Spontaneous intracranial epidural hematoma originating from dural metastasis of hepatocellular carcinoma

Spontaneous Acute Epidural Hematoma Associated With Metastatic Hepatocellular Carcinoma: A Case Report

Spontaneous acute epidural hematoma (AEDH) co-occurring with metastatic hepatocellular carcinoma (HCC) of the skull is rare, with only 7 documented cases in existing literature. This report describes the case of a 42-year-old man who presented with decreased consciousness following intermittent headaches following minor head trauma. Computed tomography imaging revealed an AEDH, prompting surgical intervention. Despite preliminary assumptions linking the causes of the trauma, surgical exploration revealed no evidence of traumatic injury. Instead, an infiltrative soft-tissue mass within the skull was identified. Histopathological examination confirmed that the mass was a metastatic HCC. Despite the successful hematoma evacuation, the patient's neurological status did not improve. This case underscores the importance of considering metastatic disease in the differential diagnosis of AEDH, particularly in patients with a history of malignant tumors, irrespective of prior indications of bone metastasis. Furthermore, it emphasizes the need to enhance diagnostic and therapeutic strategies for such complex cases.

Cryptogenic recurrent spontaneous intracranial epidural hematoma: A case report and literature review

Background

Spontaneous epidural hematoma (EDH) has been suggested to be associated with adjacent infective pathologies, dural vascular malformations, extradural metastases, or coagulopathies. Cryptogenic spontaneous EDH is extremely rare.

Case presentation

The present study reports the case of a cryptogenic spontaneous EDH in a young woman following sexual intercourse. She was diagnosed with consecutive EDH at three different sites within a short time. After three timely operations, a satisfactory outcome was achieved.

Conclusion

EDH should be investigated when a young patient develops headaches and shows signs of increased ICP after emotional hyperactivity or hyperventilation. If early diagnosis and surgical decompression can be carried out in time, the prognosis would be satisfactory.

Spontaneous epidural hematoma induced by rivaroxaban: A case report and review of the literature

Background:

Trauma is the most frequent reason for epidural bleeding. However, numerous investigation had discovered that anticoagulants such as rivaroxaban could cause epidural hematoma. Here, we present a case of epidural hematoma in young man who got rivaroxaban as treatment of deep vein thrombosis.

Case Description:

A 27-year-old male with a history of deep vein thrombosis and one month of rivaroxaban medication presented with seizure and loss of consciousness following a severe headache. A CT scan of the head revealed epidural bleeding, and emergency blood clot removal was performed. As a reversal, prothrombin complex was utilized.

Conclusion:

Rivaroxaban has the potential to cause an epidural hemorrhage. Reversal anticoagulant should be administered before doing emergency surgery.

Sinovenous outflow in lateral sinus dural arteriovenous fistulas after stereotactic radiosurgery: a retrospective longitudinal imaging study

PURPOSE

To investigate sinovenous outflow restriction (SOR) in lateral sinus dural arteriovenous fistulas (LSDAVFs) after Gamma Knife radiosurgery (GKRS) and its association with complete obliteration.

METHODS

We retrospectively (1995-2019) enrolled 39 patients with LSDAVFs who had undergone GKRS alone and evaluated their angiography and magnetic resonance imaging (MRI) before and after GKRS. The LS conduits ipsilateral and contralateral to the DAVFs were scored using a 5-point scoring system, with scores ranging from 0 (total occlusion) to 4 (fully patent). SOR was defined by a conduit score < 2. Demographics, imaging features, and outcomes were compared between patients with and without ipsilateral SOR after GKRS. Logistic regression analysis was performed to estimate the odds ratio (OR) for obliteration with the imaging findings.

RESULTS

After a median angiographic follow-up of 28 months for the 39 patients, the ipsilateral LS became more restrictive (median conduit score before and after GKRS: 2 vs. 1, p = .011). Twenty-one patients with ipsilateral SOR after GKRS had a significantly lower obliteration rate (52.4% vs. 94.4%, p = .005) than those without SOR. Follow-up SOR was independently associated with a lower obliteration rate (OR 0.05, p = .017) after adjustment for age, cortical venous reflux, and absent sinus flow void on MRI.

CONCLUSION

This study demonstrates a restrictive change of outflow in LSDAVFs after GKRS and a lower obliteration rate in patients with SOR. Follow-up imaging for SOR may help predict outcomes of these patients.

Spontaneous acute epidural hematoma secondary to skull and dural metastasis of hepatocellular carcinoma: A case report

BACKGROUND

The skull and dura are uncommon sites for the metastasis of hepatocellular carcinoma (HCC). Spontaneous acute epidural hematoma (AEDH) is also very rare. We report here a spontaneous AEDH secondary to skull and dural metastasis of HCC. This case is extremely rare.

