Cranial Metastasis of Hepatocellular Associated
with
Chronic
Carcinoma
Epidural
Hematoma
Case Report— — Naoyuki Department
NAKAO, Kenji KUBO and Hiroshi MORIWAKI
of Neurological
Surgery,
Hidaka
General Hospital,
Gobo , Wakayama
Abstract A case of cranial year-old male and computed emissary
metastasis
is presented. tomographic
veins
might
the artificial
bone-flap
Key words:
cranial
of hepatocellular The epidural appearance.
be a cause
of the slowly
implanted metastasis,
carcinoma
previously
expanding may
hepatocellular
Bone metastasis from hepatocellular carcinoma (HCC) occurs with an incidence of 5.8%.141 The metastatic site is most frequently the vertebrae, followed by the sternum and ribs. 14) Cranial metastasis of HCC occurs less commonly than from breast, lung, and prostate cancers '6) and few cases have been reported.913,ia,ao'21 We report a case of cranial metastasis of HCC associated with chronic epidural hematoma. The pathogenesis of this uncom mon complication is discussed.
Received
June present
13, 1991; address:
epidural
hematoma
in a 58
chronic clinical course the diploic marrow or
, and the outward displacement contributed to the chronic course . epidural
of
hematoma
sclerotic, irregular margin in the right frontal bone. A postcontrast computed tomographic (CT) scan showed a homogeneously enhanced mass in the right frontal bone, extending into extra and intra cranial regions (Fig. 1). Cerebral angiograms dem onstrated a tumor stain in the right frontal bone, which was richly supplied by branches of the right external carotid arterial system.
Report
This 58-year-old male presented in August, 1989 with a painful mass beneath the scalp in the right frontal region, which had been progressively growing for 1 month. One year previously, he underwent partial hepatectomy for a tumor in the right lobe of the liver, which was histologically diagnosed as HCC. On admission, he was alert and well oriented, with intact cognitive and neurological functions. Physi cal examination found an elastic-hard mass, 7.5 x 6.5 x 2.0 cm, in the right frontal region. Skull x ray films revealed an osteolytic defect with a non
Author's
with
an unusual from either
hematoma
also have carcinoma,
Introduction
Case
associated
hematoma demonstrated Associated bleeding
Accepted N. Nakao, Japan.
September M.D.,
Department
Fig.
1
Postcontrast
CT
right
bone.
frontal
scan,
showing
a tumor
in the
9, 1991 of Neurological
Surgery,
Wakayama
Medical
College,
Wakayama,
Fig. 2
Precontrast operation, tracranial
CT
scan
showing
6 months no abnormality
after
the
first
in the
in
space.
The tumor was radically removed with the sur rounding normal bone through a right frontal craniotomy. At operation, the tumor was found to in vade the dura, but not the cerebral parenchyma. The involved dura was totally removed and the defect repaired with lyophilized dura. A cranioplasty was performed with an artificial bone-flap of methyl methacrylate. Histological examination showed the tumor to be HCC. The postoperative course was uneventful. He was discharged without neurological deficits. No evidence of recurrence appeared for 6 months. A precontrast CT scan taken on February, 1990 reveal ed no abnormality in the intracranial space (Fig. 2). In May, 1990, he was readmitted with an enlarging mass beneath the scalp adjacent to the operative site
and a 2-week history of gradually worsening headache. There was no history of head trauma. Physical examination found an elastic-hard mass, 4.0 x 3.0 x 2.0 cm, just anterior to the operative site. The artificial bone-flap was unfixed and movable. Neurological examination found no abnor mality. Postcontrast CT scans demonstrated a tumor in the right frontal bone and an epidural mass with mixed high and low densities and an enhanced margin (Fig. 3). The epidural mass was mainly beneath the artificial bone-flap, displacing it out ward. A chest x-ray film showed no evidence of pulmonary metastasis, but an abdominal CT scan revealed HCC recurrence in the liver. Laboratory studies found no evidence of hemorrhagic diathesis. The tumor and the artificial bone-flap were totally removed through a right frontal craniotomy. A semiliquefied hematoma was found in the epidural space. The affected bone was soft and had been replaced by soft, yellow-brown, highly vascular tumor tissue. Considerable oozing from the diploic spaces invaded by the tumor was resistant to plug ging with bone wax. Total removal of the epidural hematoma demonstrated that the thickened dura was free of tumor. Histological examination revealed HCC with no evidence of intratumoral hemorrhage (Fig. 4). Microscopic examination of the thickened dura found formation of granulation tissue on the dura, but no evidence of tumoral infiltration. The postoperative course was uneventful and he was discharged without neurological deficits 1 month after the second operation. He spent a use ful life until November, 1990, when he died of liver failure.
