Chronic encapsulated intracerebral hematoma--a well-defined disease. Report on two cases and review of the literature

Chronic Encapsulated Intracerebral Hematoma after Carbon Ion Therapy for Chordoma Mimicking Malignant Glioma: A Case Report

Chronic encapsulated intracerebral hematoma is a rare type of intracerebral hemorrhage. Reportedly, it is associated with vascular malformations, including arteriovenous malformations, cavernous hemangiomas, microaneurysms, and venous malformations. Recently, an association between chronic encapsulated intracerebral hematoma and stereotactic radiosurgery for arteriovenous malformations has been reported. In general, as the hematoma enlarges, symptoms progress slowly. In this report, we present a case of a 50-year-old woman who had undergone clivus chordoma resection and carbon ion therapy for the clivus respectively 27 and 20 years before developing chronic encapsulated intracerebral hematoma with rapidly progressing disturbance of consciousness. She was referred to our hospital because of difficulty walking due to left hemiparesis. Head computed tomography and magnetic resonance imaging showed a cystic lesion in the right temporal lobe with perifocal edema. On the second day of hospitalization, the patient's consciousness worsened. We suspected a malignant glioma and performed an emergency craniotomy; however, the pathological diagnosis was chronic encapsulated intracerebral hematoma. After the rehabilitation therapy, the patient became ambulatory and was discharged. To the date of reporting, the patient remained recurrence-free. Chronic encapsulated intracerebral hematoma may be due to invasive craniotomy or carbon ion therapy. It usually progresses slowly; however, in some cases, such as this one, it may cause rapid deterioration of consciousness.

Chronic encapsulated intracerebral hematomas: a systematic review

BACKGROUND

Chronic encapsulated intracerebral hematoma (CEICH) is a rare type of intracerebral hematoma (ICH) with peculiar radiological features and presenting as subtle slow-growing lesion exerting mass effect. We performed a systematic review of the literature focused on diagnosis and management of patients affected by CEICH.

MATERIAL AND METHODS

A literature search according to the PRISMA statement was conducted using PubMed and Scopus databases and pertinent Mesh terms. All papers that reported intraventricular CEICH, or CEICH cases treated conservatively or by CT-guided needle aspiration were not included in this study. A total of 40 papers were included in this review, with 58 patients (38 males and 20 females) and a mean age of 41.44 ± 20.05 years (range 1-80).

RESULTS

Neurological symptoms of onset include those related to an increase in intracranial pressure (ICP) in 28/58 cases (48.2%), seizures in 17/58 cases (29.3%), motor deficits in 14/58 cases (24.1%). The most frequent localization is atypical in 45/58 cases (77.6%). Surgical approach is not specified in 21/58 cases (36.2%), craniotomy was performed in 31/58 cases (53.4%), craniectomy in 5/58 cases (8.6%) and only in one case (1.7%) an endoscopic approach was performed. CEICH are usually located in an atypical site.

CONCLUSIONS

There is not an association with anticoagulants and antiplatelets intake. Arteriovenous malformation is the most frequent cause. Surgery is suggested, and craniotomy is the most used approach even if further investigation should be directed to analyze the efficacy of endoscopic approach of these lesions, which may show favorable outcome.

A Case of Bilateral Cerebellar Chronic Encapsulated Intracerebral Hematoma with Rapidly Progressive Symptoms

Chronic encapsulated intracerebral hematoma (CEIH) is a rare cerebrovascular disease featuring progressively expanding intracranial hematoma. We treated a man in his 70s with bilateral cerebellar CEIH. He had presented at another hospital with dizziness, and imaging showed two independent hemorrhagic space-occupying lesions in the bilateral cerebellar hemispheres. The symptoms progressed relatively rapidly, and there were signs of impending cerebellar herniation; he was transferred to our institution, and emergency surgery was performed. The operative findings included a hematoma with partial capsulation. We diagnosed CEIH from preoperative magnetic resonance imaging and computed tomography findings, clinical course, and pathological findings. The postoperative course was satisfactory. We present this case of bilateral cerebellar CEIH, as an extensive search of the literature suggests that this has not been reported before. Although CEIH is a condition that is usually hard to diagnose preoperatively, good outcomes can be achieved with appropriate surgical treatment. It is therefore important to keep this clinical entity in mind and not miss the right timing to operate.

