive advanced disease. Early recognition and vigorous support were critical in patient management. Surgical excision of bleeding metastases may be beneficial in selected instances.

Choriocarcinoma with brain metastases. Successful management of increased intracranial pressure with barbiturates

Choriocarcinoma is a potentially curable neoplasm. Although the presence of intracranial metastases worsens the ultimate prognosis, several reports have shown successful response to therapy. This clinical report outlines a method by which the appropriate therapy may be initiated in a patient with intracranial metastases, who otherwise may not have survived the interval necessary for the induction of successful therapy.

Neoplastic cerebral aneurysm from metastatic gestational choriocarcinoma. Case report

This case of metastatic gestational choriocarcinoma presented as intracerebral hemorrhage from an atypical distal middle cerebral artery aneurysm. Operative evacuation of the intracerebral hematoma was undertaken and histopathological examination revealed choriocarcinoma invading the vessel wall. Neoplastic cerebral aneurysms are unusual, being reported in metastatic choriocarcinoma, cardiac myxoma, bronchogenic carcinoma, and undifferentiated carcinoma. Metastatic choriocarcinoma should be considered in the differential diagnosis of intracerebral hemorrhage in women of child-bearing age. Recent advances in treatment have resulted in a 75% cure rate for metastatic choriocarcinoma.

Cerebral hemorrhage from unsuspected choriocarcinoma

A patient is presented who developed a frontal intracerebral hemorrhage, which proved to be due to a metastasis of a choriocarcinoma. The patient's uterus and adnexa had been removed two years previously for a non-malignant disorder. two years previously for a non-malignant disorder. The authors stress the importance of cytological examination of the bloody fluid on evacuation of a hematoma.

Brain hemorrhage from intracranial tumor

Brain hemorrhage from an intracranial tumor was encountered in 7 males and 6 females during a 4-year period. In 5 patients, hemorrhage was responsible for the first signs of a previously unsuspected neoplasm. The intracranial lesion was demonstrated by computed tomography (CT scanning) in each patient. Characteristic CT scan findings included: a neoplastic core (high or low density); small, multifocal clots usually at the margin of the tumor; and, surrounding, often extensive, edema. Enhancement of the tumor tissue with intravenous injection of 60% Hypaque was observed in the 8 patients so studied. The regions which were enhanced had a peripheral distribution corresponding to the site of hemorrhage. Microscopic examination demonstrated 7 glioblastoma multiforme, 1 oligodendroglioma, 4 metastatic carcinomas (including 1 each of bronchogenic carcinoma, melanoma, hypernephroma, and adrenal carcinoma), and 1 hemangiopericytoma. High-grade malignancy and extensive, abnormal vascularity appeared to be predisposing factors.

The neuropathology of stroke

Vascular-circulatory derangements affecting the function of the central nervous system may result in parenchymal lesions that are hemorrhagic, ischemic, or mixed. Most nontraumatic intraparenchymal brain hemorrhages are found in asssociation with cerebral arteriolar sclerosis and other stigmata of hypertensive disease, such as hypertrophy of the left cardiac ventricle and granular kidneys. Global temporary ischemia, the type that exists during severe and transient hypotension, results in a wide variety of parenchymal lesions that may be bilateral, hypotension, results in a wide variety of parenchymal lesions that may be bilateral, unilateral, supratenorial, or infratentorial. The cerebral and cerebellar cortices, white matter, basal ganglia, brain stem, and spinal cord may be involved simulatenously or there may be isolated, focal lesions that are confined occasionally to any one of these areas. Regions ischemia, the type induced through the occlusion of a major intracranial artery, evolves through a stage of acute encephalomalacia, during which the morphologic change consists of alternating cellular swelling and shrinkage. This is followed by leukocytic inflammation at three to four days and the beginning of resolution at about the tenth day after arterial occlusion. In the evolution of this form of abnormal circulation, after a few minutes, some neurons in the most distal arterial territories show the first recognizable changes. In these neurons the mitochondria swell massively. Astrocytes and neurites in the same foci are selectively swollen, whereas oligodendrocytes and capillaries remain structurally unchanged during the initial stages of ischemic injury.