Metastatic hepatocellular carcinoma presenting as epidural hematoma: case report

Successful Treatment of Anal Canal Cancer Metastasis to the Cranial Bones: A Case Report and Literature Review

Single metastasis to the cranial bone represents a very uncommon occurrence that can arise from an anal canal cancer. No cases of cranial bone metastasis from anal canal carcinoma are available in the literature. Herein, we present a case of a unique metastatic lesion to the right parietal bone that occurred after curative chemoradiotherapy of primary squamous cell anal canal carcinoma. The patient received radiotherapy and systemic platinum-based chemotherapy, with optimal local control, high compliance and a well tolerable level of toxicity.

Spontaneous Epidural Hemorrhage in Sickle Cell Disease, Are They All the Same? A Case Report and Comprehensive Review of the Literature

Trauma to the skull causing injury to the middle meningeal artery, middle meningeal vein, or dural venous sinuses is responsible for most cases of epidural hemorrhage (EDH). Spontaneous EDH is a rare entity in clinical practice. Common causes include sinusitis, coagulation abnormalities, dural metastasis, and Langerhans cell histiocytosis. Isolated nontraumatic EDH is an exceedingly rare complication of sickle cell disease (SCD). We report a case of spontaneous EDH in a patient with SCD and review the world literature regarding this rare entity. A 20-year-old African American female with sickle cell disease presented with vaso-occlusive crisis. About 24 hours after hospital admission, the patient had sudden deterioration of her mental status. An emergent CT scan of the head revealed a large right-sided frontoparietal epidural hematoma with midline shift, subfalcine, and uncal herniation. The patient underwent emergent hematoma evacuation but died 24 hours after surgery.

Cancer-associated stroke: Pathophysiology, detection and management (Review)

Numerous types of cancer have been shown to be associated with either ischemic or hemorrhagic stroke. In this review, the epidemiology and pathophysiology of stroke in cancer patients is discussed, while providing vital information on the diagnosis and management of patients with cancer and stroke. Cancer may mediate stroke pathophysiology either directly or via coagulation disorders that establish a state of hypercoagulation, as well as via infections. Cancer treatment options, such as chemotherapy, radiotherapy and surgery have all been shown to aggravate the risk of stroke as well. The clinical manifestation varies greatly depending upon the underlying cause; however, in general, cancer‑associated strokes tend to appear as multifocal in neuroimaging. Furthermore, several serum markers have been identified, such as high D‑Dimer levels and fibrin degradation products. Managing cancer patients with stroke is a delicate matter. The cancer should not be considered a contraindication in applying thrombolysis and recombinant tissue plasminogen activator (rTPA) administration, since the risk of hemorrhage in cancer patients has not been reported to be higher than that in the general population. Anticoagulation, on the contrary, should be carefully examined. Clinicians should weigh the benefits and risks of anticoagulation treatment for each patient individually; the new oral anticoagulants appear promising; however, low‑molecular‑weight heparin remains the first choice. On the whole, stroke is a serious and not a rare complication of malignancy. Clinicians should be adequately trained to handle these patients efficiently.

Surgical management of coincidental metastases to upper cervical spine and skull from hepatocellular carcinoma: a case report

Metastases to the skull or upper cervical spine from hepatocellular carcinoma (HCC) are very rare. We herein report a unique case of two-site surgery for both skull and upper cervical spine metastases from HCC. The patient was a 64-year-old man with cervical pain. Computed tomography (CT) revealed osteolytic change related to metastatic cervical spine and occipital bone tumors. Two-stage surgery involving posterior occipitocervical fusion and occipital bone tumor resection was performed. The patient’s pain decreased in severity, and postoperative radiotherapy and chemotherapy could be conducted. The postoperative course was favorable, and the patient exhibited improvement in his activities of daily living. Neither cervical spine X-ray examination nor CT showed any instrumentation failure, such as screw loosening, before the patient died of liver failure 13 months after surgery. Patients with both skull and upper cervical spine metastases from liver cancer may have a markedly unfavorable prognosis. Even in these patients, however, surgery as an aggressive palliative treatment may prolong the survival period or maintain the quality of life as long as the patient’s general condition permits.