CASE SUMMARY

A 48-year-old male patient with a history of HCC developed unconsciousness spontaneously. Head computed tomography showed "a huge AEDH in the left parietal and occipital region with osteolytic destruction of the left parietal bone. Emergent operation was performed to evacuate the hematoma and resect the lesion. Pathological study revealed that the lesion was the metastases from HCC. The patient died of lung infection, anemia, and liver failure 3 wk after operation.

CONCLUSION

Spontaneous AEDH caused by hepatocellular carcinoma (HCC) dural and skull metastases is extremely rare, the outcome is poor. So, early diagnosis is important. If the level of AFP does not decrease with the shrinkage of intrahepatic lesions after treatment, it is necessary to be alert to the existence of extrahepatic metastases. Since most of the patients had scalp and bone masses, physicians should pay attention to the patient's head palpation. Once a patient with the history of HCC had sudden neurological dysfunction, the possibility of spontaneous AEDH caused by the skull and dura mater metastases should be considered. Since hemorrhage is common in the skull HCC metastases, for patients with spontaneous AEDH accompanied by skull osteolytic lesions, it is also necessary to be alert to the possibility of HCC. For AEDH secondary to HCC metastases, early diagnosis and timely treatment are critical to improve the patients’ outcomes.

Spontaneous acute epidural hematoma associated with chronic subdural hematoma due to dural metastasis of gastric carcinoma: a case report and literature review

Background: Non-traumatic spontaneous acute epidural hematoma (EDH) happening to chronic subdural hematoma (SDH) caused by dural metastases is a rare entity. Pathogenesis can be derived from infection, coagulopathy, and inflammation. Malignant tumors metastasize to dura mater is one of the most infrequent causes. The exact mechanism remains elusive in spite of several possible speculations. The clinical manifestations, management and outcomes vary among reported cases.Case Description: A 45-year-old woman without history of trauma presented with headache, vomiting and disturbance of consciousness and developed brain hernia rapidly. On arival, she has lost into coma with Glasgow coma scale (GCS) score 5, bilateral pupils were not equal, with disappeared reflectance. Emergency imaging prompted large acute EDH, combined with SDH, arising from dural granular neoplasm confirmed intraoperatively. Four days after surgery, the bilateral pupils were equal in size and sensitive to light reflection.Conclusion: Dural metastases can cause EDH, chronic SDH can also be resulted from metastatic tumors of dura mater. When dealing with spontaneous non-traumatic hematoma around the dura mater, to make the precise diagnosis is sometimes doubtful and confusing. The stream of diagnostic thinking should be opened, including medical diseases such as liver and kidney disease, drug history, history of cancer and other possible clues. Thus, a detailed and purposeful systematic medical history review and physical examination is important in order to make more appropriate strategies for the clinic.

Superior Sagittal Sinus Tumor Eroding through the Skull: An Unfamiliar Presentation of Hepatocellular Carcinoma and Literature Review

Background

Hepatocellular carcinoma (HCC) most commonly develops in patients with liver cirrhosis caused by hepatitis C and B virus. HCC is the most common cause of death in people with cirrhosis. The lungs, bone, and lymph nodes are frequent sites of metastasis of HCC.

Patients and Methods

We present a case of solitary skull metastasis as the first symptom of HCC. A literature review with regard to HCC skull metastasis was undertaken.

Results

This patient had HCC based on chronic hepatitis C. He presented with an erosive lesion masquerading as a scalp lipoma resulting in hepatocellular carcinoma with retrograde reflux and sinus metastases. The lesion was ultimately resected, but the patient died within one week from liver failure. Seventeen similar cases were found in the literature. Median age of the patients was 58 years with 95% being male and 35% having viral hepatitis. Surgery was the preferred treatment with chemotherapy and radiation being other options. Outcome was acceptable but baseline liver disease is a limiting factor.

Discussion

Cranial metastases of HCC are rare but should be considered in patients with chronic hepatitis C presenting with scalp skin lesions.

Intracranial dural, calvarial, and skull base metastases

Metastatic disease to the intracranial dura, the calvarium, and the skull base is relatively uncommon but presents unique diagnostic and management challenges in the patient with cancer. Modern imaging techniques have facilitated the detection of intracranial tumor deposits, leading to increased incidence. While dural and calvarial metastases often present with nonspecific symptoms, skull base metastases present with distinct clinical syndromes dependent on the local neurovascular structures affected. Intracranial dural metastases can often be confused with meningioma and pose a diagnostic challenge, as well as significant neurologic morbidity, especially in the setting of hemorrhage. Surgical intervention may be helpful in selected patients for symptomatic relief as well as survival benefit. Management paradigms need to take into account the relative risks, benefits, and likely outcomes for each possible modality of treatment. Surgical excision is useful in many patients and in combination with radiation therapy can provide significant palliation. While medical therapy is rarely an initial therapy in these entities, it may be of added benefit dependent on the underlying tumor histology and prior treatment history. Occasionally treatment with curative intent is justified.