Chronic Encapsulated Intracerebral Hematoma as an Occasional Finding in Sudden Cardiac Death

Chronic encapsulated intracerebral hematoma (CEIH) is a rare solid mass characterized by the presence of a fibrotic capsule that can present a variety of signs and symptoms due to the mass effect and hydrocephalus. It may be caused by post-traumatic or spontaneous bleeding as related to an adjacent aneurysm, angiomas or neoplasms. Differential diagnosis must be applied in order for it to mimic neoplasm or a vascular malformation. Several cases of CEIH have been reported but only a few of them have an intraventricular localization. A forensic autopsy of a 50-year-old male who died suddenly while driving is discussed. Gross analysis, histology and toxicology were performed and a CEIH of the right lateral ventricle was found in a case of acute coronary death.

Septum Pellucidum Chronic Encapsulated Hematoma With Osseous Metaplasia Mimicking Recurrent Astrocytoma and Shunt-Related Foreign Body Granuloma

We present a very rare case of chronic encapsulated intracerebral hematoma involving the septum pellucidum and the foramen of Monro that by location radiological appearance, and clinical history was mimicking a recurrent astrocytoma or a shunt-related foreign body granuloma.

A young adult underwent the resection of a juvenile pilocytic astrocytoma as a child, and with a mass encasing the tip of an old non-functioning ventricular catheter, the differential diagnosis of shunt-related foreign body granuloma versus recurrent low-grade glioma was raised. Although chronic encapsulated intracerebral hematomas have been reported in the literature, the anatomical location of the lesion in the presented case was unique, with radiological and history findings also posing a peculiar diagnostic challenge. Chronic encapsulated intracerebral hematomas are benign entities that may also be found to involve deep and midline supra-tentorial structures usually not prone to spontaneous intraparenchymal hemorrhages. When symptomatic, surgical resection of the hematoma can be both diagnostic and curative.

Chronic encapsulated expanding hematoma after stereotactic radiosurgery of cerebral arteriovenous malformation

Stereotactic radiosurgery has become excellent alternative treatment for cerebral arteriovenous malformations (AVM). This technique has expanded to treatment of larger AVM which is not amenable to surgical management. However, its variable adverse effects should be also taken into considerations sincerely because of radiobiological characteristics such as delayed onset and progressive neurological deteriorations. Herein, we report a case in which progressively expanding hemorrhagic cyst with repeated bleedings so called chronic encapsulated expanding hematoma was developed on several years after radiosurgery treatment. Neurological and radiological findings were improved by surgical removal.

The Role of Neurosurgery in the Treatment of Intracranial Tumor-Like Inflammatory Lesions

BACKGROUND

Different inflammatory diseases can manifest as intracranial lesions. They may be indistinguishable from intracranial neoplasms in the clinical setting, imaging studies, or laboratory studies. The value of surgery in the diagnosis and the treatment of such lesions is still unclear.

METHODS

A total of 3066 reports of histopathologic examinations over a 10-year period were reviewed. Forty patients with an inflammatory intracranial lesion were identified. Clinical, radiologic, and follow-up data were analyzed and the diagnostic and therapeutic value of surgery was assessed.