Acute spontaneous intracranial epidural haematoma and disseminated intravascular coagulation in a paediatric sickle cell patient

An African American teenage boy during an acute sickle cell crisis spontaneously developed acute bifrontal epidural haematomas (EDHs) in addition to disseminated intravascular coagulation (DIC). The successfully evacuated EDH reaccumulated postoperatively. After multiple transfusions, the patient underwent repeat surgery. Subsequent maximal medical therapy was unable to significantly improve the patient's neurological status, and due to family wishes, care was withdrawn. EDH are the most common emergent neurosurgical complication of sickle cell disease (SCD). Twenty-two such cases have been previously reported. We present one further complicated by DIC leading to reaccumulation of the patient's EDH. An understanding of the mechanisms of EDH formation in SCD and their associated radiological findings could help clinicians identify when a patient is at high risk of EDH formation and thus offer the potential for early intervention prior to the development of an emergency.

Scapular metastasis of hepatocellular carcinoma presenting as acute bleeding and hematoma: A case report of safe and effective treatment

RATIONALE

The occurrence of bleeding and hematoma from bone metastasis of hepatocellular carcinoma (HCC) is extremely rare.

PATIENT CONCERNS

We present a case of scapular metastasis of HCC in a 69-year-old man who presented with acute bleeding and hematoma.

DIAGNOSES

Chest computed tomography showed a large hematoma within the right pectoral muscle of the right upper chest and an exophytic metastatic mass in the right scapula with bony destruction, which caused the intramuscular hematoma. The final diagnosis was scapular metastasis of HCC presenting as acute bleeding and hematoma.

INTERVENTIONS

Selective right subclavian angiography showed a hypervascular metastatic lesion in the right scapula. Subsequently, embolization of the tumoral feeding artery using a microcoil was performed and tumoral bleeding was stopped.

OUTCOMES

The patient was discharged on hospital day 14 without any complications.

LESSONS

Despite being extremely rare, the possibility of bleeding from bone metastasis of HCC needs to be considered. Transcatheter arterial embolization may be an effective means to treat bleeding from bone metastasis of HCC.

Intraparenchymal Hemorrhage due to Brain Metastasis of Hepatocellular Carcinoma

Although extrahepatic metastases from hepatocellular carcinoma (HCC) are present in only 5–15% of cases, they are certainly factors associated with poor prognosis. The main sites include lung, lymph nodes, bones, and adrenal glands, in descending order. Metastasis in the central nervous system is extremely rare, and the incidences vary from 0.6 to 1.7%. We report a case of a 54-year-old man previously diagnosed with alcohol-induced cirrhosis of the liver and HCC. The patient was admitted presenting progressive left hemiparesis and headache which started 2 days earlier, with no history of cranioencephalic trauma. After admission, cranial computed tomography revealed an intraparenchymal hemorrhage area with surrounding edema in the right frontal lobe. An angioresonance requested showed a large extra-axial mass lesion located in the right frontal region with well-defined contours and predominantly hypointense signal on T2 sequence. At first, the radiological findings suggested meningioma as the first diagnostic hypothesis. However, the patient underwent surgery. The tumor was completely removed, and the morphological and immunohistochemical findings were consistent with metastatic hepatocarcinoma associated with meningioma. In postoperative care, the patient did not recover from the left hemiparesis and manifested Broca's aphasia. He had a survival time of 24 weeks, presenting acute liver failure as his cause of death. There is a lack of evidence supporting a specific management of patients with brain metastasis from HCC. Furthermore, there are no studies that evaluate different modalities of therapeutics in brain metastasis of HCC due to the rarity of this condition. Therefore, management must be individualized depending on probable prognostic factors in these patients.

