Spontaneous

Epidural Hematoma from a Hepatocellular Carcinoma

Metastasis

to the Skull

Case Report— — Yoshio NAKAGAWA, Eiji YOSHINO, Kenzo SUZUKI, Atsushi TATEBE* and Hiromu ANDACHI* Departments of Neurosurgery and *Pathology, Matsushita Memorial Hospital , Moriguchi, Osaka

Abstract A rare skull

case of acute

removed, many

epidural

in a 52-year-old but

he died

sinusoid-like

hematoma

male is reported. of large

blood

liver

vessels,

originating The

skull

tumor. which

from

Histological probably

a hepatocellular

metastasis

and epidural examination

lead

carcinoma

metastasis

hematoma

were completely

of the

to hemorrhage

and

removed formation

to the

tumor

showed

of

epidural

hematoma. Key words:

epidural

hematoma,

metastasis,

hepatocellular

Introduction Spontaneous intracranial hemorrhage from brain tumor accounts for 0.9-11% of all such hemor rhages.') The location is usually intratumoral or in tracerebral, and very rarely epidural.6) Only two cases of spontaneous epidural hematomas from brain tumor have been reported.'') Here, we report a spontaneous epidural hematoma from a metastatic hepatocellular carcinoma in the skull. Case

Report

A 52-year-old male with a 15-year history of chronic hepatitis was admitted to Matsushita Memorial Hospital on October 8, 1990. He had been well until the day before. Two hours before admission he sud denly experienced a severe headache, and became un conscious in the ambulance. On admission, he demonstrated decerebrate posture and irregular respiration. No scalp wound was present. The pupils were miotic and unrespon sive to light, and the corneal reflex was absent bilaterally. Computed tomographic (CT) scans show ed a large epidural hematoma in the suboccipital and

carcinoma

occipital areas, with an irregularly enhanced area in the center postcontrast thought to indicate active bleeding (Fig. 1). At operation, no scalp wound or skull fracture was found. Right occipital craniotomy and suboc cipital craniectomy demonstrated that the edge of the occipital bone bordering the foramen magnum was destroyed. This bone was yellowish and hemor rhagic, approximately 2 cm in diameter, and ap peared to be hemorrhagic bone tumor. The large epidural hematoma was completely removed. No ac tive bleeding from the dura or sinus was seen. The bleeding source was the destroyed occipital bone. Microscopic examination of tumor specimen found cuboidal cells surrounding sinusoid-like blood vessels, and some pigmented deposits mimicking bile pigments (Fig. 2). The histological diagnosis was metastatic hepatocellular carcinoma (Edmondson grade 2). Postoperatively, abdominal ultrasonograms demonstrated a large liver tumor. The alpha-fetopro tein level was elevated (13,541 ng/ml). He died of liver tumor on December 17, 1990. Autopsy was not permitted. Discussion

Received 1991

September

5,

1991;

Accepted

October

9,

No evidence of head injury or trauma to the scalp

Fig.

1

A:

Precontrast

regions. hematoma,

B:

CT

scans,

showing

Postcontrast indicating

CT

active

a large

scan,

epidural

showing

hematoma

irregular

in the infra

enhancement

in

and

supratentorial

the

center

of

the

bleeding.

Metastasis from hepatocellular carcinoma to the brain or skull is rare. The incidence of hepatocellular carcinoma metastasis to the brain is 1.7%, and to bone 10.1%.') The Japanese Brain Tumor Registry shows that 1.2% of all brain metastases are from hepatocellular carcinoma.2) Kuga et al.') reported that eight of nine patients with brain metastasis from hepatocellular carcinoma developed intracranial hemorrhage, so bleeding from such tumors is not unusual. Although few cases of metastasis have been reported, the number will increase as the treatment and management of primary tumors improve and techniques of imaging the brain and skull progress. We therefore emphasize that the possibility of acute bleeding from the tumor should be considered when metastasis from hepatocellular carcinoma to the brain or skull is detected. Fig. 2 Photomicrographs of the skull tumor. left: Cuboidal tumor cells surrounding sinusoid-like blood vessels. HE stain, x 50. right: Bile pigment-like pigmented deposits (arrows) are occasionally seen. HE stain, x 100.

References 1)

2) was

detected,

so

the

hemorrhage

in

this

case

presumably occurred spontaneously. Spontaneous epidural hematoma has previously developed in only one metastatic skull tumor from hepatocellular car cinoma 5) and one dural metastasis from ovarian car cinoma.') A characteristic histological feature of both tumors was an abundance of blood vessels with thin walls. sinusoid-like hemorrhage

The present tumor also had many blood vessels, which probably lead to and formation of epidural hematoma.

3)

4)

5)

Anegawa S, Hirohata S, Tokutomi T, Kuramoto S: Spontaneous epidural hematoma secondary to dural metastasis from an ovarian carcinoma. Case report. Neurol Med Chir (Tokyo) 29: 854-856, 1989 Committee of Brain Tumor Registry in Japan: Brain Tumor Registry in Japan, vol 6. 1987, pp 38-42 (in Japanese) Kuga Y, Waga S, Itoh H: Intracranial hemorrhage due to brain metastasis from hepatocellular carcinoma. Case report. Neurol Med Chir (Tokyo) 30: 768-771, 1990 Liver Cancer Study Group of Japan: Survey and follow-up study of primary liver cancer in Japan: Report 6. Kanzo 26: 254-262, 1985 (in Japanese) Nakao S, Sato S, Fukumitsu T, Ogata M, Shirane H: Cranial metastasis of hepatocellular carcinoma.

6)

Report of three cases. Neurol Med Chir (Tokyo) 25: 229-234, 1985 (in Japanese) Wakai S, Yamakawa K, Manaka S, Takakura K: Spon taneous intracranial hemorrhage caused by brain tumor: Its incidence and clinical significance. Neurosurgery 10: 437-444, 1982

Address reprint requests to: Y. Nakagawa, M.D., Depart ment of Neurosurgery, Matsushita Memorial Hospital, 2-35 Sotojima-cho, Moriguchi, Osaka 570, Japan.