Successful Preoperative Endovascular Embolization of an Extreme Hypervascular Glioblastoma Mimicking an Arteriovenous Malformation

Glioblastoma Presenting as Spontaneous Subarachnoid Hemorrhage: Technical Case Note of Combined Endovascular and Microsurgical Vision-Sparing Treatment

BACKGROUND

Clinical utility of endovascular adjunct for tumor resection is well established, but its role in acute subarachnoid hemorrhage secondary to neoplastic pseudoaneurysm rupture has not been reported.

CASE DESCRIPTION

We discuss a 46-year-old patient presenting with a World Federation of Neurological Surgeons grade 1 subarachnoid hemorrhage from a ruptured posterior cerebral artery pseudoaneurysm due to glioblastoma tumor invasion.

CONCLUSIONS

A combined targeted endovascular embolization with microsurgical resection to spare the calcarine artery was used to avoid disruption to the optic radiation fiber pathway.

Glioblastoma Multiforme Associated with Arteriovenous Malformation: A Case Report and Literature Review

Although microvascular proliferation can be observed in glioblastoma, obvious vascularity coupled with coexisting cerebral arteriovenous malformation (AVM) is extremely rare. This report is of a rare case of glioblastoma, coexisting with a cerebral AVM. A 20-year-old male presented with progressive right hemiparesis within 1 month. Cranial magnetic resonance imaging revealed a large bleeding tumor with surrounding dilated vessels. Cerebral angiography demonstrated a left frontal AVM with a 1.2 cm nidus. The patient underwent preoperative embolization and radical resection. The coincidence of glioma and AVM was a rare association. However, the concept of hypervascular glioblastoma has been used in different states from different literature reviews; therefore, the role of proangiogenic factors should be addressed

Complete resection of hypervascularised extraventricular neurocytoma after preoperative embolisation

A 13-year-old female arrived at the Emergency Department with a two-week history of headache, and bilateral papilloedema on examination. The initial study with CT and MRI showed a large multicystic left frontal mass with calcification surrounded by peripheral oedema, subacute intralesional bleeding and association of multiple large vessels. She was initially operated on in another centre where a subacute haematoma was found, evacuating to multiple vessels and arteriolised veins. Despite the earlier neuroimaging findings, arteriovenous malformation (AVM) was suspected, so she was referred to our centre for further treatment. We performed angiography, MR angiography and MRI with advanced sequences, diagnosing a highly vascularised intra-axial tumour which was embolised. The patient was then definitively operated on, with the resulting finding of extraventricular neurocytoma (EVN). EVN are extremely rare lesions, not previously described in the literature as hypervascularised lesions, which in our case required prior angiography and embolisation for proper diagnosis and adequate management.

Brain angiometastasis from a non-seminomatous germ cell tumor: A case report

•

Brain metastasis from non-seminomatous germ cell tumors (NSGCTs) are rare.

•

Brain metastasis from an NSGCT with high-flow AV shunting are uncommon.

•

The term angiometastasis corresponding to formation of the brain metastasis from an NSGCT with numerous AV shunts.

Introduction

Brain metastasis from non-seminomatous germ cell tumors (NSGCT) is rare. Herein, we describe the second reported case of brain metastasis from a NSGCT with high-flow arteriovenous (AV) shunts, and propose a novel surgical treatment plan.

Clinical case

The patient was a 34-year-old male who presented with hemiparesis and hemianesthesia. Magnetic resonance angiography revealed three vascular lesions with afferent vessels and efferent vessels. Angiography displayed two high-flow AV shunts. During angiography, the patient experienced sudden neurological deterioration and consequently underwent surgery. During surgery, a lesion with large AV shunts was observed, with arterialized drainage veins, pedicled arterial vessels affluent to the nidus, and an absent pial plane. The surgical technique was adapted to lesion morphology using special bipolar forceps. Histological and immunohistochemical tests confirmed that the lesion was a NSGCT.

Discussion

NSGCTs are clinically more aggressive than seminomas. Lesions with an AV shunt and glioma combination are designated as angiogliomas. Therefore, we termed the lesion in the present case as an “angiometastasis,” which was formed from numerous AV shunts. The use of presurgical embolization has been reported to improve long-term survival in patients with intra-axial hypervascular tumors with AV shunts.

Conclusion

We here propose a novel strategy for the management of hypervascular brain metastasis from NSGC, consisting of angiography, tumor embolization, and the use of an angiometastatic surgical technique with special bipolar forceps. This case report may help neurosurgeons make better surgical decisions in the management of highly vascularized brain metastasis.

Glioblastoma Mimicking Meningioma: Report of 2 Cases

BACKGROUND

Glioblastoma can mimic various pathologies, including arteriovenous malformation, hemorrhage from ischemic stroke, cerebral contusion, metastatic disease, lymphoma, and infection. The literature is limited regarding diagnostic confusion with meningioma. Herein, we present 2 patients that exhibited imaging, including cerebral angiography during preoperative embolization, which was consistent with meningioma, but where final surgical diagnosis revealed glioblastoma.

CASE DESCRIPTION

Case 1 was a 57-year-old woman presenting with headache, ataxia, and memory lapses for the past month. Brain magnetic resonance imaging (MRI) demonstrated a heterogeneous-enhancing right temporoparietal mass with broad contact along the right tentorium, cerebrospinal fluid (CSF) cleft sign, and dural tail sign-consistent with meningioma. Patient underwent angiography with successful polyvinyl alcohol foam (PVA) particle embolization of the petrosquamosal branch of the right middle meningeal artery (MMA) and meningeal branch of the right occipital artery, resulting in significant devascularization of the tumor blush. Subsequently, the patient underwent tumor resection, where pathology revealed glioblastoma. Case 2 was a 60-year-old man presenting with right hemiparesis. Brain MRI demonstrated a left parasagittal, heterogeneous-enhancing mass abutting the falx with a dural tail sign-consistent with meningioma. Patient underwent angiography with successful PVA particle embolization of the left MMA, resulting in significant devascularization of the tumor blush. Patient underwent a tumor resection where pathology revealed glioblastoma.

CONCLUSIONS

Glioblastoma can mimic meningioma on MRI with dural tail sign, CSF cleft sign, and broad dural contact. Moreover, cerebral angiography can reveal tumor feeders commonly associated with meningioma. These features can contribute to diagnostic confusion. Based on these 2 cases, preoperative embolization of tumor feeders is possible with glioblastoma.