Spontaneous acute epidural hematoma developed due to skull metastasis of hepatocelluar carcinoma: A case report and review of the literature

Acute epidural hematoma (AEDH) is one of the most common pathological types of head trauma, and may develop without an accidental event, although this is uncommon. The present study reports the case of a 41-year-old male patient that developed spontaneous AEDH due to skull metastasis of hepatocellular carcinoma (HCC). The man was admitted to Chonnam National University Hwasun Hospital and Medical School due to drowsiness and right-sided hemiparesis. A computed tomography scan of the head revealed the presence of a large AEDH and a lytic bone lesion in the left posterior fossa and parieto-occipital region, which exhibited heterogeneous enhancement. The perioperative findings revealed a large amount of mixed-stage epidural hematoma and a soft hemorrhagic mass that exhibited lytic change on the occipital bone. No evidence of head trauma, such as skull fracture or scalp contusion, was detected. The pathological diagnosis was hematoma with metastatic HCC. The current study reports the rare case of a patient with a metastatic tumor located in the skull that resulted in the development of spontaneous AEDH. Once a sudden and unpredicted neurological deficit occurs in a patient with HCC that is also diagnosed with skull metastasis, the possibility of spontaneous AEDH developing from the metastasis should be considered.

HbSC Disease and Spontaneous Epidural Hematoma with Kernohan's Notch Phenomena

Spontaneous (nontraumatic) acute epidural hematoma is a rare and poorly understood complication of sickle cell disease. A 19-year-old African American male with hemoglobin SC disease (HbSC) presented with generalized body aches and was managed for acute painful crisis. During his hospital stay he developed rapid deterioration of his mental status and computed topography revealed a spontaneous massive epidural hematoma with mass effect and midline shift with Kernohan's notch phenomena for which urgent craniotomy and evacuation was done. We report the first case of HbSC disease associated with catastrophic epidural hematoma progressing to transtentorial herniation and Kernohan's notch phenomena within few hours with rapid clinical deterioration. The etiopathogenesis and the rare presentation are discussed in detail in this case report.

Solitary scalp metastasis - a rare presentation of hepatocellular carcinoma

Introduction

Hepatocellular carcinoma (HCC) is among the commonest cancers in the world. Metastasis is one of the most significant factors affecting prognosis. Common sites of extrahepatic metastases include lungs, regional lymph nodes and less commonly bone.

Case presentation

A 56-year-old male presented with a painless occipital scalp lump of three months duration, with recent rapid enlargement. His skull x-ray showed a lytic lesion over occipital bone and the contrast CT scan of the brain showed a scalp mass with destruction of the adjacent skull. Core biopsy of the lesion revealed a metastatic deposit from a hepatocellular carcinoma.

Conclusion

Primary presentation with skeletal metastases are rare in HCC with only a few reported cases. Here we report a case of HCC presenting as a solitary scalp lump.

Concomitant Subdural Hemorrhage and Intracerebral Hemorrhage due to Brain Metastasis of the Hepatocellular Carcinoma

Hemorrhagic metastatic brain tumors of hepatocellular carcinoma (HCC) are rare and have been mostly presented as intracranial hemorrhage (ICH). A 51-year-old male patient presented with sudden altered level of consciousness. He suffered from HCC since 2010 and transarterial chemoembolization was performed three times for HCC. The brain computed tomography (CT) scans revealed subdural hematoma (SDH) in the right fronto-temporal area and 6.0×3.5 cm sized ICH in the right parieto-occipital lobe. Brain angiographic CT scans demonstrated that the hemorrhagic lesions did not include any enhancing lesions and vascular abnormalities. We undertook a decompressive craniectomy and evacuation of the acute SDH and ICH. During evacuation of ICH, the yellowish mass was observed in the cortical surface of the right occipital lobe. Pathological examination displayed the findings of metastatic brain tumor from HCC. Metastatic brain tumors should be considered in the differential diagnosis as a cause of spontaneous SDH with ICH.

