Sudden hemorrhage in an acoustic neuroma. Case report

Vestibular Schwannoma Leading to Contacting Aneurysm Rupture: An Unusual Presentation

Subarachnoid hemorrhage (SAH) is a rare manifestation of brain tumors, being even rarer in vestibular schwannomas. We report the second case of a posterior circulation aneurysm close to the tumor capsule, responsible for SAH as an initial manifestation of a vestibular schwannoma. A 67-year-old female was admitted to the Emergency Department with sudden onset of nausea and headache. A diagnosis of a SAH and a tumor of the right cerebellopontine angle was made. An angiography showed an aneurysm in the dependency of the right anterior inferior cerebellar artery (AICA), juxtaposed to the tumor capsule. The patient underwent surgery, the tumor was removed, and the aneurysm was treated. This case highlights that SAH in patients with vestibular schwannoma may originate from a contact aneurysm. Although exceedingly rare, surgeons should consider this scenario in vestibular schwannoma presenting with SAH, and angiography is important for its diagnosis.

The Clinical Implications of Spontaneous Hemorrhage in Vestibular Schwannomas

Background  Spontaneous hemorrhage into vestibular schwannomas (VSs) is rare and can render more rapid symptom onset and a seemingly poorer prognosis for an otherwise benign pathology. We describe our series of hemorrhagic VS (HVSs) and systematically reviewed the literature to better understand relevant clinical factors and outcomes. Methods  Retrospective case review series and systematic review of the literature using PRISMA guidelines. Results  Fifty-three patients with HVS met inclusion criteria. Compared with historical data for all VS, patients with HVS had relatively higher rates of perioperative mortality, significant preoperative facial weakness, and harbored relatively larger tumors. Regardless of the extent of resection (EOR), surgery for HVS resulted in significant improvement of facial weakness ( p  = 0.041), facial numbness ( p  < 0.001), vertigo ( p  < 0.001), and headache ( p  < 0.001). Patients with facial weakness tended to have larger tumors ( p  = 0.058) on average and demonstrated significant improvement after surgery, irrespective of EOR ( p  < 0.01). The use of blood-thinning medications did not affect patient health outcome. Histopathology of HVS samples showed an increased number of dilated/ectatic thin-walled vascular channels, reflective of potentially increased vascular permeability and hypervascularity. Conclusion  HVS may be an aggressive subgroup of VS, associated with a surprisingly high mortality rate. When features of HVS are identified on imaging, these patients should be treated expeditiously, especially given that facial nerve dysfunction, which is identified in more than half of patients with HVS, appears to be reversible. Overall, this study has significant implications in the management of VS, raising awareness of a small, but highly morbid subgroup.

Repeated spontaneous intra-tumoural and subarachnoid haemorrhage in an anticoagulated patient with a previously-irradiated vestibular Schwannoma: Case report

Subarachnoid hemorrhage caused by vestibular schwannomas (VS) is rare with no clear pathological mechanism supported in the existing literature. However, anticoagulation treatment as well as previous radiation therapy appear to be a crucial risk factor for subarachnoid haemorrhage from a VS. We report an unusual case of both intratumoural and subarachnoid haemorrhage in a patient with a VS on anticoagulation treatment previously treated with stereotactic radiosurgery. We emphasize the need for caution when considering the use of radiation therapy for treatment of VS in patients on chronic anticoagulation therapy.

A unique pediatric case of intratumoral hemorrhage in a sporadic vestibular schwannoma

Vestibular schwannomas (VSs) are tumors that commonly occur in the eighth cranial nerve. They are usually associated with type 2 neurofibromatosis. They are uncommon in children, and sporadic cases of pediatric VS are even rarer. In general, VSs are benign lesions with less than 1% chance of intratumoral hemorrhage. Adult cases of hemorrhage in VS are well documented. We present the first pediatric case of intratumoral hemorrhage in VS in the absence of any features of NF in an 11-year-old child who complained of holocranial headache and sensorineural hearing loss in the left ear. We further discuss the pathogenesis and clinical features, and review the literature of intratumoral hemorrhage in patients of VS.