RESULTS

We identified 24 women and 16 men (mean age, 47 years). The diameter of the lesion varied between 1 and 5.5 cm (mean, 2.6 cm). The location of the inflammatory lesion was intracerebral supratentorial (n = 18, 45%), intrasellar/suprasellar (n = 5, 12.5%), cerebellar (n = 5, 12.5%), in the brainstem (n = 4, 10%), in the cerebellopontine angle (n = 3, 7.5%), meningeal (n = 3, 7.5%), and at other locations (n = 6, 15%). Seventeen patients underwent surgical removal of the mass lesion, whereas in 23 patients a biopsy was taken. The lesions were classified into 7 groups: specific (infectious) granuloma (n = 10, 25%), unspecific granuloma (n = 7, 17.5%), idiopathic inflammatory pseudotumor (n = 5, 12.5%), demyelinating lesions (n = 5, 12.5%) encapsulated hematoma (n = 4, 10%), organized cerebral infarction (n = 3, 7.5%), and vasculitis (n = 4, 10%). Surgery was judged as valuable in 35 patients (87.5%).

CONCLUSIONS

The differential diagnosis of intracranial inflammatory lesions involves a wide spectrum. Surgery has a diagnostic and/or therapeutic value in most entities and clinical circumstances. However, attention must be taken to avoid surgery without a therapeutic or diagnostic value for the patient.

Chronic encapsulated intraventricular hematoma in a pediatric patient: case report

Chronic encapsulated intraventricular hematoma (CEIVH) is a rare, intraventricular, nonneoplastic mass lesion that can become symptomatic from mass effect or obstructive hydrocephalus. Only 5 cases have been reported in the literature, and only one of these occurred in a pediatric patient and dates back to the pre-modern neuroimaging and pre-microsurgical era of neurosurgery. Imaging features can mimic those of many more common intraventricular lesions, such as choroid plexus tumors or cavernous malformations. In all reported symptomatic cases, resection was safely performed and led to a cure and symptom resolution. Here, the authors present a case of CEIVH in a pediatric patient, describe the operative techniques of resection, review the available literature, and discuss current understanding of the pathophysiology, making this the most comprehensive report on this disease entity to date. The case is a 14-year-old boy who presented with headaches and emesis. Computed tomography showed a hyperdense mass in the trigone of the right lateral ventricle. Magnetic resonance imaging showed a contrast-enhancing well-circumscribed mass. Right temporal craniotomy utilizing a posterior middle temporal gyrus transcortical approach was performed, and gross-total resection was achieved. Pathology revealed a CEIVH. The boy's postoperative course was uncomplicated, and he was discharged 2 days after surgery.

Frequency and Predicting Factors on Chronic Expanding Intracerebral Hematoma in Spontaneous Intracerebral Hemorrhage

BACKGROUND

Chronic expanding intracerebral hematoma is a well-known complication of spontaneous intracerebral hemorrhage. However, because chronic expanding intracerebral hematoma is relatively rare, it has not been studied systemically. The purpose of this study was to characterize a patient population with chronic expanding intracerebral hematoma, and to identify the predictive factors for it.

METHODS

We retrospectively evaluated 112 patients with spontaneous putaminal hemorrhage who were treated at our institution between January 1, 2010 and December 31, 2015. Data on age, sex, Glasgow Coma Scale score, presence of intraventricular hemorrhage, and intracerebral hemorrhage volume were collected, and their predictive values for chronic expanding intracerebral hematoma were investigated. We also evaluated the predictive value of a characteristic radiological finding at onset called the "layer sign," which was represented as a fluid level adjacent to the clot.

RESULTS

Chronic expanding intracerebral hematoma was observed in 4 patients (4.9%) with spontaneous intracerebral hemorrhage. Only the layer sign was significantly related to chronic expanding intracerebral hematoma (P = .003), and was found to be independently associated with chronic expanding intracerebral hematoma in a multivariate analysis (odds ratio, 18.6; 95% confidence interval, 1.19-291.0; P = .037).

CONCLUSIONS

The frequency of chronic expanding intracerebral hematoma in those with spontaneous intracerebral hemorrhage was estimated at 4.9%. The layer sign was a useful factor for predicting chronic expanding intracerebral hematoma.

Twenty-Year Follow-up of Chronic Encapsulated Intracerebral Hematoma

This is the first case report of a patient with chronic encapsulated intracerebral hematoma who developed excessive perifocal edema and symptoms 20 years after his initial diagnosis.