Epidural hematoma secondary to solitary skull metastasis from an ovarian carcinoma

We report a rare case of an acute epidural hematoma (EDH) due to solitary skull metastasis in a 60-year-old patient treated earlier for ovarian carcinoma. The patient presented with head injury followed by unconsciousness and computerized tomography showed a large EDH in the right parietal region along with a contusion of left temporal-parietal lobe and subarachnoid hemorrhage in left sylvian fissure. Emergency craniotomy and evacuation of the EDH was performed and the hemorrhage was determined to be secondary to skull metastasis of ovarian carcinoma; the patient recovered and received whole brain radiation therapy.

Solitary skull metastasis as the first symptom of hepatocellular carcinoma: case report and literature review

Skull metastasis from hepatocellular carcinoma (HCC) is reported rarely. In addition, solitary skull metastasis as the first symptom of HCC is reported even less. Here, we reported a case of solitary skull metastasis as the first symptom of HCC and reviewed the literature on skull metastasis. A 49-year-old male patient was admitted to Jinjiang Hospital of Quanzhou Medical College with a painless parietal-occipital scalp mass, and he denied any history of hepatic disease. A cranial computed tomography demonstrated a hypervascular enhancement with osteolytic change in the right parietal-occipital region, cranial magnetic resonance imaging indicated a highly enhanced and osteolytic skull tumor, and abdominal computed tomography showed a huge tumor in the liver. The other examinations showed no other metastases. Laboratory data showed no liver dysfunction while hepatitis B surface antigen was positive, and alpha fetal protein level was high. A craniectomy was performed and the mass was totally removed. The histological diagnosis was skull metastasis from HCC. The patient was subsequently treated by transcatheter arterial chemoembolization. In a review of published literature, the incidence of skull metastasis from HCC in the period between 1990 and 2011 has significantly increased. The misdiagnosis rate of skull metastases as the first symptom from HCC was high. Therefore, it is necessary to give each patient with a scalp mass that has invaded the skull a liver ultrasound or computed tomography scan. On the other hand, we found that metastases that occurred in the calvaria site were more frequent than those that occurred in the skull base and facial skeleton. This may be worthy of further investigation in the future.

Intracranial hemorrhage in patients with cancer

Intracranial hemorrhage (ICH) is a common neurological emergency in patients with cancer, typically occurring late in the disease course, although it occasionally heralds the cancer diagnosis. ICH in these patients often occurs from unique mechanisms, especially intratumoral hemorrhage or coagulopathy, whereas hypertensive hemorrhage is rare. Lung, melanoma, breast, and glioblastoma multiforme are the most commonly associated solid tumors, partly because of their ubiquity and frequent brain involvement, whereas leukemia is the most commonly associated hematological cancer. Patients typically present with focal neurological deficits, headache, and encephalopathy, and their initial diagnostic evaluation and management should follow standard guidelines, although steroids and/or surgical resection should be strongly considered in those with intratumoral hemorrhage. Short-term outcomes are comparable to ICH in the community, whereas long-term outcomes are generally poor, corresponding to the prognosis of the underlying cancer. This review focuses on the recent advances and special considerations in cancer-related intracranial hemorrhage.

Spontaneous intracranial epidural hematoma originating from dural metastasis of hepatocellular carcinoma

Spontaneous intracranial epidural hematoma (EDH) due to dural metastasis of hepatocellular carcinoma is very rare. A 53-year-old male patient with hepatocellular carcinoma, who was admitted to the department of oncology, was referred to department of neurosurgery because of sudden mental deterioration to semicoma with papillary anisocoria and decerebrate rigidity after transarterial chemoembolization for hepatoma. Brain computed tomography (CT) revealed large amount of acute EDH with severe midline shifting. An emergent craniotomy and evacuation of EDH was performed. Active bleeding from middle cranial fossa floor was identified. There showed osteolytic change on the middle fossa floor with friable mass-like lesion spreading on the overlying dura suggesting metastasis. Pathological examination revealed anaplastic cells with sinusoidal arrangement which probably led to spontaneous hemorrhage and formation of EDH. As a rare cause of spontaneous EDH, dural metastasis from malignancy should be considered.