Clinically significant intratumoral hemorrhage in patients with vestibular schwannoma

OBJECTIVES

The frequency of intratumoral hemorrhage (ITH) in vestibular schwannoma (VS) remains undefined.

METHODS

Retrospective case series of all patients diagnosed with hemorrhagic VS between 2003 and 2015 at a single tertiary academic skull base center.

RESULTS

Five patients with ITH were evaluated, representing 0.4% of all newly diagnosed VS evaluated at the authors' center during this time. The median age at time of diagnosis was 66 years (range 39-83), four of five cases occurred in men, and all had sporadic unilateral tumors. The frequency of ITH among patients receiving anticoagulation was 5.6% (2 of 36), compared to only 0.2% (3 of 1356) in non-anticoagulated patients (P = 0.006), representing a 25-fold increase. At time of hemorrhage, all patients had acute onset of headache, disequilibrium, and progression of hearing loss; three reported trigeminal symptoms, and two exhibited acute moderate facial paresis. The median tumor size at diagnosis of hemorrhage was 3.1 cm (range 2.4-4.2 cm), and three patients had radiological evidence of hydrocephalus. All patients underwent microsurgical resection. There were no perioperative deaths. At a median follow-up of 25 months (3-70 months), no patient has experienced tumor recurrence.

CONCLUSION

Tumor-associated hemorrhage in VS occurs in 0.4% of cases and commonly presents with acute neurological change. The risk of clinically significant hemorrhage is greater in patients receiving anticoagulation compared to the general VS population. Prompt microsurgical resection should be pursued when possible since tumor removal may improve neurological symptoms, relieve brainstem compression, and reduce the risk of repeat hemorrhage.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:1420-1426, 2017.

Imaging review of the temporal bone: part I. Anatomy and inflammatory and neoplastic processes

From a clinical-radiologic standpoint, there are a limited number of structures and disease entities in the temporal bone with which one must be familiar in order to proficiently interpret a computed tomographic or magnetic resonance imaging study of the temporal bone. It is helpful to examine the region in an organized and systematic fashion, going through the same checklist of key structures each time. This is the first of a two-part review that provides a practical approach to understanding temporal bone anatomy, localizing a pathologic process with a focus on inflammatory and neoplastic processes, identifying pertinent positives and negatives, and formulating a differential diagnosis.

Clinical and radiological aspects of cerebellopontine neurinoma presenting with recurrent spontaneous bleedings

BACKGROUND

Neurinomas are benign, usually encapsulated, tumors growing in peripheral nerve sheath with a high incidence in the cerebellopontine angle.

CASE DESCRIPTION

We report a case of vestibular neurinoma (VN) with a "biphasic" pattern of intratumoral hemorrhage presenting with cephalalgia along with progressive ipsilateral mild impairment of both VII and VIII cranial nerves. A thorough preoperative magnetic resonance imaging study better characterized the patchy pattern of the round shaped lesion, resulting in three different intensity signals, due to the peculiar characteristics of the tumoral mass and the recurrent bleedings, respectively. Postoperatively, histological examination confirmed the diagnosis of neurinoma.

CONCLUSION

Hemorrhagic VN are rare tumors; from the first case described in 1974 only 43 more have been reported in the literature so far. Noteworthy, "biphasic" bleedings are even rarer. From an accurate review of the literature we collected and thus emphasized the radiological and clinical features of this rare entity. Eventually, we suggest that the early surgical removal of clots and tumor is essential to provide the best chance of neurological improvement.

Acoustic schwannoma presenting as acute posterior fossa hematoma: case report and review of the literature

Acoustic schwannomas usually present with gradually progressive unilateral sensorineural hearing loss. As the tumor enlarges, symptoms and signs develop when the adjacent cranial nerves, cerebelhim, and/or brainstem become compressed. Rarely, acoustic tumors present with acute subarachnoid or intratumoral hemorrhage. Of the 12 cases of acoustic schwannoma with tumoral hemorrhage presented in the literature of which we are aware, this is the third such case of a patient presenting with spontaneous pure intratumoral hemorrhage and the first such case presenting with sudden multiple cranial nerve palsies, The purpose of this report is to increase the awareness of this rare form of presentation of acoustic schwannoma in the hope of achieving better preservation of cranial nerves.

