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

A Case of Metastatic Choriocarcinoma With Intracerebral Hemorrhage Caused by a Ruptured Pseudoaneurysm

A rare cause of cerebral hemorrhage is the metastasis of choriocarcinoma from gynecology. Herein, we report a case of a patient with brain metastasis of choriocarcinoma with cerebral hemorrhage. A 14-year-old female who had undergone surgery for a hydatidiform molar pregnancy presented with a disturbance of consciousness due to cerebral hemorrhage. Imaging studies revealed the presence of a cerebral aneurysm and several mass lesions in the lung field, and high serum beta-human chorionic gonadotropin level was confirmed. Thus, we suspected cerebral hemorrhage caused by brain metastasis of choriocarcinoma. She went into a coma, and an emergency craniotomy was performed to remove the hematoma and aneurysm. The pathology of the aneurysm was pseudoaneurysm due to the rupture of the vascular wall caused by increasing metastatic cells from choriocarcinoma in the cerebrovascular wall. Therefore, multidrug chemotherapy was immediately initiated. The choriocarcinoma, including the metastatic lesions, is in remission. To improve the outcome of choriocarcinoma, it must be diagnosed early, and treatment should be immediately started. Moreover, neurosurgeons should be aware of such diseases and consider them as one of the differential diagnoses, particularly in females of reproductive age with cerebral hemorrhage.

Non-myxoma neoplastic cerebral aneurysms: A systematic review

Neoplastic cerebral aneurysms (NCAs) are highly rare lesions characterized by invasion of cancerous cells within the wall of an artery leading to aneurysm formation. While NCAs caused by myxomas are well characterized in the clinical literature, rarer etiologies have also been reported and are typically associated worse clinical outcomes. We performed the first PRISMA-compliant systematic literature review of true, non-myxoma neoplastic cerebral aneurysms using the PubMed/MEDLINE, Embase, Scopus, and Google Scholar databases. Data of interest included age, sex, aneurysm size, number of aneurysms, aneurysm location, neoplasm type, aneurysm treatments, cancer treatments, risk of rupture, intracerebral hemorrhage prevalence, subarachnoid hemorrhage prevalence, and survival at 90 and 180 days. A total of 50 studies met our inclusion criteria. The mean age of the patient population was 37.4 years (SD: ±16.8) and had an overall female preponderance (39/50, 78%). Of these NCA cases, 29/50 (58.0%) were choriocarcinomas, 10/50 (20.0%) were related to lung cancer, and 11/50 (22.0%) had other origins of variable pathologies. 90-day survival rates were 60.0% (15/25) for choriocarcinomas, 28.6% (2/7) for the lung cancer group, and 14.3% (1/7) for the other origins group. 180-day survival rates were 52.0% (13/25) for the choriocarcinoma group, 14.3% (1/7) for the lung cancer group, and 0% (0/7) for the other origins group. Prognosis of NCA patients ultimately depends on the course of disease progression and cancer management. Further research is needed to better understand optimal treatment modalities for patients with NCAs.

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.

Intracerebral hemorrhage cause by a ruptured oncotic aneurysm from choriocarcinoma metastasis

Ruptured oncotic aneurysms from choriocarcioma metastasis are very rare. One rare case of metastatic cerebral choriocarcioma with an initial presentation of intracerebral hemorrhage is reported. A 25-year-old woman initially presented with sudden onset of alteration of consciousness. The computed tomography scan showed left parietal hematoma and CT angiography showed a small aneurysm of the left middle cerebral arteries territories. Her chest X-ray showed two lung masses. A craniectomy was performed to remove the hematoma and decompression following the aneurysm excision. After surgery the patient regained consciousness and had no neurological deficit. The pathology reported metastatic choriocarcioma and her beta – HCG was 73,656 units. After recovery she received chemotherapy with an etoposide, methotrexate, actinomycin D, cyclophosphamide, and vincristine/oncovine (EMA-CO) regimen.

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.

Ruptured distal middle cerebral artery aneurysm filled with tumor cells in a patient with intravascular large B-cell lymphoma

The authors describe a very rare case of intravascular large B-cell lymphoma in a woman whose ruptured distal middle cerebral artery (MCA) aneurysms were filled with lymphoma cells. A 69-year-old woman who had undergone artificial graft replacement for an aortic aneurysm presented with transient left hemiparesis. Magnetic resonance imaging demonstrated a small fresh cerebral infarction in the right frontal lobe, although major cervical and cerebral arteries were shown to be intact on MR angiography. Antiplatelet and anticoagulation treatments commenced. On the 21st day after onset, the patient suffered a subarachnoid hemorrhage, and a digital subtraction angiogram revealed aneurysmal lesions in the distal MCA. Based on the histological examination of the resected aneurysms, proliferation of large B-cell lymphoma was identified in the dilated arterial lumen. On the 71st day after ischemic onset, intracranial hemorrhage recurred, and she died. Postmortem examination revealed similar lymphoma cells only in the intimal layer that had grown on the artificial graft, and it was decided that the patient had had intravascular large B-cell lymphoma. The preceding cerebral infarction was thought to be due to occlusion of the distal MCA by tumor embolus, which may be the initial pathological stage in aneurysm formation. For patients with incomprehensible ischemic cerebral stroke, neoplasm must be taken in consideration.

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.

Intracranial aneurysms associated with other lesions, disorders or anatomic variations

Intracranial aneurysms (IAs) can be related to or associated with some vascular anatomic variations, lesions, diseases, or systemic disorders in which a causative or predisposing factor(s) in aneurysm formation can be identified. This article includes flow-related, infectious, traumatic iatrogenic, and neoplastic aneurysms and aneurysms related to systemic disorders and drug abuse. In some conditions, IAs associated with other disorders are true aneurysms. Most of them, however, are false aneurysms. Characteristics and management of these unusual aneurysms are discussed.