Spontaneous epidural hematoma from skull base metastasis of hepatocellular carcinoma

We report a case of an acute spontaneous epidural hematoma (EDH) due to skull base metastasis in a 46-year-old male patient with hepatocellular carcinoma (HCC). The patient presented with the acute onset of severe headache followed by unconsciousness, and computed tomography showed a large EDH in the right temporal and parietal lobes with midline shift. Emergency evacuation of the EDH was performed, and the hemorrhage was determined to be secondary to skull base metastasis of HCC.

Little response of cerebral metastasis from hepatocellular carcinoma to any treatments

OBJECTIVE

We retrospectively evaluated the survival outcome of patients with brain metastasis from hepatocellular carcinoma (HCC).

METHODS

Between 1991 and 2007, a total of 20 patients were diagnosed as having brain metastasis from HCC. The mean age of the patients was 55 +/- 13 years, and 17 (85.0%) were men. Seventeen (85.0%) patients had already extracranial metastases. The median time from diagnosis of HCC to brain metastasis was 18.5 months. Fourteen (70.0%) patients had stroke-like presentation due to intracerebral hemorrhage (ICH). Ten (50.0%) patients had single or solitary brain metastasis. Among a total of 34 brain lesions, 31 (91.2%) lesions had the hemorrhagic components.

RESULTS

The median survival time was 8 weeks (95% CI, 5.08-10.92), and the actuarial survival rates were 85.0%, 45.0%, 22.5%, and 8.4% at 4, 12, 24, and 54 weeks. Age < 60 years, treatment of the primary and/or extracranial lesions, and recurrent ICH were the possible prognostic factors (p = 0.044, p < 0.001, and p = 0.111, respectively). The median progression-free survival (PFS) time was 3 months (95% CI, 0.95-5.05).

CONCLUSION

The overall survival of the patients with brain metastasis from HCC was very poor with median survival time being only 8 weeks. However, the younger patients less than 60 years and/or no extracranial metastases seem to be a positive prognostic factor.

Skull metastasis from hepatocellular carcinoma with chronic hepatitis B

A 56-year-old male visited our hospital for evaluation of an occipital mass. Contrast computed tomography showed hypervascular enhancement with osteolytic change in the skull and a huge enhanced mass in the liver. Magnetic resonance imaging showed bone metastasis in the thoracic vertebrae. Assays for hepatitis B surface antigen and hepatitis B core antibody were positive and his liver condition was Child-Pugh grade A. Our diagnosis was hepatocellular carcinoma (HCC) with skull and vertebrae metastases on chronic hepatitis B. He was treated with radiation therapy for bone metastases and transcatheter arterial chemoembolization for HCC. But he developed acute respiratory failure because of aspiration pneumonia, congestion and oedema with haemorrhage of the lungs and died. Dissection showed HCC with multiple bone metastases. The liver tumor was categorized as well-differentiated HCC, Edmondson classification I, trabecular type and pseudoglandular type. In the liver mild infiltration of lymphocytes was seen in Glisson’s capsules which were significantly enlarged with well preserved limiting plates. Piecemeal necrosis was not obvious. No fibrosis was noted. An 8 cm × 7 cm × 3 cm metastatic lesion had formed in the left occipitotemporal part of the cranial bone. The lesion was osteolytic and showed invasion into the dura mater. Neither the subdural cavity nor the brain showed involvement from the metastatic tumor. However, skull metastasis from HCC is very rare and it affects the patient’s prognosis and the quality of life. Therefore, it is very important to make an early diagnosis and carry out proper management of skull metastasis from HCC.

Intracerebral and subarachnoid hemorrhage in patients with cancer

OBJECTIVE

To analyze the risk factors, presentation, etiologies, and outcomes of adult cancer patients with intracranial hemorrhage (IH).