[Subclinical apoplexy in pituitary tumors]

Acute pituitary apoplexy is a rare event, even in patients with pituitary macroadenomas. On the other hand, the presence of necrotic/hemorrhagic areas, especially in macroadenomas, seems to be more common than earlier reported in the CT period. After the introduction of MR in the presurgical workup of these patients, these apopleptic areas have been more easily diagnosed preoperatively. Forty consecutive patients with pituitary macroadenomas were studied with high-resolution 1.5 T T1 coronal, sagittal and axial slices over the sellar region. Special attention was paid in the detection of necrotic, cystic and hemorrhagic areas within these tumors. Ten patients had hemorrhagic/necrotic areas within their tumors, without any sign or symptom of acute apoplexy. These areas varied from small (2 mm) to very large (30 mm) ones. Seven patients had non-secreting tumors, 2 GH and 1 prolactin secreting tumors, which is the same profile of secretory pattern for the whole series (40 patients). The clinical picture included (other than that caused by endocrine secretion) slowly progressive (but not acute) visual loss (n = 8) and headache (n = 3). After surgical decompression of the surrounding structures and visual apparatus, which was facilitated by the presence of the necrotic areas, there was visual improvement in 6 patients and headache resolution in 2. The presence of asymptomatic apopletic areas in these macroadenomas and their absence in microadenomas as can be seen in the literature suggest that they are related more to the size of the tumor than to its endocrine secretion pattern. This is in agreement with a vascular insufficiency hypothesis in the pathogenesis of these lesions.

Vestibular schwannoma with repeated intratumoral hemorrhage

A symptomatic hemorrhage from a vestibular schwannoma is extremely rare, despite its relatively high incidence in the cerebellopontine angle. Much more unusual are repeated intratumoral hemorrhages. The authors report on such a rare case of repeated intratumoral hemorrhage from a vestibular schwannoma, presenting with sudden exacerbation of headache, nausea and vomiting. This second hemorrhage was confirmed by CT scan on the day of the onset of symptomatic exacerbation, which was 9 days after the initial CT scan, showing an enlarged amount of blood within the tumor. The MRI scan confirmed this CT finding. After removal, the tumor proved to be a typical vestibular schwannoma of mixed Antoni types A and B. Thin-dilated vessels with hemorrhage and hemosiderin-laden macrophages were observed. The patient's postoperative course was uneventful. A total of 28 reported cases of a single intratumoral hemorrhage in vestibular schwannomas, and one reported case of repeated hemorrhage are reviewed.

Sudden Hearing Loss in Acoustic Neuroma Patients

Patients with acoustic neuroma may have sudden sensorineural hearing loss. Most patients with sudden hearing loss seek medical attention promptly, but the diagnosis of an acoustic neuroma may be delayed for months or years because sudden hearing loss is an unusual initial symptom of an acoustic neuroma. In a retrospective review of 836 cases of sudden hearing loss, we found 13 patients with acoustic neuromas. The prevalence of acoustic neuromas for those screened with auditory brain stem response or magnetic resonance imaging was 2.5%. In addition to these 13 patients, 79 acoustic neuroma patients treated in our clinic had well-documented sudden hearing loss as the initial symptom. Hearing loss in these 92 patients ranged from mild to profound. Associated symptoms of pain, facial paresthesia, or unilateral tinnitus preceding the sudden hearing loss were suggestive of an acoustic neuroma, as was a midfrequency (U-shaped) hearing loss. A history of other diseases or events that might explain the sudden hearing loss, a normal electronystagmogram, or recovery of hearing does not eliminate the possibility of a tumor. Because there are no clinical findings that clearly distinguish those patients with acoustic neuromas from other patients with sudden hearing loss, we recommend either an evaluation with auditory brain stem response or gadolinium-enhanced magnetic resonance imaging for any patient with sudden hearing loss.

