J Neurosurg 49:301-302, 1978
Metastatic melanoma simulating subdural hematoma Case report
F. JOHN PALMER, M.B., CH.B., M.R.C.P., M.R.A.C.R., F.R.C.R., AND ANTHONY P. POULGRAIN, M.B., B.S., F.R.C.S., F.R.C.S.I.
Departments of Radiology and Neurosurgery, Prince Henry Hospital, Little Bay, New South Wales, Australia w' Metastatic melanoma tends to be found in subcortical white matter and this localization may produce clinical or radiological features that are unusual in metastatic disease. A case is described that closely simulated a subdural hematoma both clinically and radiologically. KEY WORDS cerebral metastasis subdural hematoma ~
M
ETASTASIS to the central nervous system occurs in approximately 50% of cases of malignant melanomas. 1 The tumor may be found anywhere in the brain or spinal cord. However, there appears to be a distinct potentiality for melanoma metastases to localize in the subcortical white matter. 2,e The tumor may subsequently rupture onto the cortical surface, which may lead to clinical or radiological features that are unusual in metastatic disease. Case Report
This 33-year-old woman presented with frontal headaches which had persisted since she hit her head against a garage door 3 weeks previously. The blow was not severe and consciousness was not impaired. One week before admission she developed clumsiness and weakness in the left arm. Examination. At the time of admission, she was conscious and well oriented. The only positive findings were early papilledema and
J. Neurosurg. / Volume 49 / August, 1978
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9
mild left hemiparesis. A radioisotope cerebral scan with technetium-99m pertechnetate demonstrated abnormal uptake in the right parietotemporal region, and electroencephalography revealed abnormal slow wave activity in the same region. Blood counts, electrolytes, urinalysis and a chest radiograph were normal. Right common carotid angiography showed a 5-mm " s q u a r e " shift of the pericallosal artery to the left side. There was also a crescent-shaped avascular space overlying the right temporal lobe (Fig. 1). This was demonstrated to better advantage in the oblique view. No neovascularity was identified. These studies and the history of recent head trauma led to a confident diagnosis of subdural hematoma. Operation. At operation (Dr. A. Gonski) a reddish-black tumor was found lying over the temporal lobe surface and occupying the space noted on the angiograms. Frozen section confirmed a diagnosis of malignant melanoma, and right temporal lobectomy 301
F. J. P a l m e r a n d A. P. P o u l g r a i n and Savitsky' found that 49% of 56 cerebral melanomas developed SAH, while SAH occurred in only two of 56 cases of metastases from other sites. Similarly, contact with the leptomeninges allows development of arterial supply from meningeal vessels. In the series of Wolpert, et al., 7 two of seven vascular metastatic melanomas showed meningeal arterial supply. A similar case, seen in this department, was misdiagnosed as a meningioma because of meningeal arterial supply and homogenous tumor blush. The present case demonstrates a further manifestation of the unusual behavior of metastatic melanoma. The tumor spreading over the cortex produced an avascular space that simulated a subdural hematoma at FIG. 1. Right common carotid angiogram angiography. The absence of a detectable showing shift of pericallosal artery to the left. An avascular space can be seen between the inner table primary site suggests that this was a primary melanoma of meningeal origin; such tumors and the temporal lobe. do occur but are extremely rare? However, a was performed. Subsequent detailed much more likely explanation is that the histology of the specimen showed typical shoulder lesion that regressed was the primary tumor. Regression of primary malignant melanoma. Postoperative Course. Two weeks after melanoma in the presence of metastases has surgery the patient suffered a grand mal been well documented? References seizure, followed by persistent dense left hemiparesis and expressive dysphasia. Repeat 1. Baker AB: Metastatic tumors of the nervous radioisotope scan