METHODS

We analyzed 208 patients retrospectively with the diagnosis of IH from the Memorial Sloan-Kettering neurology database from January 2000 through December 2007. Charts were examined for clinical and radiographic data. Survival was calculated using the Kaplan-Meier method. Survival between groups was compared via the log-rank test. Logistic regression models were used to assess for prognostic indicators of 30- and 90-day mortality.

RESULTS

There were 181 intracerebral and 46 subarachnoid hemorrhages. Sixty-eight percent of patients had solid tumors, 16% had primary brain tumors, and 16% had hematopoietic tumors. Hemiparesis and headache were the most common symptoms. Intratumoral hemorrhage (61%) and coagulopathy (46%) accounted for the majority of hemorrhages, whereas hypertension (5%) was rare. Median survival was 3 months (95% confidence interval [CI] 2-4), and 30-day mortality was 31%. However, nearly one-half of patients were completely or partially independent at the time of discharge. Patients with primary brain tumors had the longest median survival (5.9 months, 95% CI 2.9-11.8, p = 0.05). Independent predictors of 30-day mortality were not having a primary brain tumor, impaired consciousness, multiple foci of hemorrhage, hydrocephalus, no ventriculostomy, and treatment of increased intracranial pressure.

CONCLUSIONS

Intracranial hemorrhage in patients with cancer is often due to unique mechanisms. Prognosis is poor, but comparable to intracranial hemorrhage in the general population. Aggressive care is recommended despite high mortality, because many patients have good functional outcomes.

Multiple skull metastases from hepatocellular carcinoma successfully treated with radiotherapy

We report a Japanese man who presented with multiple cranial nerve palsies with hepatitis B virus-related multiple hepatocellular carcinoma (HCC). He presented with right III, IV, VI, IX, X, and XII cranial nerve palsies. Metastases involving the clivus and the right occipital bone from HCC were diagnosed by the findings of magnetic resonance imaging of the head, cerebral angiography, and 2-deoxy-2-[(18)F]fluoro-D-glucose positron emission tomography/computed tomography. In this case, over one-year survival and improvement of neurological signs were achieved by radiotherapy in spite of multiple skull metastases, which are extremely rare.

Solitary skull metastasis as initial manifestation of hepatocellular carcinoma

Background

A solitary skull metastasis from hepatocellular carcinoma (HCC) prior to diagnosis of the primary tumor without liver dysfunction is a very rare event.

Case presentation

A 71-year-old male, without known liver disease, presented to our institution with a palpable occipital scalp mass. On brain magnetic resonance imaging (MRI), a highly enhanced and osteolytic skull tumor was observed. The histological diagnosis obtained from the percutaneous needle biopsy was a cranial metastasis from HCC. The metastatic tumor was removed via occipital craniectomy, and the two primary liver mass lesions were subsequently treated by transarterial chemoembolization.

Conclusion

An isolated skull metastasis may be the sole initial presentation of HCC. Early diagnosis is essential in order to treat the primary disease. A skull metastasis from HCC should be considered in the differential diagnosis in patients with subcutaneous scalp mass and osteolytic defects on X-ray.

Management of stroke in cancer

Cerebrovascular disorders, including brain infarction, brain hemorrhage, and cerebral venous thrombosis, can occur as an early sign of cancer, but typically occur late in the clinical course. These disorders are due to a variety of pathogenic mechanisms, including coagulation disorders associated with the cancer, invasion or compression of vessels from tumor in or adjacent to the brain, and the adverse effects of cancer therapy. The appropriate therapy for these cerebrovascular disorders is empiric in most instances, because as yet there are no prospective treatment trials for them. A review of the existing literature reveals that improvement in patient quality of life and prevention of further cerebrovascular events can be obtained in some clinical situations.

