Symptomatic hemorrhage associated with recurrent pilocytic astrocytoma with granulation tissue--case report

Hemorrhagic presentation of intracranial pilocytic astrocytomas: literature review

Pilocytic astrocytomas (PAs) are seemingly innocuous and benign tumors. However, in recent times, many case series have documented high rates of hemorrhage in these neoplasms. We hereby provide a detailed analysis on hemorrhagic pilocytic astrocytomas (HPA) in adults and report one such case managed at our institute. In addition, salient differences between adult and pediatric hemorrhagic PA have been briefed. Hospital records were retrieved for our case. Literature review was conducted by searching online databases for the following keywords-pilocytic astrocytoma, hemorrhage, cranial, pediatric, and adults. A 22-year-old male with neurofibromatosis-1 presented with sudden onset headache and vomiting of 3-day duration. Imaging revealed a lobulated suprasellar lesion with obstructive hydrocephalus. Pterional transsylvian approach and subtotal resection were performed. Histopathology showed features of PA with bleed. Including current report, a total of 26 cases have been reported. Mean age was 37 years (21-75 years) and they are mostly found in the third decade. The male:female ratio was 2.1:1. Sudden headache with vomiting was the most common symptoms. Tumors were mostly located in cerebral hemispheres (n = 9/34.6%), hypothalamus/suprasellar region (n = 7/27%), and cerebellum (n = 6/23%). Two-thirds underwent gross total excision. There were two deaths and except one case, no recurrences were reported in those with available follow-ups. Hemorrhagic presentation of a PA is rare, although more commonly seen in adults and most commonly located in cerebral hemispheres. Maximal safe resection is the standard treatment and recurrences are rare.

Delayed hemorrhage after surgery and radiation in suprasellar pilocytic astrocytomas

Delayed intracranial hemorrhage is a rare complication of treatment for central nervous system tumors. This may be secondary to malignant transformation of the tumor or vasculopathy related to radiation therapy (RT). While most reports on radiation-induced vasculopathy in children with optic pathway gliomas are associated with ischemic complications, there are only two reports of hemorrhagic complications in these patients. In both cases, the hemorrhage was asymptomatic and remote from the site of the original tumor but within the field of irradiation. We describe a female patient who underwent surgery for an optico-chiasmatic pilocytic astrocytoma (PA) at the age of 12 followed by RT at the age of 17 for tumor progression. The patient was followed with serial magnetic resonance imaging (MRI) scans showing marginal regression and no subsequent evidence of tumor recurrence, including the most recent MRI done only 6 months before the latest presentation. She then developed a symptomatic intratumoral hemorrhage at the age of 32 for which she underwent emergent surgery. To our knowledge, this is the first report of a nonaneurysmal-delayed hemorrhage within the site of previous surgery, several years after RT for a suprasellar PA. We review literature on delayed vasculopathy following the treatment of pediatric optic pathway gliomas and discuss the possible mechanisms of hemorrhage in our case. These long-term follow-up outcomes add significant insight and have implications in patient management.

Hemorrhagic Pilocytic Astrocytomas in Adults: A Case Report and Literature Review

Pilocytic astrocytomas are histologically benign tumors, generally found in the pediatric population. Onset of symptoms is generally insidious, predominantly stemming from mass effect upon nearby structures. Patients harboring a pilocytic astrocytoma may present with gait disturbance, headaches, cranial nerve deficits, as well as hydrocephalus, depending on the exact location. Although cases of adult pilocytic astrocytomas in the adult population are described, they are quite uncommon. We present a case of an adult female presenting with acute neurological compromise resulting from an acutely hemorrhagic posterior fossa pilocytic astrocytoma. Her initial neurological assessment was consistent with a Glasgow coma scale of 4T, as the patient was experiencing decerebrate posturing. An emergent external ventricular drain was placed in the emergency department for acute hydrocephalus as a temporizing measure, prior to evacuation of the associated subdural and intratumoral hemorrhages, as well as resection of the mass. After a long hospital course and extensive rehabilitation, the patient made a remarkable recovery and eventually gave birth to a child via Caesarean section three years after her initial presentation.

Pilocytic astrocytoma presenting with atypical features on magnetic resonance imaging

Pilocytic astrocytoma, which is classified as a grade I astrocytic tumor by the World Health Organization, is the most common type of glioma in children and young adults. Pilocytic astrocytoma generally appears as a well-circumscribed, contrast-enhancing lesion, frequently with cystic components on magnetic resonance imaging (MRI). However, it has been reported that the MRI appearance of pilocytic astrocytoma may be similar to that of high-grade gliomas in some cases. We here report on 6 cases of pilocytic astrocytoma with atypical MRI findings, including small cyst formation, heterogeneously enhancing tumor nodules, irregularly enhancing tumor nodules, and enhancing tumor nodules with internal hemorrhage. All tumors were successfully resected, and the histological diagnoses were pilocytic astrocytoma. When the tumor is located near a cerebral cistern or ventricle, the risk of leptomeningeal dissemination is increased. Furthermore, partial resection has also been associated with a higher risk of recurrence and leptomeningeal dissemination. To date, all but one patient are alive and recurrence-free. Because the preoperative diagnosis influences the decision on the extent of resection and because of the high risk of leptomeningeal dissemination associated with these tumors, careful and correct diagnosis by MRI is important.