showed several areas of absystem. Arch Pathoi 34:495-537, 1942 normal uptake considered to be further 2. Courville CB, Schillinger R J: Metastatic melanoblastomas of the brain. Review of metastases. A poor prognosis was anticipated literature and survey of eighteen cases. Bull Los and the patient was discharged to a hospital Angeles Neuroi Soc 4:8-22, 1939 nearer her home. Examination of the patient's skin and 3. Gibson JB, Burrows D, Weir WP: Primary melanoma of the meninges. J Pathoi Bacterinl mucosal surfaces at no time revealed a 74:419-438, 1957 primary tumor site. However, her husband 4. Madonick MJ, Savitsky N: Subarachnoid eventually recalled a black, raised lump on hemorrhage in melanoma of the brain. Arch her shoulder which had appeared about 6 Neurol Psychiatry 65:628-636, 1951 months previously, had grown for a few 5. Smith JL Jr, Stehlin JS Jr: Spontaneous regression of primary malignant melanomas with weeks, and had ultimately disappeared. regional metastases. Cancer 18:1399-1415, 1965 Discussion 6. Weller CV: Unusual cardiac and cerebral Metastatic cerebral tumors may be metastases in melanosarcoma. J Cancer Res avascular or demonstrate varying degrees and 7:313-327, 1922 types of neovascularity,a While the tendency 7. Wolpert SM, Zimmer A, Schechter MM, et al: The neuroradiology of melanomas of the cenfor neovascularity is greater in certain histotral nervous system. Am J Roentgenol Radium logical types of tumor, it is seldom possible to Ther Nucl Med 101:178-187, 1967 predict the primary site from the anglo8. Zachrisson L: Angiography of cerebral graphic appearance. metastases. Acta Radiol (Diagn) 1:521-527, The tendency of malignant melanoma to 1963 localize peripherally may produce certain clinical or radiological features that suggest Address reprint requests to: F. John Palmer, the diagnosis. Rupture through the cortex of M.B., Ch.B., Department of Diagnostic Radia vascular tumor may be followed by sub- ology, The Prince Henry Hospital, Anzac Parade, arachnoid hemorrhage (SAH). Madonick Little Bay, New South Wales 2036, Australia. 302
J. Neurosurg. / Volume 49 / August, 1978
Metastatic melanoma simulating subdural hematoma Case report
F. JOHN PALMER, M.B., CH.B., M.R.C.P., M.R.A.C.R., F.R.C.R., AND ANTHONY P. POULGRAIN, M.B., B.S., F.R.C.S., F.R.C.S.I.
Departments of Radiology and Neurosurgery, Prince Henry Hospital, Little Bay, New South Wales, Australia w' Metastatic melanoma tends to be found in subcortical white matter and this localization may produce clinical or radiological features that are unusual in metastatic disease. A case is described that closely simulated a subdural hematoma both clinically and radiologically. KEY WORDS cerebral metastasis subdural hematoma ~
M
ETASTASIS to the central nervous system occurs in approximately 50% of cases of malignant melanomas. 1 The tumor may be found anywhere in the brain or spinal cord. However, there appears to be a distinct potentiality for melanoma metastases to localize in the subcortical white matter. 2,e The tumor may subsequently rupture onto the cortical surface, which may lead to clinical or radiological features that are unusual in metastatic disease. Case Report
This 33-year-old woman presented with frontal headaches which had persisted since she hit her head against a garage door 3 weeks previously. The blow was not severe and consciousness was not impaired. One week before admission she developed clumsiness and weakness in the left arm. Examination. At the time of admission, she was conscious and well oriented. The only positive findings were early papilledema and
J. Neurosurg. / Volume 49 / August, 1978
9 melanoma
9
mild left hemiparesis. A radioisotope cerebral scan with technetium-99m pertechnetate demonstrated abnormal uptake in the right parietotemporal region, and electroencephalography revealed abnormal slow wave activity in the same region. Blood counts, electrolytes, urinalysis and a chest radiograph were normal. Right common carotid angiography showed a 5-mm " s q u a r e " shift of the pericallosal artery to the left side. There was also a crescent-shaped avascular space overlying the right temporal lobe (Fig. 1). This was demonstrated to better advantage in the oblique view. No neovascularity was identified. These studies and the history of recent head trauma led to a confident diagnosis of subdural hematoma. Operation. At operation (Dr. A. Gonski) a reddish-black tumor was found lying over the temporal lobe surface and occupying the space noted on the angiograms. Frozen section confirmed a diagnosis of malignant melanoma, and right temporal lobectomy 301