Skull metastasis from hepatocellular carcinoma

Metastasis to the skull frequently occurs in patients with lung, breast and prostate cancer. However, skull metastases from hepatocellular carcinoma (HCC) have been rarely reported. We review the literature on skull metastasis from HCC and report a case of a 46-year-old male, who was diagnosed as HCC and was operated on by trans-arterial embolization and lobectomy in Oct. 2004. He complained of a painless mass over the left frontal region for two months. Radiograph of the skull revealed an osteolytic mass about 4-5 cm in size over the left frontal region. A cranial computerized tomography demonstrated a destructive lesion with soft tissue mass over the left frontal region. A left frontal craniectomy was performed and tumor was totally removed. The histological diagnosis was cranial metastasis from HCC. Postoperative recovery was uneventful without any neurological deficits. Because of improved and advancing treatment for HCC, survival time for HCC has been lengthened and distant metastases will thus be found to increase. Early diagnosis is essential to treat the primary disease. Skull metastases from HCC should be considered as a differential diagnosis in patients with scalp subcutaneous mass and osteolytic defect on X-ray skull films.

Brain metastases from hepatocellular carcinoma in US patients

Hepatocellular carcinoma (HCC) is a disease on the rise in the United States, due to the epidemic of hepatitis C-induced liver disease. Better chemotherapy options, aggressive surgery, and liver transplantation have led to improved patient survival and an increase in late-appearing, distant metastases from HCC. Brain metastases, although formerly thought of as rare manifestations of HCC, may be more likely to come to clinical and pathological attention than extrahepatic metastases in other sites since they often produce clinical symptoms that necessitate neurosurgical intervention and metastasis removal. In addition, brain metastases from HCC are frequently associated with mass-producing hemorrhage, further requiring evacuation. Hence, pathologists are relatively more likely to encounter brain metastases from HCC as surgical specimens than metastases from HCC to some other common sites of spread, such as bone, lymph nodes, or adrenal. Brain metastases from HCC are being increasingly documented in areas of the world with high endemic rates such as Asia, but thus far have only very rarely been reported in patients native to the United States. We describe our institution's experience with three Caucasian US males, two with hepatitis C as risk factors, who developed metastatic HCC to the brain. We expect clinicians and pathologists will encounter more patients with HCC and extrahepatic metastases, particularly those to brain, in the near future.

Incidence and etiology of cerebrovascular disease in patients with malignancy

Cerebrovascular disease is common in cancer patients and often arises from mechanisms unique to malignancy. Direct tumor effects include intratumoral hemorrhage, arterial and venous sinus invasion by tumor mass or leptomeningeal infiltrates, and tumor emboli. Complications of chemotherapy, radiation therapy, and hematopoietic stem-cell transplantion for cancer can occur before, during, or years after treatment. Coagulopathic conditions involve disseminated intravascular coagulation, thrombocytopenia, nonbacterial thrombotic endocarditis, and cerebral intravascular coagulation. Finally, septic infarction from fungal or bacterial sepsis and infectious vasculitis manifest in cancer patients immunocompromised by malignancy or cancer therapy. In many cases a combination of mechanisms is causative, and both hemorrhagic and ischemic stroke can occur simultaneously. Stroke type and mechanism, as well as the stage and pathology of the neoplasm, dictate proper management and help delineate prognosis.

Skull metastasis from ampulla of Vater adenocarcinoma: case report

We report a rare case of skull metastasis from ampulla of Vater adenocarcinoma in a patient with controlled primary neoplasm. This 65-year-old Korean man presented with headache and painful parietal scalp swelling, but he did not show any neurological deficits. Computed tomography revealed an osteolytic mass that invaded and expanded through the skull tables in full-thickness. On magnetic resonance images following Gadolinium injection, the mass appeared slightly hypointense signal on all sequences and intense heterogeneous enhancement. He underwent surgical excision with artificial grafting of calvaria and dura. Postoperative radiation therapy was ensued for metastatic adenocarcinoma, and he was well for the follow-up period of 3 months. To the best of our knowledge, this is the first such case that involved the skull.