Progressing haemorrhagic stroke: categories, causes, mechanisms and managements

Haemorrhagic stroke is a severe stroke subtype with high rates of morbidity and mortality. Although this condition has been recognised for a long time, the progressing haemorrhagic stroke has not received adequate attention, and it accounts for an even worse clinical outcome than the nonprogressing types of haemorrhagic stroke. In this review article, we categorised the progressing haemorrhagic stroke into acute progressing haemorrhagic stroke, subacute haemorrhagic stroke, and chronic progressing haemorrhagic stroke. Haematoma expansion, intraventricular haemorrhage, perihaematomal oedema, and inflammation, can all cause an acute progression of haemorrhagic stroke. Specific 'second peak' of perihaematomal oedema after intracerebral haemorrhage and 'tension haematoma' are the primary causes of subacute progression. For the chronic progressing haemorrhagic stroke, the occult vascular malformations, trauma, or radiologic brain surgeries can all cause a slowly expanding encapsulated haematoma. The mechanisms to each type of progressing haemorrhagic stroke is different, and the management of these three subtypes differs according to their causes and mechanisms. Conservative treatments are primarily considered in the acute progressing haemorrhagic stroke, whereas surgery is considered in the remaining two types.

Chronic encapsulated intracerebral hematoma: Three case reports and a literature review

Background:

Chronic encapsulated intracerebral hematoma (CEIH) is one type of intracerebral hematoma that sometimes grows progressively while forming a capsule and presenting with neurological deficits. Although many cases of CEIH have been reported, correct preoperative diagnosis is very difficult. Only around 20% of cases are diagnosed preoperatively.

Case Description:

We encountered three cases of CEIH in which causes were unidentified and difficult to diagnose. All three cases were treated surgically. In the first case, a 59-year-old male was diagnosed preoperatively with metastatic brain tumor. In the second case, a 62-year-old female was diagnosed preoperatively with glioblastoma. The third case involved a 58-year-old female diagnosed preoperatively with CEIH.

Conclusion:

We should keep in mind that CEIH is a differential diagnosis for intracerebral space-occupying lesions. This report describes these three cases and discusses imaging findings and characteristics of CEIH.

Clinicopathological study on chronic encapsulated expanding hematoma associated with incompletely obliterated AVM after stereotactic radiosurgery

BACKGROUND

Chronic encapsulated expanding hematoma is a rare, but highly morbid, severe complication after stereotactic radiosurgery for intracerebral arteriovenous malformations (AVMs). The aim of this study was to clarify the clinical features and possible mechanisms of formation and expansion of this type of hematoma based on histopathological findings.

METHODS

The patients were comprised of three males and one female. Three of these patients had AVMs in the basal ganglia, while the remaining one in the frontal lobe.

RESULTS

Cerebral angiograms performed 6 months to 11 years after radiosurgery demonstrated major, but incomplete, obliteration of the nidi. Each patient developed localized enhancing mass lesions at 2, 3, 5, and 11 years after radiosurgery. The lesions expanded slowly, but progressively over time in association with marked perifocal edema. The perifocal edema disappeared immediately after removal of the hematoma; their neurological symptoms improved partially or completely. Histopathologically, the hematomas were well-encapsulated and the capsule walls uniformly consisted of an outer fibrocollagenous layer and an inner granulation layer. Immunohistochemistry revealed vascular endothelial growth factor (VEGF) expression in the endothelium of newly formed blood vessels and myofibroblasts in the hematoma capsule inner layer. Myofibroblasts also expressed VEGFR-1.

CONCLUSIONS

The activation of VEGF pathway may lead to neovascularization in the granulation layer of the hematoma capsule that serves as a continual source of bleeding and perifocal edema. Thus, radical resection of the capsule and residual nidus is strongly recommended for the management of both bleeding and edema.