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.

Acute spontaneous subdural hematoma caused by skull metastasis of hepatocellular carcinoma: case report

BACKGROUND

Skull and intracranial metastases from hepatocellular carcinoma (HCC) have seldom been reported. A skull metastasis of HCC with a tumor bleeding resulting in spontaneous subdural hematoma (SDH) is extremely unusual. We report the first case of acute spontaneous SDH in a 69-year-old woman who presented with acute onset of headache, because of tumor bleeding caused by skull metastasis of HCC.

CASE PRESENTATION

A 69-year-old woman was referred to our hospital because of progressive headache, nausea, and vomiting for 3 days. Brain computed tomography (CT) performed in the emergency department (ED) revealed a left temporal SDH with a slight mass effect and a small left temporal bone erosion. Tri-phasic abdominal CT demonstrated a large right lobe liver tumor compatible with HCC. She experienced progressive deterioration of consciousness in the intensive care unit. Follow-up CT showed an enlargement of the SDH. An emergency craniotomy for hematoma evacuation and removal of skull tumor was performed. She regained consciousness and had no neurological deficits during the postoperative course. Pathological examination of the skull specimen indicated metastasis of a HCC.

CONCLUSION

Patients with acute SDH without a history of head injury are rarely encountered in the ED. Metastatic carcinoma with bleeding should be included as a differential diagnosis for acute spontaneous SDH. Before an operation for SDH, the possibility of metastatic lesion of the skull should be considered in the surgical planning and the origin of malignancy should be sought.

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.

Retrobulbar metastasis and intracranial invasion from postoperative hepatocellular carcinoma: A case report and review of the literature

Hepatocellular carcinoma (HCC) is the most common malignant cancer of the liver and the third ranking cause of cancer-related mortality worldwide. Following the diagnosis of HCC, intrahepatic and extrahepatic metastasis patients account for ~50–75% of all HCC cases, lung and regional lymph nodes metastasis are the most common; metastasis to bone, skin and adrenal glands are rare, orbit metastasis and intracranial invasion are extremely rare. The present study reports the rare case of a patient with HCC that metastasized to the head. The patient presented with retrobulbar and intracranial invasion, and sub-scalp extension. Based on imaging findings, the lesion was initially misdiagnosed as meningioma, however, postoperative pathological examinations resulted in a definitive diagnosis of HCC metastasis. Based on the present case and a review of the relevant literature published since 2009, the current study recommends that metastasis must be considered when diagnosing retrobulbar head lesions in patients with HCC, regardless of contradictory imaging findings and other clinical indicators, which may closely mimic the original head lesion.

Retrobulbar metastasis and intracranial invasion from postoperative hepatocellular carcinoma: A case report and review of the literature

Hepatocellular carcinoma (HCC) is the most common malignant cancer of the liver and the third ranking cause of cancer-related mortality worldwide. Following the diagnosis of HCC, intrahepatic and extrahepatic metastasis patients account for ~50-75% of all HCC cases, lung and regional lymph nodes metastasis are the most common; metastasis to bone, skin and adrenal glands are rare, orbit metastasis and intracranial invasion are extremely rare. The present study reports the rare case of a patient with HCC that metastasized to the head. The patient presented with retrobulbar and intracranial invasion, and sub-scalp extension. Based on imaging findings, the lesion was initially misdiagnosed as meningioma, however, postoperative pathological examinations resulted in a definitive diagnosis of HCC metastasis. Based on the present case and a review of the relevant literature published since 2009, the current study recommends that metastasis must be considered when diagnosing retrobulbar head lesions in patients with HCC, regardless of contradictory imaging findings and other clinical indicators, which may closely mimic the original head lesion.

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.

Tumour bleed manifesting as spontaneous extradural haematoma in posterior fossa

We report a unique case of primary extradural angiosarcoma of posterior fossa manifesting as extradural haematoma in a 12-year-old boy who presented with acute onset headache, vomiting, nuchal rigidity and altered sensorium. The patient underwent a retromastoid suboccipital craniotomy on emergency basis, and the lesion was excised completely. Histopathology and immunohistochemistry revealed an angiosarcoma, following which radiation therapy was given. The patient showed complete clinical and neurological improvement. At a follow-up of 2 years he is in good health without any sign of regrowth.

Spontaneous epidural haematoma in sickle cell anaemia: case report and literature review

Non traumatic spontaneous epidural Haematoma is a rare and often unmentioned complication of sickle cell disease. It is often associated with skull bone infarction. We report an eighteen year old boy with sickle cell anaemia who developed persistence headache during a vaso-occlusive crisis. Brain computed tomography (CT) revealed a right frontal epidural Haematoma (EDH) compressing on the brain. No other etiologic factor was identified. A right frontal craniotomy and evacuation of the Haematoma was performed and he made good recovery. The possible pathogeneses of this rare condition are discussed.