Fig. 3 Postcontrast CT scans on the second admission, showing a tumor in the skull adjacent to the first operative site, and an epidural mass of mixed density with rim enhancement, displacing the ar tificial bone-flap outward.
Fig. 4
Photomicrograph showing tumor cytoplasms sinusoidal
and
of the cells
surgical specimen, with eosinophilic
hyperchromatic
arrangement.
HE stain,
nuclei
in
a
x 100.
Discussion HCC is generally highly vascular and therefore prone to bleeding. A frequent cause of death in HCC cases is rupture of the tumor associated with acute hem atoperitoneum.10) Several authors have confirmed intratumoral hemorrhage either macro or micro scopically in brain metastasis associated with spon taneous intracerebral hemorrhage .16." I In our case, cranial metastasis of HCC spontaneously caused an epidural hematoma. However, histological ex amination demonstrated no evidence of intratumoral hemorrhage. Intracranial hemorrhage associated with malignant tumor may be caused by the breakdown of the vasculature in the peritumoral tissue, due to destructive growth.") Therefore, bleeding from the surrounding tissue was a possible source of the epidural hematoma in our case. Only three cases of cranial tumor associated with epidural hematoma have been reported. One was cranial metastasis of HCC, in which epidural hematoma spontaneously developed.") The others were epidermoid1) and hemangioendothelioma,12) with a history of head trauma triggering bleeding from the tumor into the epidural space. All cases presented acute or subacute onset of symptoms due to the epidural hematoma. Our patient suffered a chronic headache which gradually worsened over 2 weeks. Several authors have reported "chronic" epidural hematomas which took several days to become symp tomatic .2,3,s,s,15,19>The CT appearance of chronic epidural hematoma also includes mixed density and rim enhancement due to the formation of granula
tion tissue 2,5) as seen in our case. The bleeding source is an important factor responsible for the chronic course. The slow development of symptoms is probably due to bleeding from venous systems such as the emissary veins perforating the cranium, the meningeal venous sinuses, or the diploic mar row. 1,15,19) In our case, no definite source of bleeding was found at operation. However, as the tumor had invaded the entire skull bone but without dural inva sion, associated bleeding from either the diploic mar row or emissary veins may have occurred. Under these circumstances, coagulation would normally en sue. Such venous bleeding might be the cause of chronic development, but the low-pressure bleeding is unlikely to strip the dura from the skull. Dural adherence to the skull, together with hemostatic processes, would prevent hematoma formation in the epidural space. Therefore, immediate dural strip ping from the skull at head injury, producing a space to receive blood, would explain the forma tion of chronic epidural hematoma far better than the classic concept of progressive dural stripping.2) Previous experimental studies have suggested that skull deformation due to head trauma may cause dural stripping from the calvarium.4'') In our case, the dura was not attached to the artificial bone-flap implaced at the first operation. The clots were ob served to accumulate mainly just below the artificial bone. Presumably, the outward displacement of the ar tificial bone-flap by the slowly expanding hematoma attenuated the increase in intracranial pressure, which may also have contributed to the chronic course of the present case. However, because HCC is highly vascular, bleeding from the tumor cannot be excluded as the origin of the epidural hematoma despite the lack of evidence. References 1)
