Brain Tumors Manifesting as Intracranial Hemorrhage

Toru IWAMA, Akio OHKUMA, Yoshiaki MIWA, Shingo SUGIMOTO,

Takeshi ITOH, Mitsuaki TAKADA*, Yusuke TANABE**,
Takashi FUNAKOSHI***, Noboru SAKAI †
and Hiromu YAMADA †

Department of Neurosurgery, Prefectural Gifu Hospital, Gifu;

*Department of Neurosurgery
, Takayama Red Cross Hospital, Takayama, Gifu;
**Department of Neurosurgery
, Gifu City Hospital, Gifu;
***Department of Neurosurgery , Daiyukai General Hospital, Ichinomiya, Aichi;
† Department of Neurosurgery, Gifu University School of Medicine, Gifu

Abstract

The clinical course and computed tomographic (CT) findings of 23 patients with brain tumors
manifesting as tumoral hemorrhage were reviewed. The most common symptoms were headache
and clouding of consciousness. A CT finding of a lesion located next to a solid or irregular clot indi
cated intratumoral hemorrhage. Precontrast CT demonstrating an indent on the hematoma surface
was a valuable indicator of tumoral hemorrhage. A CT finding of accumulated levels of blood⁄
fluid or a hyperdense mass containing small hematoma indicated intratumoral hemorrhage, and ob
scure hyperdensity indicated intratumoral hemorrhagic infarction. Such findings were often difficult
to distinguish from spontaneous intracerebral hemorrhage due to other factors. The incidence of
rebleeding from residual tumors was high, carrying a very poor prognosis, so radical removal of brain
tumors with hemorrhage is very important.

Key words: brain neoplasm, intracranial hemorrhage, computed tomography,

apoplectic symptoms, clinical course

Introduction between January, 1979 and March, 1990. Table 1

summarizes the clinical courses of all patients.
Previously unsuspected brain tumors occasionally
manifest as intracranial hemorrhage, which must be I. Onset and symptoms
differentiated from spontaneous intracranial hemor All 23 patients had a clear history of acute
rhage caused by cerebral aneurysm, vascular mal episodes indicating sudden intracranial bleeding
formation, or hypertensive cerebrovascular dis despite being asymptomatic previously. No
ease. 1,6,11,12."6) Although such cases have been widely predisposing factors were present except in Case 12
reported, the clinical features have not been fully who became unconscious following head injury. The
reviewed. The purpose of our study was to establish most common symptoms were headache, vomiting,
the clinical features and diagnostic problems of in and/or loss of consciousness due to acute increases
tracranial brain tumors manifesting as intracranial in intracranial pressure.
hemorrhage.
II.Initial investigation and diagnosis
Clinical Study Initial computed tomographic (CT) scans revealed
11 cases of brain tumor with hemorrhage, five of sub
This study included 23 cases of brain tumors cortical hemorrhage, three of cerebellar hemorrhage,
manifesting as intracranial hemorrhage, 10 males three of brain tumor with no detectable hemorrhage,
and 13 females with ages from 2 to 81 years (mean: and one of cerebral hemorrhagic infarction. Based
46.8 years) seen at five participating medical facilities on this initial diagnosis, the cases were divided into
Group 1 of 14 brain tumor cases with or without
Received January 21, 1991; Accepted July 30, 1991 hemorrhage, and Group 2 of nine cases with subcor
 Table 1 Clinical summary of 23 cases of brain tumor manifesting as hemorrhage

tical hemorrhage, cerebellar hemorrhage, or cerebral postcontrast CT as homogeneous with hyperdense

hemorrhagic infarction but not suspected of brain areas, called a "solid mass" (Fig. 3). Postcontrast
tumor. CT scans showed the one case of subarachnoid
Table 2 summarizes the CT appearance of cases in hemorrhage as an extraparenchymal mass.
Group 1. The tumoral hemorrhage was diagnosed Angiography demonstrated dislocation of the
perioperatively in the three cases where CT did not cerebral vessels in four cases, and tumor staining
detect the hematoma. The precontrast CT scans in two meningioma cases (Cases 8, 14). No other ab
demonstrated a large indent in the hematoma in two normalities were found.
of the six cases demonstrating a solid or irregular Table 3 summarizes the initial CT findings for the
clot. Postcontrast CT scans revealed a mass in the nine cases in Group 2. Precontrast CT scans
hematoma margin, called a "core," in five of these demonstrated a solid clot in eight cases and cerebral
six cases (Fig. 1), with the other case demonstrating a hemorrhagic infarction in one. No postcontrast CT
ring-like enhancement surrounding the hematoma, studies were obtained. Moderate to severe perifocal
called a "thick wall." Postcontrast CT scans also edema was present in all cases except one of extra
demonstrated this thick wall in the two cases in parenchymal tumor which was eventually diagnosed
which precontrast CT scans revealed accumulated as acoustic neurinoma.
levels of blood/fluid (Fig. 2). Precontrast CT scans Angiography demonstrated extravasation of con
showed small multiple hematomas or intratumoral trast medium in one case of astrocytoma (Case 15),
hemorrhagic infarction in two cases, visualized by and dislocation of cerebral vessels in two. However,
 Table 2 CT findings for Group 1 patients

no other abnormalities were found. III. Site of tumoral hemorrhage

Emergency surgery to evacuate the hematoma was The locations of tumoral hemorrhage determined
conducted in the two cases of dislocated vessels, by CT and/or perioperative findings were in
revealing tumoral hemorrhage. Brain tumor was tracerebral or intracerebellar (13 cases), intratumoral
diagnosed in the other seven cases after repeat CT (8), subdural (1), and subarachnoid (1).
scanning and conservative therapy (Fig. 4). The nine
patients in Group 2 demonstrated discrepancies in IV. Treatment and outcome
the actual clinical course and the typical clinical All brain tumors were surgically removed except
course for hypertensive intracerebral or in one case of rapid deterioration resulting in death.
tracerebellar hemorrhage (Table 3). However, the
CT findings corresponded well with typical CT
of hypertensive hemorrhages.