Chronic encapsulated intracerebral hematoma associated with cavernous angioma--case report

An 80-year-old male presented with a chronic encapsulated intracerebral hematoma (CEIH) with surrounding edema under the right frontal lobe manifesting as slow exacerbation of disturbance of orientation and gait. He had a history of cerebral infarction with an asymptomatic cavernous angioma in the right frontal lobe. The CEIH was diagnosed as bleeding from the cavernous angioma, and surgical removal was performed. The hematoma was chronic and covered by a thick capsule. In addition, mass tissue covered with the organized hematoma was found near the capsule, which was excised and found to be a cavernous angioma. CEIH is a special type of intracerebral hemorrhage, and bleeding from a cavernous angioma is occasionally seen. CEIH should be considered in the case of a hemorrhagic intracranial lesion with a chronic, progressive course with capsule formation and edema around the lesion. The source of bleeding is unknown in about half of the reported cases, and occult vascular malformation may be involved, necessitating care in diagnosis.

Chronic Intraventricular Encapsulated Hematoma in an Adult: A Case Report

This case report is a presentation of a chronic intraventricular encapsulated hematoma in an adult who presented with gait disturbance, fever, palsy of N. III, N. VI and N. VII, and photophobia. Ophthalmoscopy revealed a bilateral papilledema. Computed tomography scans and magnetic resonance imaging revealed an intraventricular mass in the lateral ventricle. Preoperative diagnosis could not rule out a neoplasm. The lesion was totally removed with open surgery and was found to be a chronic intraventricular encapsulated hematoma. A chronic intraventricular encapsulated hematoma is a rare entity. After the removal of the mass, the clinical symptoms of the patient gradually resolved.

Chronic encapsulated intracerebral haematoma

We report a rare chronic encapsulated intracerebral haematoma (CEICH). A 52-year-old man had two seizures. Unenhanced computed tomography scanning of the head revealed a hypodense tumour with clusters of calcification in the left temporal lobe. Magnetic resonance imaging of the brain showed a left temporal tumour with a hypointense centre and hyperintense periphery on T(1)-weighted imaging and heterogeneous hypointensity on T(2)-weighted imaging. The tumour was heterogeneously enhanced after gadolinium injection. Craniotomy was carried out and a CEICH in the left temporal lobe was completely excised. No vascular anomaly was found. The tumour was histologically confirmed to be a CEICH. The patient recovered well after the operation. In this report, we describe this rare case and discuss the characteristics of CEICH.

Ruptured chronic encapsulated intracerebral hematoma in infancy: review of the literature with a case report

OBJECTIVES

We report a case of a 2-month-old boy with chronic encapsulated intracerebral hematoma (EICH) and discuss clinical, radiological and pathological features of the case.

CONCLUSIONS

Chronic EICH in infants is extremely rare in the literature. Only two cases have been previously reported. One of the cases reported in the literature was supratentorial and the other was infratentorial.

Chronic intraventricular encapsulated hematoma presenting unique radiological features: a case report

BACKGROUND

Chronic encapsulated hematoma is relatively rare and the exact mechanisms of this condition remain uncertain. In this report, we present a case of chronic encapsulated hematoma in the lateral ventricle and discuss the pathophysiology of this condition.

CASE DESCRIPTION

A 68-year-old-woman presented with progressive gait disturbance. Magnetic resonance imaging (MRI) showed a dumbbell-shaped mass arising from the wall of the right lateral ventricle. The mass connecting to the ventricle wall mimicked a hemorrhagic tumor and the other part mimicked a cystic mass. Cerebral angiography demonstrated arteriovenous shunt in the right lateral ventricle wall. The operative findings revealed that the part arising from the ventricle wall contained hematoma showing various stages of coagulation and that the cystic mass visible on MRI was a granulomatous solid mass. Histologic examination revealed that the capsules of both were compatible with chronic encapsulated intracerebral hematomas.

CONCLUSION

In the present case, one part of the mass contained only granulomatous tissue, indicating the possibility that the mass was undergoing spontaneous resolution. This fact might indicate that the presence of neo-vascularization in the capsule is not the sole factor in the expansion of hematoma.