F. J. P a l m e r a n d A. P. P o u l g r a i n and Savitsky' found that 49% of 56 cerebral melanomas developed SAH, while SAH occurred in only two of 56 cases of metastases from other sites. Similarly, contact with the leptomeninges allows development of arterial supply from meningeal vessels. In the series of Wolpert, et al., 7 two of seven vascular metastatic melanomas showed meningeal arterial supply. A similar case, seen in this department, was misdiagnosed as a meningioma because of meningeal arterial supply and homogenous tumor blush. The present case demonstrates a further manifestation of the unusual behavior of metastatic melanoma. The tumor spreading over the cortex produced an avascular space that simulated a subdural hematoma at FIG. 1. Right common carotid angiogram angiography. The absence of a detectable showing shift of pericallosal artery to the left. An avascular space can be seen between the inner table primary site suggests that this was a primary melanoma of meningeal origin; such tumors and the temporal lobe. do occur but are extremely rare? However, a was performed. Subsequent detailed much more likely explanation is that the histology of the specimen showed typical shoulder lesion that regressed was the primary tumor. Regression of primary malignant melanoma. Postoperative Course. Two weeks after melanoma in the presence of metastases has surgery the patient suffered a grand mal been well documented? References seizure, followed by persistent dense left hemiparesis and expressive dysphasia. Repeat 1. Baker AB: Metastatic tumors of the nervous radioisotope scan showed several areas of absystem. Arch Pathoi 34:495-537, 1942 normal uptake considered to be further 2. Courville CB, Schillinger R J: Metastatic melanoblastomas of the brain. Review of metastases. A poor prognosis was anticipated literature and survey of eighteen cases. Bull Los and the patient was discharged to a hospital Angeles Neuroi Soc 4:8-22, 1939 nearer her home. Examination of the patient's skin and 3. Gibson JB, Burrows D, Weir WP: Primary melanoma of the meninges. J Pathoi Bacterinl mucosal surfaces at no time revealed a 74:419-438, 1957 primary tumor site. However, her husband 4. Madonick MJ, Savitsky N: Subarachnoid eventually recalled a black, raised lump on hemorrhage in melanoma of the brain. Arch her shoulder which had appeared about 6 Neurol Psychiatry 65:628-636, 1951 months previously, had grown for a few 5. Smith JL Jr, Stehlin JS Jr: Spontaneous regression of primary malignant melanomas with weeks, and had ultimately disappeared. regional metastases. Cancer 18:1399-1415, 1965 Discussion 6. Weller CV: Unusual cardiac and cerebral Metastatic cerebral tumors may be metastases in melanosarcoma. J Cancer Res avascular or demonstrate varying degrees and 7:313-327, 1922 types of neovascularity,a While the tendency 7. Wolpert SM, Zimmer A, Schechter MM, et al: The neuroradiology of melanomas of the cenfor neovascularity is greater in certain histotral nervous system. Am J Roentgenol Radium logical types of tumor, it is seldom possible to Ther Nucl Med 101:178-187, 1967 predict the primary site from the anglo8. Zachrisson L: Angiography of cerebral graphic appearance. metastases. Acta Radiol (Diagn) 1:521-527, The tendency of malignant melanoma to 1963 localize peripherally may produce certain clinical or radiological features that suggest Address reprint requests to: F. John Palmer, the diagnosis. Rupture through the cortex of M.B., Ch.B., Department of Diagnostic Radia vascular tumor may be followed by sub- ology, The Prince Henry Hospital, Anzac Parade, arachnoid hemorrhage (SAH). Madonick Little Bay, New South Wales 2036, Australia. 302
J. Neurosurg. / Volume 49 / August, 1978