2) 3) 4) 5)
6)
Abou-Samra M, Marlin AE, Story JL, Brown WE Jr: Cranial epidermoid tumor associated with subacute extradural hematoma. Case report. J Neurosurg 53: 574-575, 1980 Bullock R, VanDellen JR: Chronic extradural hematoma. Surg Neurol 18: 300-302, 1982 Clavel M, Onzain I, Gutierrez F: Chronic epidural hematoma. Acta Neurochir (Wien) 66: 71-81, 1982 Ford LE, McLaurin RL: Mechanism of extradural hematomas. J Neurosurg 20: 760-769, 1963 Handa J, Handa H, Nakano Y: Rim enhancement in computed tomography with chronic epidural hematoma. Surg Neurol 11: 217-220, 1979 Hojo S, Hirano A: Pathology of metastases, in
Takakura K, Sano K, Hojo S, Hirano A (eds): Metastatic Tumors of the Central Nervous System. Tokyo, Igaku-Shoin, 1982, pp 104-108 7) 8) 9)
10)
11)
12)
13)
14)
15)
Hooper R: Observations on extradural haemorrhage. Brit J Surg 47: 71-87, 1959 Jackson IJ, Speakman TJ: Chronic extradural hematoma. J Neurosurg 7: 444-447, 1950 Kan D, Kan M, Murata K, Mishima T, Onishi H, Kodama T, Nishimura H, Nishioka M, Takemoto T: A case of hepatocellular carcinoma with skull metastases. Kanzo 21: 1385-1389, 1980 (in Japanese) Kew MC, Geddes EW: Hepatocellular carcinoma in rural southern Africa blacks. Medicine (Baltimore) 61: 98-108, 1982 Mandybur TI: Intracranial hemorrhage caused by metastatic tumors. Neurology (Minneap) 27: 650 655, 1977 Maroon JC, Haines SJ, Phillips JG: Calvarial hemangioendothelioma with intracranial hemor rhage. Case report. Neurosurgery 4: 178-180, 1979 Nakao S, Sato S, Fukumitsu T, Ogata M, Shirane H: Cranial metastasis of hepatocellular carcinoma. Report of three cases. Neurol Med Chir (Tokyo) 25: 229-234, 1985 (in Japanese) Nakashima T, Okuda K, Kojiro M, Jimi A, Yamaguchi R, Sakamoto K, Ikari T: Pathology of hepatocellular carcinoma in Japan: 232 consecutive cases autopsied in ten years. Cancer 51: 863-877, 1983 Nora PF, Rosenbluth PR: Chronic extradural
hematoma.
16)
17)
18)
19)
20)
21)
Amer
J Surg
94: 628-631,
1957
Ohno M, Sugiyama N, Mizawa I, Tsuda H, Nakanishi K: Sudden onset multifocal brain metastasis of liver cancer: Case report. Neurol Med Chir (Tokyo) 24: 969-973, 1984 (in Japanese) Otsuka S, Fukumitsu T, Yamamoto T, Komori H, Shirane H: Brain metastasis of hepatocellular car cinoma presenting with hemorrhage: Case report. Neurol Med Chir (Tokyo) 27: 654-657, 1987 Phadke JG, Hughes RC: Hepatocellular carcinoma with cranial metastasis and hyperglobulinemia. J Neurol Neurosurg Psychiatry 44: 1171-1172, 1981 Trowbridge WV, Porter RW, French JD: Chronic ex tradural hematomas. Arch Surg (Chicago) 69: 824 830, 1954 Wakisaka S, Tashiro M, Nakano S, Kita T, Kisanuki H, Kinoshita K: Intracranial and orbital metastasis of hepatocellular carcinoma: Report of two cases. Neurosurgery 26: 863-866, 1990
Yasunaga A, Tsujimura M, Shibata S, Ono H, Mori K, Abe M, Tsuchiya R: Simple metastasis of hepatocellular carcinoma to the skull. A case report. No Shinkei Geka 10: 655-658, 1982 (in Japanese)
Address
reprint
requests
to: N. Nakao,
M.D.,
of Neurological Surgery, Wakayama lege, 7-27 Wakayama 640, Japan.