Fig. 1 Case 5. A: Precontrast CT scan, showing a Fig. 2 Case 4. Precontrast CT scan 2 weeks after
solid hematoma in the left parietal lobe. An in onset, demonstrating a ring-like hyperdense le
dent on the hematoma surface (arrow) appears sion with moderate perifocal edema. Ac
as a hypodense area. B: Postcontrast CT cumulated levels of blood/fluid inside the le
scan, demonstrating a ring-like enhancement sion indicate an intratumoral hemorrhage.
of the hypodense lesion, called a "core."
 rhage was found in the other tumor specimens.

Discussion

Hemorrhage from a brain tumor frequently occurs,

and is a primary cause of spontaneous intracranial
hemorrhage. Although not always symptomat
ic,4,1o,16>
tumoral hemorrhage should be suspected in
brain tumor patients demonstrating sudden deterio
ration of clinical symptoms,",") but must be differ
entiated from hemorrhage caused by some other
disease. However, determining the cause is often
difficult even with advanced diagnostic modalities
Fig. 3 Case 6. A: Precontrast CT scan, demon
such as CT.Z,s,6,,3)
strating an obscure hyperdense lesion in the
Intracranial hemorrhage originating from brain
cerebellar hemisphere. B: Postcontrast CT
tumors accounts for 0.9-10.2% of all reported in
scan, showing a homogeneous enhancement
of the cerebellar lesion.
tracranial hemorrhage. 1,5,6,9,13)Tumoral hemorrhage
occurs in 1.7-9.6% of all primary or metastatic in
tracranial tumors. 1,3-5,10,12,15,16)
Intracranial hemor
Complete removal was achieved in 15 cases, with the rhage was the primary symptom in the diagnosis of
others undergoing subtotal removal. The six met nearly 40% of all brain tumors with intracranial
astatic brain tumors were totally removed, but re hemorrhage, and brain tumors first manifest as
peat CT scans revealed additional brain metastases hemorrhage in 0.54-3.4% of all cases. 1,6,11,12,16)
In our
in four of the six. Tumor rebleeding occurred in six series, 3.4% of brain tumors (23 of 675 patients)
of 11 cases with subtotal removal or with further treated at participating medical facilities manifested
brain metastases. as tumoral hemorrhage, which agrees well with
The outcome was generally poor in cases with previous findings. This indicates that, contrary to
malignant histology and bleaker in cases of previous belief, intracranial hemorrhage is not an un
rebleeding. common first sign of a previously unsuspected brain
tumor.
V. Histological findings Our study agreed with previous reports that
Table 1 gives the histological diagnosis for all cases clouding of consciousness and headache are the most
receiving surgery. High vascularity was noted in four common symptoms following hemorrhage. 1,6)
cases (Cases 8, 12, 17, 23) (Fig. 5) and coagulation Hemorrhage is more likely with some types of
necrosis in three (Cases 5, 7, 8). Irregularly dilated tumor. 1,7,16)Oligodendroglioma, glioblastoma, and
vessels were found in the case of acoustic neurinoma metastatic tumor are associated with hemorrhage,
(Case 21). No specific evidence of tumoral hemor although Kondziolka et al.4) reported that

Table 3 CT findings and diagnoses for Group 2 patients

 Fig. 4 Case 20. A: Initial precontrast CT scan, demonstrating a round hyperdense mass in the right
cerebellar hemisphere. B, C: Precontrast CT scan (B) 2 weeks after onset shows no abnor
malities, but postcontrast CT scan (C) revealed a small lesion on the surface of the right cerebellar
hemisphere (arrow). D, E: Pre (D) and postcontrast CT scans (E) 6 weeks after initial symp
toms, showing enlargement of the previously enhanced lesion plus perifocal edema.

macroscopic hemorrhage occurs more frequently in

low-grade astrocytoma than in glioblastoma. In our
experience, hemorrhage was associated more with
astrocytoma and metastatic brain tumor. Among
metastases, malignant melanoma and lung cancer
were likely to cause hemorrhage.',',')
Head injury, hypertension, shunt procedures, and
anticoagulants are predisposing factors for tumoral
hemorrhage.',',',',', 12,16) However, hypertension
generally is probably unrelated to the etiology of
tumoral hemorrhage. 1,4,7,8,10)We had only one such
case who became comatose after head injury.
Histological features of tumoral hemorrhage in
Fig. 5 Case 12 (fibrillary astrocytoma). Photomicro
clude tumor necrosis with vessel-wall degeneration,
graph of the tumor specimen, showing small
astrocytic cells with a slightly irregular nucle many thin-wall vessels, thrombosis, and ruptured
us, forming microcysts. Capillary blood vessels vessels.a,6,',1s>
We observed such findings infrequent
are a little more prominent than usual. HE ly, but the histological specimens may have been too
stain, x 200. limited. The mechanism of bleeding has not been de
fined, but presumably fragile vessels are ruptured
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Significance of hemorrhage into brain tumors.
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