Case report: magnetic resonance demonstration of haemorrhagic acoustic neuroma

A 70-year-old patient with a history suggestive of acoustic neuroma developed sudden neurological symptoms. CT showed an enhancing mass in the left cerebello-pontine angle thought to be a meningioma. Magnetic resonance (MR) with gadolinium enhancement demonstrated appearances consistent with a haemorrhagic acoustic neuroma, a diagnosis confirmed at surgery. The literature regarding haemorrhagic intracerebral tumours and MR appearances of acoustic neuroma is reviewed.

Magnetic resonance imaging of hemorrhagic acoustic neuroma

A rare case report of a large hemorrhage acoustic neuroma is described with computed tomography and magnetic resonance imaging findings. Magnetic resonance imaging provides precise definition of the hemorrhage and relationship of the tumor to surrounding structures.

CT and MRI of haemorrhage into intracranial neuromas

Six patients with haemorrhage into intracranial neuromas were studied by computed tomography (CT) and magnetic resonance imaging (MRI) at 0.5 T with spin-echo pulse sequences. The nature of the tumour and the presence of a haematoma were confirmed by surgery and microscopic examination in all cases. Four neuromas arose from the acoustic nerves and two from the trigeminal. Four of the six patients suffered from sudden onset or rapid worsening of symptoms including headache, vertigo and/or hemifacial motor and sensory disturbances. CT in the acute stage revealed a hyperdense area or a fluid-fluid level (FFL). The hyperdense area disappeared on CT repeated in the chronic stage. On MRI in subacute and chronic stages the haemorrhage showed hyperintensity on both T1 and T2 weighting in five cases examined between 16 and 46 days after the onset, and isointensity on T1 weighting and an FFL on T2 weighting in one case examined 12 days after the onset of symptoms. A well-defined low intensity rim indicating prior haemorrhage was observed on T2-weighted images in three cases. MRI was more effective than CT in detecting haemorrhage into the tumours and in staging it.

Trigeminal neurinoma presenting with intratumoral hemorrhage: report of two cases

We report 2 cases of trigeminal neurinoma presenting with spontaneous intratumoral hemorrhage. There are only 2 similar cases reported in the literature. Presenting symptoms were headache, diplopia, disturbed consciousness and trigeminal disturbance with sudden onset. CT scan showed a typical fluid-fluid level within low-density mass in the cerebellopontine angle in one case. On MRI, one case showed a typical fluid-fluid level on T2-weighted image and another one had mixed signal intensities including hyper- and hypointensities on both T1- and T2-weighted images. Histologically, increased vascularity, consisting of dilated and thin-walled vessels presenting telangiectatic or cavernous angiomatous appearances were observed in the specimens in both cases. The size of these tumors was about 3 cm each in diameter. Risk factors for hemorrhage appear to be large tumor size and increased vascularity.

Neurinomas presenting as spontaneous intratumoral hemorrhage

Massive intratumoral or subarachnoid hemorrhage from neurinomas is very rare. The authors report on six patients, four men and two women, with neurinomas that presented as spontaneous intratumoral hemorrhage. The average age of the patients was 56.8 years (range, 31-74 years). Neurinomas originated from the acoustic nerve in four patients and from the trigeminal nerve in two. Four cases were accompanied by the sudden occurrence of clinical symptoms such as headache, double vision, and hemisensory or motor disturbance. The maximum diameter of the tumors ranged from 2.8 to 3.8 cm (average, 3.1 cm). Histological examinations showed massive hemorrhage and increased vascularity, with dilated, thin-walled vessels, in all cases. The size of the tumor and the increase in vascularity with dilated, thin-walled vessels within neurinomas are important pathogenetic factors of hemorrhage. When sudden onset of symptoms or rapid worsening of chronic symptoms occurs in neurinomas, intratumoral or subarachnoid hemorrhage should be considered as a possible cause, and magnetic resonance imaging can be an important tool in obtaining correct diagnosis.

MR of hemorrhagic acoustic neuromas

The magnetic resonance (MR) appearance of hemorrhagic acoustic neuromas has not previously been reported. Four patients with surgically proven acoustic neuromas containing spontaneous hemorrhage were preoperatively evaluated with MR imaging. All patients presented with new onset of symptoms and three had subarachnoid hemorrhage. Signal changes on T1- and T2-weighted spin echo sequences were characteristic for acute, subacute and chronic intraparenchymal hemorrhage. Recognition of hemorrhagic changes on MR is important since more rapid surgical intervention is required in this patient subgroup.