Department Medical
Col
with
Chronic
Carcinoma
Epidural
Hematoma
Case Report— — Naoyuki Department
NAKAO, Kenji KUBO and Hiroshi MORIWAKI
of Neurological
Surgery,
Hidaka
General Hospital,
Gobo , Wakayama
Abstract A case of cranial year-old male and computed emissary
metastasis
is presented. tomographic
veins
might
the artificial
bone-flap
Key words:
cranial
of hepatocellular The epidural appearance.
be a cause
of the slowly
implanted metastasis,
carcinoma
previously
expanding may
hepatocellular
Bone metastasis from hepatocellular carcinoma (HCC) occurs with an incidence of 5.8%.141 The metastatic site is most frequently the vertebrae, followed by the sternum and ribs. 14) Cranial metastasis of HCC occurs less commonly than from breast, lung, and prostate cancers '6) and few cases have been reported.913,ia,ao'21 We report a case of cranial metastasis of HCC associated with chronic epidural hematoma. The pathogenesis of this uncom mon complication is discussed.
Received
June present
13, 1991; address:
epidural
hematoma
in a 58
chronic clinical course the diploic marrow or
, and the outward displacement contributed to the chronic course . epidural
of
hematoma
sclerotic, irregular margin in the right frontal bone. A postcontrast computed tomographic (CT) scan showed a homogeneously enhanced mass in the right frontal bone, extending into extra and intra cranial regions (Fig. 1). Cerebral angiograms dem onstrated a tumor stain in the right frontal bone, which was richly supplied by branches of the right external carotid arterial system.
Report
This 58-year-old male presented in August, 1989 with a painful mass beneath the scalp in the right frontal region, which had been progressively growing for 1 month. One year previously, he underwent partial hepatectomy for a tumor in the right lobe of the liver, which was histologically diagnosed as HCC. On admission, he was alert and well oriented, with intact cognitive and neurological functions. Physi cal examination found an elastic-hard mass, 7.5 x 6.5 x 2.0 cm, in the right frontal region. Skull x ray films revealed an osteolytic defect with a non
Author's
with
an unusual from either
hematoma
also have carcinoma,
Introduction
Case
associated
hematoma demonstrated Associated bleeding
Accepted N. Nakao, Japan.
September M.D.,
Department
Fig.
1
Postcontrast
CT
right
bone.
frontal
scan,
showing
a tumor
in the
9, 1991 of Neurological
Surgery,
Wakayama
Medical
College,
Wakayama,
Fig. 2
Precontrast operation, tracranial
CT
scan
showing
6 months no abnormality
after
the
first
in the
in
space.
The tumor was radically removed with the sur rounding normal bone through a right frontal craniotomy. At operation, the tumor was found to in vade the dura, but not the cerebral parenchyma. The involved dura was totally removed and the defect repaired with lyophilized dura. A cranioplasty was performed with an artificial bone-flap of methyl methacrylate. Histological examination showed the tumor to be HCC. The postoperative course was uneventful. He was discharged without neurological deficits. No evidence of recurrence appeared for 6 months. A precontrast CT scan taken on February, 1990 reveal ed no abnormality in the intracranial space (Fig. 2). In May, 1990, he was readmitted with an enlarging mass beneath the scalp adjacent to the operative site
and a 2-week history of gradually worsening headache. There was no history of head trauma. Physical examination found an elastic-hard mass, 4.0 x 3.0 x 2.0 cm, just anterior to the operative site. The artificial bone-flap was unfixed and movable. Neurological examination found no abnor mality. Postcontrast CT scans demonstrated a tumor in the right frontal bone and an epidural mass with mixed high and low densities and an enhanced margin (Fig. 3). The epidural mass was mainly beneath the artificial bone-flap, displacing it out ward. A chest x-ray film showed no evidence of pulmonary metastasis, but an abdominal CT scan revealed HCC recurrence in the liver. Laboratory studies found no evidence of hemorrhagic diathesis. The tumor and the artificial bone-flap were totally removed through a right frontal craniotomy. A semiliquefied hematoma was found in the epidural space. The affected bone was soft and had been replaced by soft, yellow-brown, highly vascular tumor tissue. Considerable oozing from the diploic spaces invaded by the tumor was resistant to plug ging with bone wax. Total removal of the epidural hematoma demonstrated that the thickened dura was free of tumor. Histological examination revealed HCC with no evidence of intratumoral hemorrhage (Fig. 4). Microscopic examination of the thickened dura found formation of granulation tissue on the dura, but no evidence of tumoral infiltration. The postoperative course was uneventful and he was discharged without neurological deficits 1 month after the second operation. He spent a use ful life until November, 1990, when he died of liver failure.
Fig. 3 Postcontrast CT scans on the second admission, showing a tumor in the skull adjacent to the first operative site, and an epidural mass of mixed density with rim enhancement, displacing the ar tificial bone-flap outward.
Fig. 4
Photomicrograph showing tumor cytoplasms sinusoidal
and
of the cells
surgical specimen, with eosinophilic
hyperchromatic
arrangement.
HE stain,
nuclei
in
a
x 100.
Discussion HCC is generally highly vascular and therefore prone to bleeding. A frequent cause of death in HCC cases is rupture of the tumor associated with acute hem atoperitoneum.10) Several authors have confirmed intratumoral hemorrhage either macro or micro scopically in brain metastasis associated with spon taneous intracerebral hemorrhage .16." I In our case, cranial metastasis of HCC spontaneously caused an epidural hematoma. However, histological ex amination demonstrated no evidence of intratumoral hemorrhage. Intracranial hemorrhage associated with malignant tumor may be caused by the breakdown of the vasculature in the peritumoral tissue, due to destructive growth.") Therefore, bleeding from the surrounding tissue was a possible source of the epidural hematoma in our case. Only three cases of cranial tumor associated with epidural hematoma have been reported. One was cranial metastasis of HCC, in which epidural hematoma spontaneously developed.") The others were epidermoid1) and hemangioendothelioma,12) with a history of head trauma triggering bleeding from the tumor into the epidural space. All cases presented acute or subacute onset of symptoms due to the epidural hematoma. Our patient suffered a chronic headache which gradually worsened over 2 weeks. Several authors have reported "chronic" epidural hematomas which took several days to become symp tomatic .2,3,s,s,15,19>The CT appearance of chronic epidural hematoma also includes mixed density and rim enhancement due to the formation of granula
tion tissue 2,5) as seen in our case. The bleeding source is an important factor responsible for the chronic course. The slow development of symptoms is probably due to bleeding from venous systems such as the emissary veins perforating the cranium, the meningeal venous sinuses, or the diploic mar row. 1,15,19) In our case, no definite source of bleeding was found at operation. However, as the tumor had invaded the entire skull bone but without dural inva sion, associated bleeding from either the diploic mar row or emissary veins may have occurred. Under these circumstances, coagulation would normally en sue. Such venous bleeding might be the cause of chronic development, but the low-pressure bleeding is unlikely to strip the dura from the skull. Dural adherence to the skull, together with hemostatic processes, would prevent hematoma formation in the epidural space. Therefore, immediate dural strip ping from the skull at head injury, producing a space to receive blood, would explain the forma tion of chronic epidural hematoma far better than the classic concept of progressive dural stripping.2) Previous experimental studies have suggested that skull deformation due to head trauma may cause dural stripping from the calvarium.4'') In our case, the dura was not attached to the artificial bone-flap implaced at the first operation. The clots were ob served to accumulate mainly just below the artificial bone. Presumably, the outward displacement of the ar tificial bone-flap by the slowly expanding hematoma attenuated the increase in intracranial pressure, which may also have contributed to the chronic course of the present case. However, because HCC is highly vascular, bleeding from the tumor cannot be excluded as the origin of the epidural hematoma despite the lack of evidence. References 1)