Calcified cerebellopontine angle hematoma mimicking recurrent acoustic neurinoma

The authors describe a case of calcified, organized hematoma in the cerebellopontine angle which developed 20 years after subtotal removal of an acoustic neurinoma, presenting as a recurrence of acoustic neurinoma on computed tomography. It points out the difficulty in differentiating a recurrent tumor from an organized hematoma in this particular case because of neuroradiological similarity and masked clinical symptoms by the long-standing neurological deficits after the original surgery. MRI scanning would have been helpful in this circumstances.

Acoustic neuroma presenting as a cyst with fluid level

A rare case of large cystic acoustic neurinoma with fluid level is described. The pathogenesis of the lesion and its differential diagnosis, particularly from meningioma, are briefly discussed.

Massive hemorrhage into intracranial neurinomas

Massive bleeding into an intracranial neurinoma is a rare event. The 12th case of this particular occurrence, which was precipitated by weight lifting, is described and a review of the literature is presented. Risk factors for bleeding appear to be tumor size and vascularity. Presenting symptomatology is abrupt and includes headache, nausea, vomiting, and depressed consciousness. Preexisting symptoms referrable to and marked dysfunction of the cranial nerve of origin are present. Deficits of neighboring cranial nerves are frequent. Computed tomography demonstrates the hemorrhages and the tumors. Mild head injury and physical exertion were precipitating factors in two cases. One-fourth of the patients died, while the others made good recoveries.

Acoustic schwannoma presenting as subarachnoid hemorrhage due to ruptured contact aneurysm

The authors report a rare combination of aneurysm and acoustic schwannoma in a 66-year-old housewife, who developed subarachnoid hemorrhage from a ruptured aneurysm arising from an arterial branch of the posterior inferior cerebellar artery on the tumor capsule. Association of aneurysm and cerebellopontine angle schwannoma is extremely rare, and there has been no report of subarachnoid hemorrhage due to ruptured contact aneurysm, although previous reports indicated a small number of acoustic schwannomas accompanying hematomas in and around tumors.

Spontaneous massive haemorrhage into acoustic neuroma during anticoagulation therapy

We report the case of a 58-year old man who bled into an undiagnosed acoustic neuroma while on long-term anticoagulation therapy which was commenced following aortic valve replacement. The patient presented with multiple cranial nerve-paralysis of sudden onset. The tumour was subtotally removed but died 5 days postoperatively from recurrent haemorrhage into the tumour bed.

Spontaneous subarachnoid hemorrhage and negative cerebral panangiography. Review of 140 cases

One hundred and forty consecutive patients who sustained proven spontaneous subarachnoid hemorrhage (SAH) with negative cerebral panangiography were studied retrospectively. Attention was directed to the presence, amount, and distribution of subarachnoid blood on computerized tomography (CT) scans. It was determined that the finding of blood on CT had a significant association with clinical grade, loss of consciousness, ventricular ratio, fixed ischemic deficit, and total of all complications, but not with epilepsy, hypertension (previously known or detected on admission), treated hydrocephalus, rebleeding, angiographic spasm, and eventual outcome (which was generally excellent on follow-up examination). The distribution of blood, predominantly around the basal cisterns, suggests leakage from ventriculostriate and thalamoperforating vessels as the cause of SAH, and closer study of these vessels is suggested.

Haemorrhage in pituitary tumours

Evidence of haemorrhage was found in 58 of 320 verified pituitary adenomas (18.1%). Haemorrhage occurred as acute or subacute apoplexy and recent or old silent haemorrhages. The differentiation was based on the predominant clinical features, the operative findings and the length of the history. There was a relatively high incidence of giant or large recurrent adenomas, invasiveness, malignant change, increased vascularity and sinusoidal characteristics on histology among the haemorrhagic tumours. The majority (53.4%) were hypopituitary but 39.6% had no obvious endocrine defect. CT scan has helped in the early preoperative diagnosis of haemorrhage in pituitary adenoma. Transcranial surgery appeared a most effective mode of treatment in the current series.