2) 3) 4) 5)
6)
Abou-Samra M, Marlin AE, Story JL, Brown WE Jr: Cranial epidermoid tumor associated with subacute extradural hematoma. Case report. J Neurosurg 53: 574-575, 1980 Bullock R, VanDellen JR: Chronic extradural hematoma. Surg Neurol 18: 300-302, 1982 Clavel M, Onzain I, Gutierrez F: Chronic epidural hematoma. Acta Neurochir (Wien) 66: 71-81, 1982 Ford LE, McLaurin RL: Mechanism of extradural hematomas. J Neurosurg 20: 760-769, 1963 Handa J, Handa H, Nakano Y: Rim enhancement in computed tomography with chronic epidural hematoma. Surg Neurol 11: 217-220, 1979 Hojo S, Hirano A: Pathology of metastases, in
Takakura K, Sano K, Hojo S, Hirano A (eds): Metastatic Tumors of the Central Nervous System. Tokyo, Igaku-Shoin, 1982, pp 104-108 7) 8) 9)
10)
11)
12)
13)
14)
15)
Hooper R: Observations on extradural haemorrhage. Brit J Surg 47: 71-87, 1959 Jackson IJ, Speakman TJ: Chronic extradural hematoma. J Neurosurg 7: 444-447, 1950 Kan D, Kan M, Murata K, Mishima T, Onishi H, Kodama T, Nishimura H, Nishioka M, Takemoto T: A case of hepatocellular carcinoma with skull metastases. Kanzo 21: 1385-1389, 1980 (in Japanese) Kew MC, Geddes EW: Hepatocellular carcinoma in rural southern Africa blacks. Medicine (Baltimore) 61: 98-108, 1982 Mandybur TI: Intracranial hemorrhage caused by metastatic tumors. Neurology (Minneap) 27: 650 655, 1977 Maroon JC, Haines SJ, Phillips JG: Calvarial hemangioendothelioma with intracranial hemor rhage. Case report. Neurosurgery 4: 178-180, 1979 Nakao S, Sato S, Fukumitsu T, Ogata M, Shirane H: Cranial metastasis of hepatocellular carcinoma. Report of three cases. Neurol Med Chir (Tokyo) 25: 229-234, 1985 (in Japanese) Nakashima T, Okuda K, Kojiro M, Jimi A, Yamaguchi R, Sakamoto K, Ikari T: Pathology of hepatocellular carcinoma in Japan: 232 consecutive cases autopsied in ten years. Cancer 51: 863-877, 1983 Nora PF, Rosenbluth PR: Chronic extradural
hematoma.
16)
17)
18)
19)
20)
21)
Amer
J Surg
94: 628-631,
1957
Ohno M, Sugiyama N, Mizawa I, Tsuda H, Nakanishi K: Sudden onset multifocal brain metastasis of liver cancer: Case report. Neurol Med Chir (Tokyo) 24: 969-973, 1984 (in Japanese) Otsuka S, Fukumitsu T, Yamamoto T, Komori H, Shirane H: Brain metastasis of hepatocellular car cinoma presenting with hemorrhage: Case report. Neurol Med Chir (Tokyo) 27: 654-657, 1987 Phadke JG, Hughes RC: Hepatocellular carcinoma with cranial metastasis and hyperglobulinemia. J Neurol Neurosurg Psychiatry 44: 1171-1172, 1981 Trowbridge WV, Porter RW, French JD: Chronic ex tradural hematomas. Arch Surg (Chicago) 69: 824 830, 1954 Wakisaka S, Tashiro M, Nakano S, Kita T, Kisanuki H, Kinoshita K: Intracranial and orbital metastasis of hepatocellular carcinoma: Report of two cases. Neurosurgery 26: 863-866, 1990
Yasunaga A, Tsujimura M, Shibata S, Ono H, Mori K, Abe M, Tsuchiya R: Simple metastasis of hepatocellular carcinoma to the skull. A case report. No Shinkei Geka 10: 655-658, 1982 (in Japanese)
Address
reprint
requests
to: N. Nakao,
M.D.,
of Neurological Surgery, Wakayama lege, 7-27 Wakayama 640, Japan.
Department Medical
Col
